Hémodynamie et insuffisance cardiaque: Approche diagnostique et thérapeutique E. Marc Jolicoeur MD MSc MHS FCRP-C FACC marc.jolicoeur@icm-mhi.org
Déclaration de conflits d intérêts Marc Jolicoeur déclare les intérêts suivants: 1. Comité aviseur: Eli Lilly Astra Zeneca 2. Bourse de recherche Astra Zeneca 3. Contrat de recherche Neovasc Inc.
Résistance pulmonaire Cathéterisme D HÉMODYNAMIE Transeptal CMP-H Détection de shunt p-vad Thérapie cellulaire Ablation ROH Revascularisation extrême Réparation mitrale
Taux de croisement = 26%
N Engl J Med 2011;364:1617-25.
Occlusions totale chronique Artère occluse> 3 months Prévalence: - 1/3 des patients référées pour PCI - 46% amenable à une intervention (technique + viabilité) CTO coronaire D Stone et al. Circulation 2005;112:2364
Bénéfices de PCI-CTO Possible effet sur: 1. Diminution angine 1 2. Amélioration FEVG 2-3 3. besoins en pontages 4 Bénéfices sur mortalité et autres points d aboutissment plus robustes sont controversés 1. Olivari, JACC 2003;41:1672 2. Dzavik, AHJ 2001;142:301 3. Sirnes, EHJ 1998;19:273 4. Aziz, CCI 2007;70:15
CTO et mortalité OR = 0.56 [0.43 to 0.72] All-cause mortality Joyal et al, AHJ 2010
Contemporary CTO PCIs studies Study Survival benefit Multivariable analyses Significant limitations Validated results Noguchi, 2000 N = 226 Yes - No Suero, 2001 N = 2,007 Yes 10% stents No TOAST-GISE 2003 N= 390 Yes Total of 6 deaths No Hoye, 2005 N = 874 Yes Drozd, 2006 N = 459 No Prasad, 2007 N = 1,262 No Not adjusted for non-cto PCIs or adjunct medication Follow up limited to patients discharged w/o major complication LVEF and renal function missing > 35 %, not adjusted for non-cto PCI Aziz, 2007 N = 543 Yes 20 candidate predictors for 19 deaths No De Labriole, 2008 N =172 No Patients free of procedural complication included in the analysis Valenti, 2008 N = 486 Yes Demonstration of viable myocardium No Safley, 2008 N = 2608 Yes Survival not adjusted for creatinine clearance, LVEF, Ht, and medication No No No No No
Research question In patients with documented myocardial ischemia & viability, is a successful CTO percutaneous recanalization associated with a clinical benefit in comparison to a failed CTO intervention? Main hypothesis After adjusting for key clinical variables, + the referral bias, + anatomic predictors of failure +concomitant non-cto PCI, a successful CTO intervention will be associated with a favourable cardiovascular outcomes Catheterization and Cardiovascular Interventions 79:603 612 (2012)
Model 3. Additional Analyses Models Successful CTO PCI HR [95% CI] Unadjusted analysis 0.85 [0.61 to 1.18] Multivariable analyses: 1. Clinical predictors of adverse events 0.90 (0.64 to 1.25) 2. Clinical predictors of adverse events + propensity of attempting a CTO recanalization 0.94 [0.67 to 1.33] 3. Clinical predictors of adverse events + propensity of attempting a CTO recanalization + propensity of procedural failure 0.97 [0.46 to 1.12] 4. Clinical predictors of adverse events + propensity of attempting CTO recanalization + change in Duke Index from the non-cto PCI 0.95 (0.68 to 1.35)
Research question In patients with documented myocardial ischemia & viability, is a successful CTO percutaneous recanalization associated with a clinical benefit in comparison to a failed CTO intervention? Main hypothesis After adjusting for key clinical variables, + the referral bias, + anatomic predictors of failure +concomitant non-cto PCI, a successful CTO intervention will be associated with a favourable cardiovascular outcomes Catheterization and Cardiovascular Interventions 79:603 612 (2012)
Chirurgie Beck I : Mount Sinai Hospital, Cleveland, Ohio Réduction de mortalité de 43% Réduction taille infarctus de 60%
Reducer (TM) - Neoavasc Prothèse implantée dans le sinus coronaire JACC 2007;49:1783 Engendre une réduction de la lumière du sinus coronaire pour moduler le flux et la pression sinusale L élévation de la pression sinusale augmente la perfusion sousendocardique pour amoindrir l ischémie et l angine
Effect on Defect Size Defect size - 20cm 2 Defect size 11cm 2 Pre-Reducer Implantation Post-Reducer Implantation (6 Months)
Choc cardiogénique Historiquement:
BIAo = recommandation de grade 1 NEJM 2012
