William Wijns MD PhD The Lambe Institute for …...Tu, Reiber, Wijns et al. JACC CV Interv...
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ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
William Wijns MD PhD
The Lambe Institute for Translational Medicine and Curam
Saolta University Healthcare Group
The Smart Sensors Lab, Director
National University of Ireland Galway, Ireland
Chairman PCR
Institutional Research Grants (to former institution) from Biotronik, MiCell, MicroPort, Terumo
Co-founder of Argonauts, an innovation facilitator
Scientific Advisor Rede Optimus Research
Steering Committee & Honoraria: MicroPort
2020-01-29_HIGH TECHMarseille
Relations of Interest Disclosure
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
William Wijns MD PhD
2020-01-29_HIGH TECHMarseille
Le futur de la Cardiologie Interventionnelle
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
SCIENTIFIC ADVANCES & CARDIOVASCULAR MORTALITYNabel and Braunwald. N Engl J Med 2012;366:54-63
1958Coronary
arteriographydeveloped
(Sones)
1977Coronary
angioplastydeveloped(Grüntzig)
1993Superiority of
primary PCI vs. fibrinolysis in
acute MI noted
2002Efficacy of
drug-eluting vs. bare-
metal stents determined
1967First description of CABG(Favaloro)
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
FIM Percutaneous Coronary Angioplasty 1978
Perfect surgical candidate with a simple to deal with lesion (focal, large vessel, easily
accessible, straight proximal segment)
From “symptomatic” to prognostic indications 2016
Acute Presentations of CAD
• Primary PCI for STEMI
• High-risk unstable angina
Elective PCI / chronic patients
Equipoise with CABG for subsets of patients with left main stenosis
± multivessel disease
CTO no longer a frontier
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
Primary endpoint
No. at risk Medical therapy 1344 1222 688 559 381 301FFR-guided PCI 1056 980 696 566 406 328
Medical therapy
FFR-guided PCI
Hazard ratio 0.72 (95% CI 0.54-0.96) P=0.024
28% lower (relative)*
4.5% lower (absolute)
Cardiac Death or Myocardial Infarction
Zimmermann et al.
European Heart Journal, Volume 40, Issue 2, 07 January 2019, Pages 180–186 https://doi.org/10.1093/eurheartj/ehy812 *Relative benefit of FFR-guided PCI not different among studies
FAME 2NCT01132495
DANAMI-3-PRIMULTINCT01960933
I
Compare-AcuteNCT01399736
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
After adjustment for - patient- site-level- procedural factors
FFR-guided revascularization was associated with a 43% lower risk of mortality at 1 year
compared with angiography-only revascularization
1 year all-cause mortality
Hazard Ratio: 0.57
95% confidence interval: 0.45 to 0.71; p < 0.0001)
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
0
.50
.75
.25
1.0
FFR = 0.74
FFR = 0.74
Q-FR = 0.75
Tu, Reiber, Wijns et al. JACC CV Interv 2014;7:768-77 & Tu, Reiber, Wijns et al. JACC CV Interv 2016;9:2024-5
• Needs only 2 angio runs from biplane or monoplane systems
• Computation speed < 2 min
• Rendering of Q-FR color-coded pullbacks for all branches in the same calculation
• High Diagnostic Accuracy 87% (95%CI 80-94) vs FFR measured by pressure wire after adenosine
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
No
TA
VI
No
TA
VI
SurgicalRisk
# Patients
TAVISurgery
TATF
A.P. Kappetein, EuroPCR, AYNTK
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
2019
PARTNER 3
Evolut LOW RISK
Low
>/=
CLINICAL EVIDENCE ACROSS RISK CATEGORIESCLINICAL EVIDENCE ACROSS RISK CATEGORIES
2017
PARTNER 2A
SURTAVI
NOTION I
20162011
PARTNER 1A
2014
CoreValve HR
2012
PARTNER 1B
2014
CoreValve ER
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
2010 Guidelines on myocardial revascularisation
The Task Force on Myocardial Revascularisation of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)
Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI)
Authors/Task Force Members: William Wijns (Chairperson) (Belgium), Philippe Kolh (Chairperson) (Belgium), Nicolas Danchin (France), Carlo Di Mario (UK), Volkmar Falk (Switzerland), Thierry Folliguet (France), Scott Garg (The Netherlands), Kurt Huber (Austria), Stefan James (Sweden), Juhani Knuuti (Finland), Jose Lopez-
Sendon (Spain), Jean Marco (France), Lorenzo Menicanti (Italy), Miodrag Ostojic (Serbia), Massimo F. Piepoli (Italy), Charles Pirlet (Belgium), Jose L. Pomar (Spain), Nicolaus Reifart (Germany), Flavio L. Ribichini (Italy), Martin J. Schalij (The Netherlands), Paul Sergeant (Belgium), Patrick W. Serruys (The Netherlands), Sigmund
Silber (Germany), Miguel-Sousa Uva (Portugal), David Taggart (UK).
