sin título de diapositiva...bss, rss and variation of syntax score after lm pci left main left main...
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L A P A Z Daniel Berrocal, MD, PhD, FACC
Jefe de Cardiologia Intervencionista
Intervencionismo Coronario
de Alto Riesgo
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L A P A Z Daniel Berrocal, MD, PhD, FACC
Jefe de Cardiologia Intervencionista
NO TENGO CONFLICTO DE INTERESES
RESPECTO A ESTA PRESENTACIÓN
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CTO
Ca+
Tortuosidad extrema
Enfermedad difusa
Edad
FE%
EPOC
Como definimos riesgo?
Presentación
Clínica
Riesgo
de sangrado
COMPLEJIDAD
ANATÓMICA
(SYNTAX)
RIESGO CLÍNICO
(EuroScore-STS)
(TACTICS)
IR
Dbt
Comorb
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50
40
30
20
10
0
0 1 2 3 4 5
Cu
mu
lati
ve M
AC
E %
Follow Up Time (years)
2746 2452 2351 2178 2077 1880
2721 2485 2410 2235 2166 1952
# at Risk
Selective
Invasive
Routine
Invasive
Cumulative risk of CV death or MI by risk group
High
Intermediate
Low
Routine Invasive
Selective Invasive
Fox KAA on behalf of RITA-3, FRISC-II and ICTUS trialists. ACC/i2 Summit; March 14, 2010; Atlanta, GA
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0
5
10
15
20
25
Risk stratification by EKG, prior history of IHD and humoral
markers *p<0.01
Prognostic value of early cTnI and CRP in Chest Pain Unit
Death
&
MI
at
120 d
ays (
%)
EKG - & CAD History - EKG + or CAD History + EKG + & CAD History +
TOTAL cTn I + & CRP +
Adaptado de Dr. Jose L. Navarro Estrada
4.0%
19.3%
cTn I + or CRP +
* 17.7%
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0 5 10 15 20 25 30 0 1 2 3 4 5 6 7 8 9 10 11 12 Days from Randomization Months from Randomization
Mo
rta
lity%
Meta-analysis OASIS & CURE (N=34.146)
Major Bleeding
NO Major Bleeding 2.5%
12.8%
P<0.001
Eikelboom JW et al. Circulation 2006. 114:774-782
5X 4X
Ndrepepa G et al. JACC 2008. 51:690-697
Any Bleeding
NO Bleeding
14.1%
3.3%
P<0.001
Mo
rta
lity%
20
15
10
5
0
Pooled analysis ISAR-REACT, ISAR-SWEET,
ISAR-SMART-2, and ISAR-REACT-2 (N=5.384)
14
12
10
8
6
4
2
0
Bleeding and Mortality
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P=0.04
P=0.004
Chamié D et al. TCT 2010
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Capodanno D, et al. Catheter Cardiovasc Interv In press
P < 0.001 P < 0.001 P = 0.18
Baseline SYNTAX
score
Residual SYNTAX
score
D SYNTAX Score (bSS-rSS)
Calibration(χ2): 2.45
Discrimination (AUC): 0.73
Calibration(χ2): 0.60
Discrimination (AUC): 0.72
Calibration(χ2): 3.13
Discrimination (AUC): 0.55
DHIGH-LOW = 12% DHIGH-LOW = 17% DHIGH-LOW = 3%
Two-year cardiac mortality
bSS, rSS and variation of SYNTAX score after LM PCI
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Left Main
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Left Main
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Death
CSS vs. SYNTAX score.
Better discrimination in mortality, but limitations remain
SYNTAX score
MACE
P<0.001
P≤0.03
P<0.001
P≤0.03
c-statistic = 0.62
c-statistic = 0.61
c-statistic = 0.66
c-statistic = 0.58
11.7±7.3
CSS
17.4±20.5
Tertiles are not in the
anticipated order
Modest gain in
calibration vs
SYNTAX score (χ2 8
vs 6)
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Stroke
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# 347 J.S.
♂ 87 años
SIA con isquemia posterolateral
7 días de internación en UCI
EUROscore 24%
STS 13%
Syntax 29
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Bivalirudina
Rotablator DES a Tronco
DES a ostium de CX
3 DES a trifurcacion de CX
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PRE POST
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7 Meses después
SIA con cambios laterales
Trop I= 0.9
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Rotablator 3 DES a DA
(“full metal jacket”)
Bivalirudina
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PRE POST
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diameter stenosis (%)
FF
R
100 80 60 40 20 0
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
1066 Non-LM lesions
Mismatch Disease in the Cath Lab
AMC data
16% Reverse
mismatch
57%
Mismatch
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0.75 0.84
LAD, FFR LCX, FFR
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MLA 5.7mm2
Distal LM Rupture
LM from LAD pullback LM from LCX pullback
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Híbridos
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Resultados de 130 casos hibridosTECAB-PCI
• 2001 to 2009:
• 3 MIDCAB, AH-TECAB 96, BH-TECAB 31 pts
• Mortalidad Peri-op 0.7%
• F/U: 6% IAM, 0.7% ACV, 8% nueva PCI, 0 Muertes.
• 75% Libres de MACE
Bonatti,et al. 2011 EJCTS
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Robotic EndoACAB
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ROBOTIC LIMA HARVESTING
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Cumulative survival of 410 patients undergoing totally endoscopic coronary artery
bypass grafting from 2001 to 2010 at the University of Maryland and at Innsbruck
Medical University.
Bonatti J et al. Circulation 2011;124:236-244
Copyright © American Heart Association
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Hybrid coronary revascularization (defined as the
planned combination of LIMA-to-LAD artery grafting and
PCI of ≥1 non-LAD coronary arteries may be reasonable
as an alternative to multivessel PCI or CABG in an
attempt to improve the overall risk-benefit ratio of the
procedures.
Hybrid Coronary Revascularization
I IIa IIb III
ACC/AHA/SCA 2011
Guidelines
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♀ 38
Dolor precordial típico de mas de 30 minutos
Al llegar a la guardia de nuestro centro se
constata electrocardiograma normal
Enzimas cardiacas normales
Prueba ergométrica una semana anterior leve
dolor precordial opresivo que cedió solo
Ecocardiograma transtorácico que fue normal
I II III
aVF aVL aVR
V1 V2 V3
V4 V5 V6
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24 horas
ANGOR 5/10
ECG sin cambios
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4to día post ATC
angor típico
I II III
aVF aVL aVR
V1 V2 V3
V4 V5 V6
II
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CRM ATC
Decisión de revascularización
CTO
Ca+
Tortuosidad extrema
Enfermedad difusa
Edad
FE%
EPOC
IR
Hibridos Presentación
Clínica
Riesgo
de sangrado
COMPLEJIDAD
ANATÓMICA
(SYNTAX)
RIESGO CLÍNICO
(EuroScore-STS)
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L A P A Z Daniel Berrocal, MD, PhD, FACC
Jefe de Cardiologia Intervencionista
La estratificación clínica y anatómica
es muy importante
Debemos contar con gran disponibilidad
de dispositivos y drogas
Tener en cuenta los procedimientos en etapas (“staged”)