2020-01-29_HIGH TECH Marseille 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 Relations of Interest Disclosure 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 ESC Guidelines on the diagnosis and management of chronic coronary syndromes www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
2020-01-29_HIGH TECH Marseille Le futur de la Cardiologie Interventionnelle William Wijns MD PhD ESC Guidelines on the diagnosis and management of chronic coronary syndromes www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
SCIENTIFIC ADVANCES & CARDIOVASCULAR MORTALITY Nabel and Braunwald. N Engl J Med 2012;366:54-63 1958 Coronary arteriography 1967 developed First (Sones) description of CABG (Favaloro) 2002 Efficacy of drug-eluting vs. bare- metal stents 1977 determined Coronary angioplasty developed 1993 (Grüntzig) Superiority of primary PCI vs. fibrinolysis in acute MI noted ESC Guidelines on the diagnosis and management of chronic coronary syndromes www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
FIM Percutaneous Coronary From “symptomatic” to prognostic indications 2016 Angioplasty 1978 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 Perfect surgical candidate with a simple to deal ± multivessel disease with lesion (focal, large vessel, easily accessible, straight proximal segment) CTO no longer a frontier ESC Guidelines on the diagnosis and management of chronic coronary syndromes www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
Primary endpoint Cardiac Death or Myocardial Infarction Hazard ratio 0.72 (95% CI 0.54-0.96) P=0.024 28% lower (relative)* 4.5% lower (absolute) Medical therapy FFR-guided PCI No. at risk Medical therapy 1344 1222 688 559 381 301 FFR-guided PCI 1056 980 696 566 406 328 Zimmermann et al. *Relative benefit of FFR-guided PCI European Heart Journal, Volume 40, Issue 2, 07 January 2019, Pages 180–186 https://doi.org/10.1093/eurheartj/ehy812 not different among studies ESC Guidelines on the diagnosis and management of chronic coronary syndromes www.escardio.org/guidelines FAME 2 DANAMI-3-PRIMULTI Compare-Acute (European Heart Journal 2019; 10.1093/eurheartj/ehz425) NCT01132495 NCT01960933 NCT01399736 I
After adjustment for - patient - site-level - procedural factors FFR-guided revascularization was associated with 1 year all-cause mortality a 43% lower risk of mortality at 1 year Hazard Ratio: 0.57 95% confidence interval: compared with 0.45 to 0.71; p < 0.0001) angiography-only revascularization ESC Guidelines on the diagnosis and management of chronic coronary syndromes www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
• Needs only 2 angio runs from biplane or monoplane systems • Computation speed < 2 min FFR = 0.74 • Rendering of Q-FR color-coded FFR = 0.74 pullbacks for all branches in the same calculation • High Diagnostic Accuracy 87% 1.0 (95%CI 80-94) vs FFR measured by .75 pressure wire after adenosine .50 Q-FR = 0.75 .25 0 Tu, Reiber, Wijns et al. JACC CV Interv 2014;7:768-77 & Tu, Reiber, Wijns et al. JACC CV Interv 2016;9:2024-5 ESC Guidelines on the diagnosis and management of chronic coronary syndromes www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
# Patients TAVI Surgery No TAVI No TAVI Surgical Risk TF TA A.P. Kappetein, EuroPCR, AYNTK ESC Guidelines on the diagnosis and management of chronic coronary syndromes www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
CLINICAL EVIDENCE ACROSS RISK CATEGORIES CLINICAL EVIDENCE ACROSS RISK CATEGORIES PARTNER 2A PARTNER 1B PARTNER 3 CoreValve ER NOTION I Evolut LOW RISK PARTNER 1A CoreValve HR SURTAVI 2011 2012 2014 2014 2016 2017 2019 Low >/= ESC Guidelines on the diagnosis and management of chronic coronary syndromes www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
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 www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
Clinical cardiologist (non interventional) The Heart Team The patient with CAD Interventional Cardiac cardiologist surgeon Task Force composition = 8 clinical cardiologists (non interventional) ESC Guidelines on the diagnosis and management of chronic coronary syndromes www.escardio.org/guidelines + 9 interventional cardiologists + 8 cardiac surgeons (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
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 www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
2018 ESC/EACTS 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: 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). 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 www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
EACTS Public Criticism following the publication of EXCEL at 5-year follow-up • 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 ESC Guidelines on the diagnosis and management of chronic coronary syndromes www.escardio.org/guidelines (European Heart Journal 2019; 10.1093/eurheartj/ehz425)
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