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O USIC na Lesão de Tronco de Coronária Esquerda 

X Simpósio de Intervenção Percutânea para o Clínico Belo Horizonte - MG. O USIC na Lesão de Tronco de Coronária Esquerda . J Ribamar Costa Jr. Pacientes com lesão em TCE representam um grupo heterogêneo. Syntax Trial: Serruys PW et al. N Engl J Med. 2009 Mar 5;360(10):961-72.

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O USIC na Lesão de Tronco de Coronária Esquerda 

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  1. X Simpósio de Intervenção Percutânea para o Clínico Belo Horizonte - MG O USIC na Lesão de Tronco de Coronária Esquerda  J Ribamar Costa Jr.

  2. Pacientes com lesão em TCE representam um grupo heterogêneo... Syntax Trial: Serruys PW et al. N Engl J Med. 2009 Mar 5;360(10):961-72.

  3. E mesmo no TCE, há uma diversidade de apresentações... Syntax Trial: Serruys PW et al. N Engl J Med. 2009 Mar 5;360(10):961-72.

  4. Distribuição da placa no TCE de acordo com USIC 90% das lesões acometem TCE - DA Oviedo et al. Circ Cardiovasc Interv. 2010 Apr;3(2):105-12.

  5. A importância de definir de antemão a morfologia do TCE: Kim YH et al. Am J Cardiol. 2006 Jun 1;97(11):1597-601

  6. Impacto de 1 vs. 2 stents no TCE Palmerini T. et al. Circ Cardiovasc Interv. 2008 Dec;1(3):185-92.

  7. Potenciais utilidades do USIC no TCE... • Avaliação de lesões intermediárias/ambíguas • Importância do diagnóstico preciso • Otimização das ICPs • É possível reduzir mortalidade?

  8. A Angiografia é suficiente para o diagnóstico ?De todos os seguimentos coronários, é no TCE que existe maior variabilidade na quantificação das estenoses… Fisher et al. Cathet Cardiovasc Diagn. 1982;8(6):565-75.

  9. A Angiografia é suficiente para o diagnóstico ? Quality control vs. Study group Clinical site vs. Quality control Clinical site vs. Study group Cameron et al. Circulation. 1983 Sep;68(3):484-9.

  10. Comparação ACQ vs. USIC no TCE Sano K et al, Am Heart J. 2007 Nov;154(5):983-8

  11. EX. 2

  12. 4.22mm 1.44mm %DS = 65.8% Area luminal minima = 7,0

  13. Pct. do sexo Masc., 49 a, angina aosesforçoshá 2 meses DM e HAS Lesão 20 – 30% no 1/3 proximal do TCE

  14. USIC ALM = 4,5mm2

  15. Qual a frequência do “mismatch” na prática clínica? 23% dos pacientes com FFR < 0,80 tinham DS<50% `a ACQ Hamilos et al. Circulation. 2009 Oct 13;120(15):1505-12.

  16. Qual a variabilidade inter-observador? Hamilos et al. Circulation. 2009 Oct 13;120(15):1505-12.

  17. QuandonãoIndicar a Intervençãoem LesõesAmbíguas de TCE MACE DM and ≥1 untreated vessel (DS>50%) 1.0 0.9 0.8 DM and no untreated vessels 0.7 0.6 No DM and ≥1 untreated vessel (DS>50%) 0.5 0.4 0.3 0.2 0.1 0.0 No DM and no untreated vessels 1.4 2.2 3.0 3.8 4.6 5.4 1.8 2.6 3.4 4.2 5.0 5.8 IVUS MLD (mm) N = 122 p with ambiguous lesions with 1 year FU • Critérios Ultrassonográficos: • DLM IVUS : 2,5 mm • AML IVUS : 6,0 mm2 • Preditores independentes MACE: • Diabetes • Vasos não tratados com DS >50% Abizaid et al. J Am Coll Cardiol 1999;34:707-15

  18. Valor de Corte para Detecção de isquemia em lesões de TCE FFR 1,2 p < 0.0001 1,1 r = 0.74 1,0 0,9 0,8 0,7 0,6 0,5 0 2 4 6 8 10 12 14 16 MLAIVUS Correlação entre IVUS e FFR 0,75 6,0 Jasti et al: Circ 110:2831, 2004

  19. TCE ALM 4,5mm2 x FFR <0,80 Park et al. unpublished data

  20. Potenciais utilidades do USIC no TCE... • Avaliação de lesões intermediárias/ambíguas • Otimização das ICPs

  21. CB 3,5 mm, 11 atm Stent CSA: 4.6 mm2 CB 3,5 mm, 15 atm Stent CSA: 11.7 mm2 “With an inflation pressure of 14.9±3.0 atm and a balloon-to-vessel ratio of 1.17±0.19, optimal stent expansion was achieved in 321 of the 334 patients (96%) who underwent IVUS evaluation, with these patients receiving only antiplatelet therapy after the procedure . Despite the absence of anticoagulation there were only 2 acute stent thrombosis (0.6%) and 1 subacute stent thrombosis (0.3%) at 2-month clinical follow-up” Colombo A. Circulation 1995;91:1676-1688

