Do Método Diagnóstico ao Terapêutico: A História da Hemodinâmica e da Cardiologia Intervencionista.

Transcrição

1 Curso Anual de Revisão em Hemodinâmica e Cardiologia Intervencionista 28 e 29 de Outubro de 2011 Do Método Diagnóstico ao Terapêutico: A História da Hemodinâmica e da Cardiologia Intervencionista. Costantino R. Costantini, M.D., Ph.D., F.A.C.C. Hospital Cardiológico Costantini Fundação Francisco Costantini Curitiba - Brasil

2 Curso Anual de Revisão em Hemodinâmica e Cardiologia Intervencionista 28 e 29 de Outubro de 2011 Potencial Conflitos de Interesse: x Centro de Ensino de Ultrassom Intracoronario ( 2008 ) Patrocinado pela Boston Scientific, sem Honorários Médicos. Doação para Fundação Francisco Costantini Costantino R. Costantini, M.D., Ph.D., F.A.C.C. Hospital Cardiológico Costantini Fundação Francisco Costantini Curitiba - Brasil

3 Cine frame from the first selective coronary arteriogram taken by F. Mason Sones, MD, on October 30, Ryan T J Circulation 2002;106:

4 Evolução do Intervencionismo 1844 Bernard coins the term cardiac catheterization 1958 Sones discovers the diagnostic coronary angiogram 1964 Dotter introduces transluminal angioplasty 1977 Gruentzig peforms the 1 st PTCA st coronary stent approved by the FDA Today Increasing realworld use of PCI in 3VD and LM, FFR FDA approval of 1 st DES 1929 Forssmann peforms the 1 st human cardiac catheterization 1962 Ricketts and Abrams use the percutaneous approach in coronary arteries 1967 Judkins perfects the transfemoral approach 1986 Sigwart and Puel implant the 1 st coronary stent CE Mark on 1 st Cribier Aortic Valve DES Feldman Mitral Valve 2012?????

5 Evolução do Intervencionismo

6 Cardiologists and Intervencionists We Have an Important Mission: To improve our patients life quality... For that we neeed: o Profissionals with competency o High judgment level o High improvement level o And Mainly... Honesty... Frans van Mieris, 1657 Kunsthistorisches Museum, Viena J.L. Pomar, (TEAM 2010)

7 Indicacão de Coronariografia 10 INDICACOES: N* 9 SINDROME INTERMEDIARIA Prof. Luiz V. Decourt 1970

8 ACUTE MYOCARDIO INFARCTION MACRUZ et al. ARQ.BRAS.CARD FAVALORO et al. AM J CARDIOL 1972 GALEANO et al. ARQ. BRAS. CARD 1973 RENTROP et al CLIN. CARD MEYER et al. CIRCULATION 1982 HARTZLER et al. AM J CARDIOL 1983

9 R. Macruz Foram operados quatro pacientes com enfarte agudo do miocárdio, após cinecoronariografia para localização exata das obstruções arteriais. A cirurgia efetuada foi a de colocação de uma ponte de safena da aorta na artéria coronária, descendente anterior (casos 1 e 3) e da aorta na coronária direita (casos 2 e 4). A evolução clínica pósoperatória foi comparada à de uma cirurgia cardíaca habitual. As arritmias existentes desapareceram tão logo se abriu o by-pass de safena. A evolução eletrocardiográfica mostrou diminuição da corrente de lesão e a onda de isquemia. Pacientes seguidos até 60 dias após o ato cirúrgico demonstraram as boas evoluções clínicas iniciais. Esta cirurgia abre, sem dúvida, novo campo com melhores perspectivas para o tratamento do enfarte agudo do miocárdio.

