Imagen y análisis funcional intracoronarios

1. Imagen y análisis funcional intracoronarios
Javier Escaned MD PhD
Hospital Clínico San Carlos
Madrid

2. 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

3. Recommendations for the clinical value of
intracoronary diagnostic techniques
ESC CPGs on Myocardial Revascularization
Windecker S et al. Eur Heart J 2014

4. Recommendations for the clinical value of
intracoronary diagnostic techniques
ESC 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

5. 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

6. 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

7. 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

8. Supplementary data of FAME II study
Stratified analysis of the primary endpoint
PCI better Medical Tx better

9. Post PCI FFR and long-term outcome
Johnson N et al. JACC. 2014;64(16):1641-1654

10. 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.

11. Reclassification of treatment with FFR
interrogation of all stentable vessels (RIPCORD)
Curzen N et al . Circ Cardiovasc Interv. 2014

12. 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

13. 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

14. Diagnosis efficiency of hybrid iFR/FFR approach
(ADVISE II)
Escaned J et al JACC C Intvn 2015

15. Diagnosis efficiency of Pd/Pa
(An ADVISE II post hoc analysis)
Echavarría-Pinto M J et al JACC C Intvn 2015

16. 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

17. Can contrast injection better approximate FFR compared
to pure resting physiology? (CONTRAST)
contrast = 85.5% accuracy
iFR = 79.6% accuracy
Pd/Pa = 78.4% accuracy
superior accuracy (p<0.001)
Optimal binary cutoff for contrast Pd/Pa ≤0.83
Johnson N et al EuroPCR 2015

18. Co-registration of angiography with
intracoronary imaging
Cases performed at Hospital Clinico San Carlos / Madrid

19. 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

20. 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%)

21. FFR 0.58
Intracoronary FFR mapping during i.v. adenosine
Case performed at Hospital Clinico San Carlos / Madrid

22. Adenosine-free iFR pressure mapping
DES 2.25 x 15
Pre
Post
Case performed at Hospital Clinico San Carlos / Madrid

23. Nijjer S et al. JACC Cardiol Intv. 2014
iFR coronary mapping and virtual PCI simulations
Pre
PCI
Post
PCI

24. Nijjer S et al. JACC Cardiol Intv. 2014
iFR coronary mapping and virtual PCI simulations

25. CABG
+
follow up
with MSCT
Influence of pressure pullback derived patterns of
diffuse disease on IMA-CABG outcome
Shiono Y et al EuroPCR 2015

26. 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

27. 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

28. 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.

29. MACE(primaryendpoint)
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

30. Modification of thrombus burden by aspiration in the
TOTAL trial assessed with OCT
Bhindi et al Eur Heart J 2015

31. 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

32. 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

33. Q
R
P
s
ao
P
d
R
d>100μm
R
cap
R
d<100μm
Rmicro
Pzf
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

34. Q
R
P
s
ao
P
d
R
d>100μm
R
cap
R
d<100μm
Rmicro
Pzf
Neurohumoral
Endothelial (flow)
Metabolic
IHDVPS-Pzf
WIAMVO pattern in MRI
after STEMI
Exploring the culprit vessel of STEMI

35. 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

36. 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

37. 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

38. PREDICT-MVI: role of microcirculatory compression (zero
flow pressure, Pzf)
Teunissen PF et al Circulation C Intv 2015

39. From an strictly personal point if view:
which was the publication in 2015 that has
influenced me most?

40. 50 chapters and more than 30 clinical cases
Available at the PCR Bookshop at prconline.com
Coronary Stenosis: Imaging, Structure and Physiology
Javier Escaned and Patrick Serruys, editors

41. Muchas gracias por su atención