Le futur de la Cardiologie Interventionnelle William Wijns MD PhD - - PowerPoint PPT Presentation

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Le futur de la Cardiologie Interventionnelle William Wijns MD PhD - - PowerPoint PPT Presentation

Jun 19, 2023 30 likes •404 views

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

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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 TECH Marseille

Relations of Interest Disclosure

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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

2020-01-29_HIGH TECH Marseille

Le futur de la Cardiologie Interventionnelle

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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

SCIENTIFIC ADVANCES & CARDIOVASCULAR MORTALITY

Nabel and Braunwald. N Engl J Med 2012;366:54-63 1958 Coronary arteriography developed (Sones) 1977 Coronary angioplasty developed (Grüntzig) 1993 Superiority of primary PCI vs. fibrinolysis in acute MI noted 2002 Efficacy of drug-eluting

  • vs. bare-

metal stents determined 1967 First description

  • f CABG

(Favaloro)

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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

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

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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

Primary endpoint

  • No. at risk

Medical therapy 1344 1222 688 559 381 301 FFR-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 2

NCT01132495

DANAMI-3-PRIMULTI

NCT01960933 I

Compare-Acute

NCT01399736

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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

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)

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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

.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

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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

No TAVI No TAVI

Surgical Risk # Patients

TAVI Surgery

TA TF

A.P. Kappetein, EuroPCR, AYNTK

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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

2019

PARTNER 3 Evolut LOW RISK

Low

>/=

CLINICAL EVIDENCE ACROSS RISK CATEGORIES CLINICAL EVIDENCE ACROSS RISK CATEGORIES

2017

PARTNER 2A SURTAVI NOTION I

2016 2011

PARTNER 1A

2014

CoreValve HR

2012

PARTNER 1B

2014

CoreValve ER

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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

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

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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

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 patient with CAD

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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

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

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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

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

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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

  • 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

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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 www.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

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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

The future of Interventional Cardiology / Medicine Diagnosis and Treatment of Cardiovascular Diseases

Best of Medical Care Lifestyle Diet Pharmacology Coronary, Valvular, Structural & Peripheral Interventions CABG Valve surgery

Incremental improvement in Best of Care On behalf of Heart Team 2.0 « By and For » the individual patient

Blue Ocean Strategy

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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

10.7% 11.2%

Days 334 313 295 289 279 277 268 454 442 433 422 407 399 391

15.1% 13.2%

HR 0.93 (95% CI 0.60-1.43) p=0.73 P <0.001 for non-inferiority*

HR 0.85 (95% CI 0.58-1.25) p=0.42

SYNTAX I CABG SYNTAX II PCI

Patients (%) SYNTAX I CABG SYNTAX II PCI up to 2 years

Exploratory endpoint MACCE PCI vs CABG for 3 vessel disease

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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 PCI in patients with de novo 3 VD

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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

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Adoption of Interventional Procedures Adoption of Interventional Procedures

PROM

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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

From S.W. Windecker

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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

21

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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

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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

MSCT Assessment

3D - 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 (?)

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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

Left Main / LAD

Segment 7 = 5 points Segment 7 >20 mm = 6 points

2nd Dg 1st Dg

Multiplanar Reconstruction (MPR)

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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

Engaging the new era of Coronary Computed Tomography - facilitated PCI

Access: femoral-radial Aorta ascendens / descendens Coronary arteries Ostia Aberrant arteries Dominance, vessel length Coronary calcification Coronary physiology (CT-FFR) Vessel size, diameter, tortuosity Plaque severity and remodelling Plaque composition Collateral flow CTO: length of occlusion, degree of calcification Risk assessment / stratification by calculation of scores Procedure planning stent size, length and diameter impact on FFR Best views for imaging/procedure Reduced procedure duration, radiation and use of contrast

Think of changes in training, capacity and care delivery !

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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

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
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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

  • 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

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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

  • 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 ?

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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

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

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  • 1. Computing power
  • 2. Data analytics
  • 3. Artificial intelligence
  • 4. Electroceuticals (electrons as a drug)
  • 5. Communication technology (sensors)
  • 6. Power (batteries)
  • 7. Gene sequencing (responders vs non)
  • 8. 3D-printing
  • 9. New materials (cell protection)
  • 10. Social networks
  • 11. Robotics

What does the future hold ? Areas of Strategic Investment Horizon 2025

  • S. Oesterlee, Dublin 2016
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The synchrony of imaging and catheter movement … practice, plan and perfect…

No lead, no radiation & less X-rays and contrast for patients …

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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

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 patients patients

  • Prevent episodes of

Prevent episodes of hypoglycemia in hypoglycemia in diabetic patients diabetic patients

  • Decrease ER visits

Decrease ER visits for childhood asthma for childhood asthma exacerbations exacerbations

PJ Fitzgerald@EuroPCR 2016

Value and limitations of connected health

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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

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)
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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

IBM Watson

  • A. Grosse, Cognitive Health Leader Europe

MedTech 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

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Symposium en l’honneur du Professeur Legrand

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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

The 10 Commandments of Graeme Codrington

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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

The 10 Commandments of Graeme Codrington 1. Switch on your radar 2. Be curious and ask better questions 3. Change where you look for information 4. Why are we doing it this way? 5. Experience more, but wisely 6. Embrace different opinions 7. Look East 8. Learn from your mistakes, and from the mistakes of others 9. Confront your limiting orthodoxies

  • 10. Learn, unlearn, and relearn