European Heart Journal 2010;31:2501-55
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
The Heart Team
Task Force composition = 8 clinical cardiologists (non interventional)+ 9 interventional cardiologists + 8 cardiac surgeons
Clinical cardiologist(non interventional)
Cardiac
surgeon
Interventional
cardiologist
The patientwith CAD
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
2014 ESC/EACTS Guidelines on myocardial revascularisation
The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)
Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI)
Authors/Task Force members: Stephan Windecker (ESC Chairperson) (Switzerland), Philippe Kolh (EACTS Chairperson) (Belgium), Fernando Alfonso (Spain), Jean-Philippe Collet (France), Jochen Cremer
(Germany), Volkmar Falk (Switzerland), Gerasimos Filippatos (Greece), Christian Hamm (Germany), Stuart J. Head (Netherlands), Peter Jüni (Switzerland), A. Pieter Kappetein (Netherlands), Adnan Kastrati
(Germany), Juhani Knuuti (Finland), Ulf Landmesser (Switzerland), Günther Laufer (Austria), Franz-Josef Neumann (Germany), Dimitrios J. Richter (Greece), Patrick Schauerte (Germany), Miguel-Sousa Uva (Portugal), Giulio G. Stefanini (Switzerland), David Paul Taggart (UK), Lucia Torracca (Italy), Marco
Valgimigli (Italy), William Wijns (Belgium), and Adam Witkowski (Poland).
European Heart Journal 2014;35:2541-2619
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
2018 ESC/EACTS Guidelines on myocardial revascularisation
Authors/Task Force Members: Franz-Josef Neumann (ESC Chairperson) (Germany), Miguel Sousa-Uva (EACTS Chairperson) (Portugal), Anders Ahlsson (Sweden), Fernando Alfonso (Spain), Adrian P.
Banning (UK), Umberto Benedetto (UK), Robert A. Byrne (Germany), Jean-Philippe Collet (France), Volkmar Falk (Germany), Stuart J. Head (The Netherlands), Peter Jüni (Canada), Adnan Kastrati
(Germany), Akos Koller (Hungary), Steen D. Kristensen (Denmark), Josef Niebauer (Austria), Dimitrios J. Richter (Greece), Petar M. Seferovic (Serbia), Dirk Sibbing (Germany), Giulio G. Stefanini (Italy),
Stephan Windecker (Switzerland), Rashmi Yadav (UK), Michael O. Zembala (Poland).