10 Galiano, N et al Arq. Bras. Cardiol. 1972; 25:197

11 History Coronary Angioplasty 1977 and 2000, first cath lab PTCA of World Andreas Gruentzig (1977) (2000) N Engl J Med 1979;301:61 8 N Engl J Med, Vol. 344, No. 2 January 11, 2001

12 History Coronary Angioplasty (2011) 1979 and 2010, first PTCA of Latin America (1979) (2010) Costantini, C. et al Arq Bras Cardiol.1980;34(4):

13 CONCEPTS & TECHNOLOGY GRUNTZIG PALMAZ SCHATZ SOUSA 30~50% 15~30% Restenosis BALLOON BARE STENT DES?~? %

14 Hoje... Diagnóstico Hoje... Terapêutico Angiografia de Ultima Geracao Angiografia de Ultima Geracao Experiência da Equipe (Clínicos e Hemod) Metódos Adjuntos IVUS Histologia Virtual FFR Experiência da Equipe (Hemodinamicistas e Clin.) Honest. do Operador (Indicação, Escolha do Pac.) Metódos Adjuntos IVUS, OCT FFR Stent BOOST

15 Significant Reduction of TLR with DES Clinical Studies Raizner 1988 Schwartz 1988 ELLIS 1989 M-heart 1990 Franzen 1990 Knudtson 1990 Ccat 1993 Caveat 1993 Benestent 1993 Stress 1994 M-heart II 1994 Weintraub 1994 Marcator 1995 Boat 1996 Benestent II 1996 FIM 2001 Ravel 2002 Sirius 2002 Taxus II 2002 E-Sirius 2002 C-Sirius 2002 Elutes 2002 Aspect 2003 Taxus IV 2003 Reality SES 2005 Reality PES 2005 Isar-d SES 2005 Isar-d PES 2005 Sirtax SES 2005 Sirtax PES 2005 Taxus VI 2005 Taxus V 2005 BMS DES Caixeta SBHCI 2004, Adapted by Costantino Costantini SBHCI 2009

16 1995 SUB ACUTE THROMBOSIS IN THE REAL WORLD 10-25% IVUS AFTER LOW PRESSURE 80% STENTS UNDER EXPANDED HIGH PRESSURE AAS + TICLOPIDINE Dr Antonio Colombo SUBACUTE THROMBOSIS 0.8% VASCULAR COMPLICATIONS Colombo Circ. 95:91:1076

17 Diagnóstico Tratamento!!! Angiografia Stent BOOST IVUS FFR Imap OCT Imagens Hospital Costantini

18 Diagnóstico Confiável???????

19 Problems to Diagnose... Quality and Image Interpretation Angiogram from the Hospital Where Pt Was Admited 2006 Inferior AMI in another Hospital ARA - 64 Yrs 13Mar06

20 Problems to Diagnose... Quality and Image Interpretation ARA - 64 Yrs 13Mar06 Angiogram from the Hospital Where Pt Was Admited Liberté 3.5/20 Final Result

21 Medical Appointment With the Cardiovascular Surgeon... Receita do Cirurgião

22 ARA - 64 Yrs Mar mm² LVEF = 74 % ANGIOGRAPHIC ASSESSMENT 10 DAYS AFTER INFERIOR AMI IN OUR HOSPITAL mm 9.79 mm RCA 5.89 mm

23 ARA - 64 Yrs Mar mm² No lesion in LAD Normal Perfusion 5 years FU... LMT LCX DG LAD

24 The ESC congress September 2-6, 2006 INTELIGENCIA PARA ENTENDER DESLIZES Camenzind E. 38% p= % 16% p=0.66 TAXUS Stent Cypher Stent BMS Controls 3.9% Incidence of death or Q-Wave MI Randomised trials up to latest available follow up

25 J Am Coll Cardiol 2007;50: The 4-Year Follow-Up Trials of SES Versus BMS and PES Versus BMS S I R O L I M U S

26 11.14mm² 3.5/18 18/01/01 0,79mm² 11.33mm² RAVEL 7 yrs & 7 months 13.44mm² JAB - 58Yrs Ago08

