Imagen y análisis funcional intracoronarios

Javier Escaned MD PhD

Hospital Clínico San Carlos

Madrid

Physiology and imaging: selected areas of contributions

• Clinical practice guidelines 2014

• Better understanding of prognostic FFR information

• Symplifying assessment with imaging and physiology to increase adoption

• Potential value of physiology in STEMI

Recommendations for the clinical value of intracoronary diagnostic techniquesESC CPGs on Myocardial Revascularization

Windecker S et al. Eur Heart J 2014

Recommendations for the clinical value of intracoronary diagnostic techniquesESC CPGs on Myocardial Revascularization

Windecker S et al. Eur Heart J 2014

• … new methods and indices (including instantaneous wavefree ratio [iFR] that do not rely on the concept of maximal hyperemia have been proposed, in order to simplify studies and facilitate a wider adoption of physiological assessment.

• Further studies will need to confirm the value of these new indices in clinical decision-making

Physiology and imaging: selected areas of contributions

• Clinical practice guidelines 2014

• Better understanding of prognostic FFR information

• Symplifying assessment with imaging and physiology to increase adoption

• Potential value of physiology in STEMI

Johnson N et al. JACC. 2014;64(16):1641-1654

FFR envisaged as a continuous marker of risk

A meta-analysis of 51 FFR studies with clinical patient follow up

FFR envisaged as a continuous marker of risk

A meta-analysis of 51 FFR studies with clinical patient follow up

Johnson N et al. JACC. 2014;64(16):1641-1654

Supplementary data of FAME II study

Stratified analysis of the primary endpoint

PCI better Medical Tx better

Post PCI FFR and long-term outcome

Johnson N et al. JACC. 2014;64(16):1641-1654

Reclassification of treatment with FFR interrogation of all stentable vessels (RIPCORD)

Curzen N et al . Circ Cardiovasc Interv. 2014

200 stable patients undergoing coronary angiography.

Reclassification of treatment with FFR interrogation of all stentable vessels (RIPCORD)

Curzen N et al . Circ Cardiovasc Interv. 2014

Routine pressure wire assessment during diagnostic angiography in stable patients leads to a change in treatment strategy in 26% of the cases.

Reclassification of treatment with FFR interrogation of all stentable vessels (RIPCORD)

Curzen N et al . Circ Cardiovasc Interv. 2014

Physiology and imaging: selected areas of contributions

• Clinical practice guidelines 2014

• Better understanding of prognostic FFR information

• Symplifying assessment with imaging and physiology to increase adoption

• Potential value of physiology in STEMI and ACS

Diagnosis efficiency of hybrid iFR/FFR approach(ADVISE II)

Escaned J et al JACC C Intvn 2015

Diagnosis efficiency of Pd/Pa(An ADVISE II post hoc analysis)

Echavarría-Pinto M J et al JACC C Intvn 2015

Can contrast injection better approximate FFR compared to pure resting physiology? (CONTRAST)

Johnson N et al EuroPCR 2015

750 subjects (prospective) with 1 lesion/patient enrolled in 15 centres

Can contrast injection better approximate FFR compared to pure resting physiology? (CONTRAST)

contrast = 85.5% accuracyiFR = 79.6% accuracyPd/Pa = 78.4% accuracy superior accuracy (p<0.001)

Optimal binary cutoff for contrast Pd/Pa ≤0.83

Johnson N et al EuroPCR 2015

Co-registration of angiography with intracoronary imaging

Cases performed at Hospital Clinico San Carlos / Madrid

Aim of the study: To investigate if co-registration had the potential for improving positioning of stents compared to operator mind mapping of OCT to angiography during PCI.

n=22

Co-registration of OCT and X-ray angiography in PCI: the DOCTOR study

Hebsgaard et al. Int J Cardiol 2015; 182: 272–278

Co-registration of OCT and X-ray angiography in PCI: the DOCTOR study

Hebsgaard et al. Int J Cardiol 2015; 182: 272–278

Without access to the computer-based co-registration, segments of the target lesion indicated on OCT were left uncovered by stent in 14 patients (70%)