The Task Force on myocardial revascularisation of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery
(EACTS)
Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI)
European Heart Journal 2018. Published online August 25 doi.org/10.1093/eurheartj/ehy 394
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
• Choice of procedural MI definition
• The MI definition in the protocol was modified during the course of the study
• The rates of procedural MI according to Universal Definition have been deliberately withheld
• The all cause mortality data from EXCEL were not strongly enough emphasized
• The DSMC raised concerns that were not considered
• The ESC / EACTS GL are unsafe
EACTS Public Criticism following the publication of EXCEL at 5-year follow-up
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelineswww.escardio.org/guidelines
Type of revascularization in patients with stable
three-vessel or left main coronary artery disease
Windecker S et al., Eur Heart J 2019;40:204-12
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
The future of Interventional Cardiology / MedicineDiagnosis and Treatment of Cardiovascular Diseases
Best of Medical Care
LifestyleDiet
Pharmacology
Coronary, Valvular, Structural& Peripheral Interventions
CABGValve surgery
Incremental improvement in Best of CareOn behalf of Heart Team 2.0
« By and For » the individual patient
Blue Ocean Strategy
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
10.7%
11.2%
Days334 313 295 289 279 277 268
454 442 433 422 407 399 391
15.1%
13.2%
HR 0.93 (95% CI 0.60-1.43) p=0.73P <0.001 for non-inferiority*
HR 0.85 (95% CI 0.58-1.25)p=0.42
SYNTAX I CABG
SYNTAX II PCI
Pat
ien
ts (
%)
SYNTAX I CABGSYNTAX II PCI
up to 2 years
Exploratory endpointMACCE PCI vs CABG for 3 vessel disease
Components of the SYNTAX II « Best of PCI Practice » strategy
1. Risk stratification tool: SYNTAX Score II (incorporating clinical and anatomical
variables) to guide Heart Team decisions
2. Physiology-based revascularization
3. Second generation DES (thin strut, biodegradable polymer, everolimus-eluting
Synergy™ stent)
4. IVUS-guided optimisation of stent deployment
5. Contemporary CTO revascularization techniques
6. Guideline-directed medical therapy (LDL cholesterol ≤1.8 mmol/L)
Escaned et al. Eur Heart J. 2017;38:3124-34 – Modolo et al. Ann CardioThoracic Surg 2018;7:470-82
Clinical outcomes of state-of-the-art PCIin patients with de novo 3 VD
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines 19
Adoption of Interventional ProceduresAdoption of Interventional Procedures
PROM
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
From S.W. Windecker
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines 21
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines 22
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
MSCT Assessment3D - Maximum Intensity Projection (MIP)
Calcification of the Aorta
Calcified plaque in the LAD
Mid LAD obstructive lesion
LCX/OM bifurcation lesion
Proximal RCA obstructive lesion
Ostial lesion RCA (?)
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
Left Main / LADSegment 7 = 5 points
Segment 7 >20 mm = 6 points
2nd
Dg
1st
Dg
Multiplanar Reconstruction (MPR)
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
Engaging the new era of Coronary Computed Tomography - facilitated PCI
Access: femoral-radial
Aorta ascendens / descendens
Coronary arteriesOstiaAberrant arteriesDominance, vessel lengthCoronary calcificationCoronary physiology (CT-FFR)Vessel size, diameter, tortuosityPlaque severity and remodelling Plaque compositionCollateral flow
CTO: length of occlusion, degree of calcification
Risk assessment / stratification by calculation of scores
Procedure planningstent size, length and diameterimpact on FFR
Best views for imaging/procedure
Reduced procedure duration, radiation and use of contrast
Think of changes in training, capacity and care delivery !