  22. MAIN-COMPARE Registry Stenting (BMS vs. DES) vs. CABG Revascularization for Unprotected Left MAIN Coronary Artery Stenosis: COMparison of Percutaneous Coronary Angioplasty versus Surgical REvascularization from Multi-Center Registry January, 2000 Second quarter, 2003 June, 2006 Wave I (Era of BMS) Unprotected LMCA disease BMS CABG Wave II (Era of DES) Unprotected LMCA disease DES CABG 12 major academic institutions in Korea

  23. Dos 975 pacientes incluídos nesta análise: 756 (77.5%) foram tratados guiados por USIC 219 (22.5%) foram guiados por angiografia apenas Resultados

  24. Caso-controle entre pacientes tratados com SF145 pares no grupo USIC vs. Angiografia

  25. Mortalidade total Park SJ et al. Circ Cardiovasc Interv. 2009 Jun;2(3):167-77.

  26. Óbito / IAM Park SJ et al. Circ Cardiovasc Interv. 2009 Jun;2(3):167-77.

  27. RLA Park SJ et al. Circ Cardiovasc Interv. 2009 Jun;2(3):167-77.

  28. Óbito, IAM e RLA Park SJ et al. Circ Cardiovasc Interv. 2009 Jun;2(3):167-77.

  29. Qual valor de ALM melhor prediz TLR ? Park, unpublished data

  30. Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease PRECOMBAT Trial Seung-Jung Park, MD, PhD On behalf of the PRECOMBAT Investigators Professor of Medicine, University of Ulsan College of Medicine, Heart Institute, Asan Medical Center, Seoul, Korea

  31. Patient Flow EnrolledPatients (N=1454) Randomized Cohort N=600 CABG registry N=335 PCI registry N=475 Medication registry N=44 Assigned CABG N=300 Assigned PCI N=300 1-year follow-up CABG registry N=310 PCI registry N=457 Medication registry N=41 Treated CABG N=248 Treated PCI N=51 Treated medical N=1 Treated CABG N=24 Treated PCI N=276 Treated medical N=0 2-year follow-up CABG registry N=259 PCI registry N=289 Medication registry N=39 1-year follow-up N=296 1-year follow-up N=298 2-year follow-up N=266 2-year F/U N=270

  32. Study Procedures Sirolimus-eluting Cypher stent for all lesions Strong recommendation of IVUS-guidance Other adjunctive devices at the operator’s discretion Use of LIMA to LAD anastomosis Off- or on-pump surgery at the operator’s discretion Dual antiplatelet therapy at least for 6 months after PCI Standard medical treatment after PCI and CABG

  33. Procedural Characteristics PCI (N=300) CABG (N=300)

  34. Primary End Point of MACCE PCI CABG Non-inferiority p= 0.001 12.2 8.7 8.1 6.7 p=0.39 p=0.12

  35. Death, MI or Stroke PCI CABG p=0.83 p=0.66 4.7 4.0 4.4 3.3

  36. Ischemia-Driven TVR PCI CABG p=0.13 p=0.022

  37. Symptomatic Graft Occlusion & Stent Thrombosis to 2 Years PCI (n=300) CABG (n=300) P=0.18 Patients (%) 1.4% 0.3% PCI CABG Post-procedure; ITT population

  38. Subgroup Analysis

  39. MATRIX RegistryStudy Design Study Objective: Investigate the impact of IVUS-guided vs. angiography-only-guided PCI with Cypher™ Sirolimus-Eluting Stents (SES) in the 1,500-patient MATRIX registry Study Design: Prospective, open label, non-randomized, real world registry Primary Endpoint: TVF at 2 years (Cardiac Death, MI and clinically driven TVR) Number of Patients: 1504 consecutive PCI patients receiving a Cypher Stent Study Centers: Lenox Hill Hospital and Columbia University Medical Center Enrollment Period: 2004-2006 Presented By: Bimmer Claessen, MD, TCT 2010 Presented by Bimmer Claessen, MD at TCT 2010. See Glossary.

  40. MATRIX RegistryBaseline Differences And Procedural Characteristics Presented by Bimmer Claessen, MD at TCT 2010. See Glossary.

  41. MATRIX Registry2-year Clinical Results P=0.053 P<0.01 P=0.32 P<0.01 P=0.31 P=0.16 Presented by Bimmer Claessen, MD at TCT 2010. See Glossary.

  42. MATRIX RegistryPredictors of Events:Multivariate Analysis IVUS Use is a Significant Predictor of Reduced 2-Year Death/MI Presented by Bimmer Claessen, MD at TCT 2010. See Glossary.

  43. Considerações Finais • A elevada discordância entre angiografia e USIC / FFR, sugere que em casos de lesão isolada de TCE, outra avaliação seja feita antes de indicar procedimento de revascularização • O USIC é fundamental para compreender a extensão da doença no TCE e confirmar / descartar envolvimento da DA / CX,evitando estratégias mais complexas de tratamento. • Estudos não-randomizados sugerem benefício do implante de stent no TCE guiado por stent. Entretanto, na falta de evidência mais robusta, serve apenas como recomendação

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