27 JPG - 59 yrs Mar03 Hypertesion Hyperlipidemia LifeStyle Stress Assynptomatic with Positive Treadmill Test First Experience With Taxus Hospital Costantini March 2003 CABG Jan 1999 LIMA > DA Ok SVG > LCx Ok SVG > RCA Ø MLA=2.85 mm² Taxus 3.0 * 24 MLA=8.50 mm² MLA=3.25 mm² Taxus 3.0 * 16 MLA=7.22 mm² PRE POST

28 First Experience With Taxus Hospital Costantini March 2003 Jun yrs) JPG - 66 yrs Jun11 MLA=8.17 mm² (2011) F/U After 8 Yrs MLA=6.22 mm²

29 As DES Use Increased, PCI Use Increased among Patients with Class I CABG Indications Frutkin, A. D. et al. J Am Coll Cardiol Intv 2009;2:

30 DES Generations 1st Generation Cypher - Taxus a) Thin struts, thin permanent polymer 2nd Generation b) Bioabsorbable polymer c) No polymer 3nd Generation Bioresorbable 4nd Generation???????????????????????

31 BMS Platform Filament DES Platform DES Platform and Filament 1 st Generation 2 nd Generation 3 rd Generation Cypher Stent TAXUS Express Stent Endeavor Stent XIENCE V Stent TAXUS Liberté Stent XIENCE Prime Stent Element Stent Series Bx Velocity Stent mm ( ) Stainless Steel Express Stent mm ( ) Stainless Steel Driver Stent mm ( ) Cobalt Chromium Multi-Link Vision Stent mm ( ) Cobalt Chromium Liberté Stent mm ( ) Stainless Steel XIENCE Prime Stent mm ( ) Cobalt Chromium Element Ste nt mm ( ) Platinum Chromium

32 Average Stent Profile PROMUS Element Stent TAXUS Element Stent TAXUS Liberté Stent XIENCE V / PROMUS Stent XIENCE Prime Stent Endeavor Resolute Stent Cypher Select PlusStent mm mm mm mm mm mm mm

33 Long Term Evidence in an All-Comers Population LEADERS 1, 2, 3-yrs Clinical Results Serruys P. TCT 2010

34 NEVO RES-I: 12-months MACE and Components (NEVO vs TAXUS) Deslize???? 12-MONTH MACE AND COMPONENTS % of Patients P =0.14 NEVO Taxus Liberté NEVO TAXUS Liberté Only 25% With IVUS Post Stents two groups P=NS for all endpoints P=NS for all endpoints 12/196 20/186 1/196 4/186 4/196 6/186 5/196 10/186 7/196 11/186 MACE Death MI Death or MI TLR No reports of death or MI between 6 and 12 months in NEVO arm NEVO RES-I was not powered for clinical endpoints MACE=Major adverse cardiac events. Abizaid A., et al., EuroPCR 2010; Oral Presentation.

35 Real-world experience with TAXUS Liberté: One-year results from the 22,000 patient OLYMPIA global post-approval registry. Eric Eeckhout presentation oral ESC Congress 2008 TAXUS Liberté Stent - Related Incidence (%) Cardiac Events n= 450 n= 256 n= 160 n= 522 n=793 n=161 All Death Cardiac Death MI Re- Intervention Composite Cardiac Events Stent Thrombosis

36 NEVO RES-ELUTION I / LEADERS: Baseline Characteristics vs Cypher SP & Taxus Liberté (HCC) NEVO (n=202) LEADERS (n=857) CYPHER SP (n=301) TAXUS LIBERTÉ (n= 643) Mult Vessel, % Left Main, % NA NA Bifurcations, % NA ACC/AHA Lesion Class A B1 B2 C Vessel Diam, (mm) 2.64 ± 0.41 NA 2.65 ± ± 0.32 Lesion length, (mm) 13.8 ± ± ± ± 6.3 Difusse lesions (> 20 mm %) IVUS, % NA NA NA HCC Real World Complex Group

37 Long Term Evidence in an All-Comers Population LEADERS 1, 2, 3-yrs Clinical Results HCC 4.4 % SES Serruys P. TCT 2010

38 12-Months MACE and Components Taxus Liberté vs. NEVO vs. Taxus Liberté (HCC) Taxus Liberté (n=192) NEVO (n=196) HCC Taxus Liberté (n=643) ,8 HCC 5,3 6,1 2,2 1,3 0,5 3,2 0,2 2,0 5,4 1,4 2,5 5,9 3,5 MACE Death MI Death or MI TLR 3,6 NEVO, Abizaid A., et al., EuroPCR 2010; Oral Presentation.