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
Multidistrict Diagnosis and Treatment
1. Cardiac targets: coronary arteries, valves, other structural interventions
2. Peripheral vascular targets: PAD, hypertension, critical limb ischemia
3. Stroke prevention and treatment: LAAC, carotid stenting, acute stroke
4. Pulmonary disease: PAH, pulmonary embolism
5. Acute and chronic heart failure: implanted sensors, assist devices, ECMO
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
• Multidistrict diagnosis & intervention requires 2 or 3 dedicated rooms: a single equipment does not allow an optimal head-to-toe workflow
The CathLab of the (near) Future
• Coronary diagnosis of the (near) future requires state-of-the-art coronary CT angiography (super-fast CT volume imaging in a single heart cycle)
• Valvular (TAVI) and other structural interventions (LAAC) require Computed Tomography (CT) and echo imaging, both fused with LIVE imaging in the cathlab
CT equipment is best integrated in the cathlab environment but
with access and workflow also suitable for outpatient service
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
• Enforcing healthy lifestyle and diet
• Mitral and tricuspid intervention
• Implementing interventional treatment of stroke
• Reducing hospital stay
• Eliminating drug incompatibilities
• Preventing sudden cardiac death
• Anticipating acute atherothrombotic events
• Fighting arterial hypertension
• Diagnosing paroxysmal atrial fibrillation
• Distributing health care to the poor
• . . . / . . .
What is your most frustrating unmet need ?
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
The mobile phone : Rwanda’s weapon for distance surveillance of high-risk pregnancy
Rwanda 's hospitals use drones to deliver medical supplies
http://flyzipline.com/press/
Transformative impact of technology on care delivery
Prof J. Marescaux (IRCAD) to establish a digital training center for endoscopic surgery in Kigali
1. Computing power2. Data analytics3. Artificial intelligence4. Electroceuticals (electrons as a drug)5. Communication technology (sensors)6. Power (batteries)7. Gene sequencing (responders vs non)8. 3D-printing9. New materials (cell protection)10. Social networks11. Robotics
What does the future hold ?
Areas of Strategic Investment Horizon 2025
S. Oesterlee, Dublin 2016
The synchrony of imaging and catheter movement… practice, plan and perfect…
No lead, no radiation &less X-rays and contrastfor patients …
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
e-health solutions are relevant if they impact patient care &save money with a good business model
Decrease repeated Decrease repeated hospitalization needs hospitalization needs for heart failure for heart failure patientspatients
Prevent episodes of Prevent episodes of hypoglycemia in hypoglycemia in diabetic patientsdiabetic patients
Decrease ER visits Decrease ER visits for childhood asthma for childhood asthma exacerbationsexacerbations
PJ Fitzgerald@EuroPCR 2016
Value and limitations of connected health
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
VERILY Life Sciences
SENSORS
https://verily.com/projects/
• Mini CGM (Dexcom)• Smart Lens (Novartis)• Study Watch
INTERVENTIONS
HEALTH PLATFORMS
PRECISION MEDICINE
• Debug• Bioelectronic Medicines (GSK)• Liftware• Retinal Imaging (Nikon)• Verb Surgical (Ethicon - J&J)
• Healthcare Performance (3M)• NHS Testbed Early Intervention
(NHS & MSD)• Onduo (Sanofi)
• Immunoscape (Gilead)• MS Study (Biogen & Brigham)• One Brave Idea (NIH & AZ)• Personnalized Parkinson • Precision Medicine (NIH)• Project Baseline (Duke & Stanford)
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
IBM Watson
A. Grosse, Cognitive Health Leader EuropeMedTech Strategist, Dublin 2018
Multiple products and services
•IoT Solutions
•Medical Language
•Drug Discovery
•Medical Imaging
•Oncology
•Sepsis (real time)
•Open Health Platform
•. . . / . . .
We have spent the last 50 years or so teaching people to operate computers.Cognitive computing is about teaching computers to understand people.
Rob High – VP and CTO IBM Watson
Symposium en l’honneur du Professeur Legrand
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
The 10 Commandments of Graeme Codrington
ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
www.escardio.org/guidelines
The 10 Commandments of Graeme Codrington
1. Switch on your radar2. Be curious and ask better questions3. Change where you look for information4. Why are we doing it this way?5. Experience more, but wisely6. Embrace different opinions7. Look East8. Learn from your mistakes, and from the
mistakes of others9. Confront your limiting orthodoxies10. Learn, unlearn, and relearn