FFR 0.58

Intracoronary FFR mapping during i.v. adenosine

Case performed at Hospital Clinico San Carlos / Madrid

Adenosine-free iFR pressure mapping

DES 2.25 x 15

Pre

Post

Case performed at Hospital Clinico San Carlos / Madrid

Nijjer S et al. JACC Cardiol Intv. 2014

iFR coronary mapping and virtual PCI simulations

PrePCI

PostPCI

Nijjer S et al. JACC Cardiol Intv. 2014

iFR coronary mapping and virtual PCI simulations

CABG +

follow up with MSCT

Influence of pressure pullback derived patterns of diffuse disease on IMA-CABG outcome

Shiono Y et al EuroPCR 2015

Influence of pressure pullback derived patterns of diffuse disease on IMA-CABG outcome

Follow-up with MSCT

IMA failure: 9% 31%p=0.020

Shiono Y et al EuroPCR 2015

Physiology and imaging: selected areas of contributions

• Clinical practice guidelines 2014

• Better understanding of prognostic FFR information

• Symplifying assessment with imaging and physiology to increase adoption

• Potential value of physiology and imaging in STEMI

STEMI and multivessel disease: what to do and when?

PRAMI / Wald et al. NEJM 2013 CVLPRIT / Gershlick et al. ESC 2014

Pivotal studies supporting the value of complete revascularization in patients with STEMI and MVD (PRAMI and CVLPRIT) used angiographic guidance alone.

MAC

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DANAMI 3-PRIMULTI: staged FFR-guided management of non-culprit stenoses

Complete FFR guided revascularisation of MVD STEMI patients, staged within the index admission, reduced the primary endpoint. This reduction was driven by repeat revascularisations and not by hard endpoints

Engstrøm T et al ACC 2015

N=313

N=314

Modification of thrombus burden by aspiration in the TOTAL trial assessed with OCT

Bhindi et al Eur Heart J 2015

Modification of thrombus burden by aspiration in the TOTAL trial assessed with OCT

• No impact of thrombectomy vs. PCI-alone on pre-stent thrombus burden.

• Both interventions were associated with a low level of culprit lesion thrombus in the majority of patients, and with similar thrombus burden after stenting.

Bhindi et al Eur Heart J 2015

End or the paradigm of thrombus embolization as

major determinant of outcome (TOTAL trial)

Growing evidence of the prognostic role of intramyocardial

haemorrage in STEMI

Improving outcomes in STEMI

QR

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aoP

dR

d>100μmR

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Neurohumoral

Endothelial (flow)Metabolic

FFR, iFR, d-FFR,HSR IHDVPS, HMR, IMR

CFR (thermo), CFVR (Doppler)

IHDVPS-Pzf

Exploring the culprit vessel of STEMI

WIA

QR

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dR

d>100μmR

capR

d<100μm

Rmicro

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WIAMVO pattern in MRI after STEMI

Exploring the culprit vessel of STEMI

PREDICT-MVI: Anticipating the development of microvascular injury after primary PCI in STEMI

In PREDICT-MVI Doppler-pressure interrogation was performed in 60 pts immediately after PCI to investigate whether MVI can be anticipated in the cath lab

Teunissen PF et al Circulation C Intv 2015

PREDICT-MVI: Anticipating the development of microvascular injury after primary PCI in STEMI

Post-analysis with pressure-velocity loops allowed calculation of resistance, conductance and zero flow pressure (compression of the microcirculation)

Teunissen PF et al Circulation C Intv 2015

PREDICT-MVI: Anticipating the development of microvascular injury after primary PCI in STEMI

MRI and PET were performed to assess the predictive value of indices that could be measured in the cath lab during PPCI

Teunissen PF et al Circulation C Intv 2015

PREDICT-MVI: role of microcirculatory compression (zero flow pressure, Pzf)

Teunissen PF et al Circulation C Intv 2015

From an strictly personal point if view:

which was the publication in 2015 that hasinfluenced me most?

50 chapters and more than 30 clinical cases

Available at the PCR Bookshop at prconline.com

Coronary Stenosis: Imaging, Structure and PhysiologyJavier Escaned and Patrick Serruys, editors

Muchas gracias por su atención