(RECOVER II): Trial Using Impella LP 2.5 System in Patients With Acute Myocardial Infarction Induced Hemodynamic Instability: Arrêt prématuré
Assistance VG percutanée Système BIAo Impella 2.5 Tandem Heart Impella 5.0 ECMO Débit 0.5 L/min 2.5 L/min 4.5 L/min 5.0L/min 10.0L/min Contrindications IAo AAA Dissection MVAS coagulapathie Thrombus VG MVAS Prothèse Ao Sténose Ao CMP-H CIV Thrombus VG coagulapathie MVAS Thrombus VG MVAS Prothèse Ao Sténose Ao CMP-H CIV Neuropathie contreindication anticoagulation Facilité d insertion + (7.5F) ++ (13F) ++++ (17F) +++ (17F) ++ (18F) Support VG + ++ +++ +++ ++++ Support VD NON NON Possible NON ++ Hémolyse NON +++ ++ ++ + PLT ++ + + + ++ Durée max (Jours) 90 30 10 30 60 Impella cvad 4.0L/min
Défaillanced roite Défaillance gauche Défaillance D+G ARDS ECMO AV TandemHeart D Impella RP Impella 5.0 ECMO-AV TandemHeart Impella cvad ECMO-AV TandemHeart Double* Impella Double* ECMO-AV
Impella RP Impella cvad Performance accrue avec débit de pointe > 3.5 L/min (ad 4) Cathéter 9Fr / Pompe 14 Fr
Impella RP Anticoagulation Systémique + Accès veineux simple introducteur 22F catheter de 11F
SVP décrire
Mitraclip Permet la coaptation des feuillets Dégénérative Ancre les feuillets avec prolapse Fonctionnel Coapte les feuillets et réduit le temps requis pour la fermeture de la valve Réduit la surcharge en volume du VG Forme un pont tissulaire Limite la dilatation de l anneau Rapproche les parois du VG Limite la dilatation du VG Porcine model, 6M
Mitraclip: éligibilité dans EVEREST II En La cas surface régurgiation de prolapse de coaptation doit d un être feuillet, centrée doit être le au GAP au niveau moins et la largeur de 2mm doivent zone de être coaptation < 10 et entre 15 + mm, festons respetivement A2 et P2 Et (2/3 à moins centraux de 11mm de la ligne du plan de coaptation) de l anneau JACC Vol. 56, No. 8, 2010
EVEREST II RM 3+ ou 4+ Symptomatique: FEVG > 25% VTSVG < 55mm Asymptomatique VTSVD entre 40 et 60mm HTAP ou FA
EVEREST II RCT: Primary Endpoints Per Protocol Cohort Safety Major Adverse Events 30 days Décès + Effectiveness Redo + RM > 2 Clinical Success Rate * 12 months Device Group, n=136 9.6% Device Group, n=134 72.4% Control Group, n=79 p SUP <0.0001 p NI =0.0012 Control Group, n=74 57.0% 87.8% 0 20 40 60 Met superiority hypothesis Pre-specified margin = 6% Observed difference = 47.4% 97.5% LCB = 34.4% LCB = lower confidence bound UCB = upper confidence bound 0 20 40 60 80 100 Met non-inferiority hypothesis Pre-specified margin = 31% Observed difference = 15.4% 95% UCB = 25.4% * Freedom from the combined outcome of death, MV surgery or re-operation for MV dysfunction, MR >2+ at 12 months Investigational device limited by Federal (U.S.) law to investigational use only. PML02827 Rev. A 03/2010 18
Régistre MitraClip : Patients haut risque MitraClip peut réduire la RM Fonctionnelle, n=34 Dégénérative, n=20 00% 80% 18% 21% 100% 80% 20% 25% 60% 97% 82% 79% 60% 100% 80% 75% 40% 40% 20% 20% 0% Baseline 30 day 12 month Grade 1+/ 2+ Grade 3+/ 4+ EVEREST II High Risk Registry Data Kar, S., EuroPCR 2009 Symposium Presentation 0% 12 month Matched data Baseline 30 day 12 month Grade 1+ = Mild MR Grade 2+ = Moderate MR Grade 3+ = Moderate - Severe MR Grade 4+ = Severe MR
Percent Patients Percent Patients Haut rique: NYHA Amélioration symptomatique marquée FMR, n=34 DMR, n=20 100 80 60 40 20 0 12 8 8 100 4 2 5 80 19 18 13 60 40 3 8 12 20 0 Baseline 30 days 12 months 13 12 9 3 6 6 Baseline 30 days 12 months EVEREST II High Risk Registry Data Kar, S., EuroPCR 2009 Symposium Presentation NYHA I NYHA II NYHA III NYHA IV 12 month Matched data
Freedom from Death Régistre MitraClip : Mortalité 1.0 MitraClip Therapy vs. High Risk Control 0.8 HRR 76.4% P=0.037 0.6 0.4 30 jours: mortalité identique au traitement standard HRR Control 55.3% 0.2 0.0 Impl 30d 6m 12m At Risk High Risk (n) 78 72 65 53 Control (n) 36 34 27 22 EVEREST II High Risk Registry Data Kar, S., EuroPCR 2009 Symposium Presentation
JACC Vol. 56, No. 8, 2010
53 patients avec IVG + RM fonctionnelle - 36 implantés - 17 échecs (contrôles) succes = 67% Carillon MACE 30 jours = 1.9% European Journal of Heart Failure Advance Access published May 21, 2012
Attention étude sans insu