Do método diagnóstico ao terapêutico: a História da Hemodinâmica e da Cardiologia Intervencionista, em 15 minutos. Eulógio E Martinez

Transcription

1 Do método diagnóstico ao terapêutico: a História da Hemodinâmica e da Cardiologia Intervencionista, em 15 minutos Eulógio E Martinez

2 IVUS vs luminologia Positivo Negativo

3 estenose TCE oclusão CD sístole diástole

4 Sep DA oclusão colat CD CD

5 estenose PVS CD

6 DA Trombo

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8 Sep DA oclusão corda-guia cateterbalão DA Sep

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10 Coronary Stenosis Severity Prior to MI 100% 100% 80% 80% 60% 60% 40% 40% 20% 20% 0% Ambrose 1988 Little 1988 Nobuyoshi 1991 Giroud % <50% 50-70% >70% All Four Studies Falk E, et al. Circulation 1995;92:

11 % Occlusion at 5 Year Coronary Occlusion at 5 Years as a Function of Stenosis Severity None 0-49% 50-80% 81-95% Stenosis Severity at Baseline Alderman et al. JACC 1993

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13 Síndromes Coronárias Agudas sem Supra de ST Fisiopatologia da Lesão Trombótica Trombo em a. coronária direita em portador de angina instável

14 Fluxo TIMI e Reperfusão TIMI 3 p = 0,04 TIMI n = 455p Mort. 3,5% n = 294p Mort. 6,8% TMP 3 p = 0,008 TMP TMP 3 TMP n = 137p Mort: 0,7% n = 318p Mort: 4,7% n = 64p Mort.: 4,7% n = 230p Mort.: 7,4% Gibson - TIMI Group - Circ jan 2000

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16 A string sign in the left internal thoracic artery (LITA) because of competitive flow. The LITA had been previously anastomosed to a large (2.5 mm) left anterior descending artery that had a diameter stenosis of 40%.

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20 Contribuições da cinecoronariografia Obstruções coronárias in vivo História natural: tronco, 1, 2 e 3 vasos Espasmo coronário Circulação colateral Disfunção segmentar de VE Oclusões nas SIA Ineficácia- Vineberg Eficácia- pontes Trombo e infarto Lise espontânea : Δt vs prognóstico Reperfusão- blush SIA- placas pouco obstrutivas String-endotélio Compressão de TCE

21 Ôde à Cinecoronariografia Cinquentenário 1958 a 2008 Eulógio E Martinez

22 Luminologia Lumen de lumine The light of lights LUZ DAS LUZES Thomas J Ryan (2002)

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27 QCA restenosis- ANIST stenosis >= 50% - 38/141 = 27% stenosis >= 50 < 70% - 27/141 = 19% stenosis >= 70% - 11/141= 8%

28 EuroIntervention 2006;6: European Heart Journal 2002;4:26

29 QCA reestenose - MPS estenose >= 50% - 19/48 (39,6% ) estenose >= 50 < 70% - 13/48 (27%) estenose >= 70% - 6/48 (12,5% )

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31 Percent Diameter Stenosis PERCENT DIAMETER STENOSIS IN SEQUENTIAL ANGIOGRAMS , ,0 14,0 36,0 13,0 40 P=0,0001 P=0, ,0 5,0 P=0, Pre Post 6 mo 12 mo Angiograms

32 Late Gain CORRELATION BETWEEN LATE GAIN AND LOSS INDEX AT 6 MO 1,8 1,6 r= 0,5348 p< 0,001 1,4 1,2 1,0 0,8 0,6 0 0,2 0,4 0,6 0,8 1,0 1,2 Loss index at 6 mo

33 REGRESSION OF INTIMAL HYPERPLASIA from 6 to 12 MONTHS AFTER STENT IMPLANTATION Volumes mm³ NS 6 Months Stent AST Lume=2,5 mm² 6 months 1 year DLM=1,6 mm 300 <0,001 Lumen months AST Hiperplasia Intimal =5,1 mm² AST Lume=4,7 mm² 6 months 1 year 150 P=0,001 Neo-intima DLM=2,7 mm AST Hiperplasia Intimal =3,0 mm² 6 months 1 year Kuroda et al. Am J Cardiol 2002; 89:869

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35 Binary Restenosis Drug-Eluting Stent Trials 36,3% 26% 27% 21% 23,8% 8,9% 0% 0% 11% 4% 3% 5,5% 8,6% SIRIUS RAVEL TAXUS- I ASPECT (Hi) ELUTES (Hi) TAXUS II SIROLIMUS PACLITAXEL Drug eluting stent Taxol MR Taxol SR Control

36 PCI Database InCor (n=9088) vs. DES randomized trials Recent Acute MI. Very small vessels (RD < 2.0 mm) Total occlusion Ostial lesions. Multivessel stenting.. Saphenous grafts.. Age > 80 years Main stem. Dialysis.. InCor 30% 23% 22% 18% 17% 7% 7% 2% 1% DES trials 0% 0% 0% 0% 0% 0% 0% 0% 0% At least 68% of our patients would not have been included in DES trials conducted to date.

37 Study Design Post SES Pre SES -Total number of patients: Patients with de novo lesions treated solely with SES:. 508 (64%) -Total number of patients: Patients with de novo lesions treated with bare stents: (82%)

38 Cumulative proportion at risk (%) Cumulative incidence of clinically driven TVR* Hazard ratio 0.36 (95% CI ); p< Pre-SES 10.9 % SES 4.1 % Days 64 % risk reduction *re-intervention of a significant stenosis (>50% DS) in the presence of angina and/or myocardial ischemia

39 Odds Ratio for TLR by Subgroup at 9 mo. (Integrated SES trials; n=2074) Overall Male Female Diabetes No Diabetes LAD Non LAD Small Vessel (<3mm) Large Vessel ( 3mm) Long Lesion (>13.5mm) Short Lesion( 13.5mm) Overlap No Overlap Prior MI No Prior MI Elderly (>75yrs) NonElderly ( 75yrs) Sirolimus Odds Ratio 95% CI Control Month Single-digit MACE 0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1 1,1 # Events Prevented Per 1,000 Patients P-Values < < < < < < < < < < < < < < < < SOURCE: Integrated analysis of SIRIUS, New SIRIUS, DIRECT, SVELTE, RAVEL Trials.

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41 % Baseline Clopidogrel Resistance and Increased Risk of Ischemic Events % N = 60 Prim PCI for STEMI mM ADP Induced Plt Agg Clop Resist Quartiles of Response Q1 Q2 Q3 Q Days Death/ACS/CVA by 6 m 40 P= Q1 Q2 Q3 Q4 Matetzky et al. Circ 109: Wiviott + Antman Circ 109: 3064,2004

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