39 12-Months MACE and Components Taxus Liberté vs. NEVO vs. Cypher SP (HCC) Taxus Liberté (n=192) NEVO (n=196) HCC Cypher SP (n=301) 12 10, ,1 5,4 5, HCC 4,4 3,2 2,2 0,5 1,4 0,7 2,0 2,5 2,1 2,7 3,6 MACE Death MI Death or MI TLR NEVO, Abizaid A., et al., EuroPCR 2010; Oral Presentation.

40 Comparison of Zotarolimus-Eluting and Everolimus- Eluting Coronary Stents. vs HCC TAXUS & CYPHER REAL WORLD Xience V (N=1126) Resolute (N= 1119) HCC CYPHER (N=301) HCC TAXUS (N=643) HCC HCC MACE TLR Resolute NEJM 2010 Jul 8;363(2):136-4

41 Stent-thrombosis-free Survival (%) Can IVUS-Guided DES Implantation Prevent Stent-thrombosis-free Survival (%) Very Late Stent Thrombosis? Two propensity-score matched studies IVUS N= 884 No-IVUS N= 884 IVUS N= 1968 No-IVUS N= 655 p= 0,013 p= 0, Months of follow-up (Roy et al. Eur Heart J. 2008;29:1851-7) Days of follow-up (Costantini et cols TCT 2008)

42 Survival Free of MACE (N=2623 DES PCI Pts) IVUS (N=1968) No-IVUS (N=655) p = <0,001 Costantino Costantini et al 2010

43 Long Term Events Mean Follow Up Time: 35,6± 16,2 months p=0,001 IVUS (N=1968) No-IVUS (N=655) 10 9 p=ns 16,2 4 3,4 2,4 0,9 1,2 Death AMI TLR Thrombosis MACE 12 p=0,02 p=0,003 p=0,01 25,2 Costantino Costantini et al 2010

44 2011 IVUS (n=548) NO IVUS (n=548) P=0.006 P=0.386 P=0.004 P=0.575 P=0.177 J. Am. Coll. Cardiol. Intv. 2011;4;

45 DES uso HCC (2003/2011) 5,977 Stents Implantados % Taxus 2655 Cypher Promus 379 Biomatrix 324 Outros 292 Xience 176 Supralimus 94 Fonte: Hospital Costantini.

46 TCTMD,Wednesday, June 15, 2011

47 DESLIZE!!!!! ISTO E PROTOCOLO EXPERIMENTAL E DADOS!!!ERRADOS!!!!! Revista Veja edição 2230-ano44-nº33 17 de Agosto de 2011

48 Revista Veja de Agosto de 2011???? Rev Bras Cardiol Invas. 2009;17(1):110-6.

49 ABSORB Cohort B2 12-Month Clinical Results Incidence Rate (%) 8% 7.1% Revista Veja de Agosto de % 4% 3.6% 3.6%???? 2% 0% 0.0% 0.0% MACE ID-TLR MI Cardiac Death ARC ST (Def/Prob) ABSORB BVS 1.1 (n = 56) 63% B1 Lesions Presented at: American College of Cardiology Scientific Session/i2 Summit; April 3, 2011; New Orleans. LA.

50 Jornal da SBHCI ano XIV;N 2 Abril, Maio e Junho de2011

51 stent Bioabsorbible Respecto al stent Bioabsorbible es cierto que obtuvo la marca de la Comunidad Europea hace 3-4 meses, pero todavía no lo han comercializado. Se está realizando un estudio para ver realmente su eficacia y seguridad. Mi impresión general es que no sustituirá al menos por 5 años al los stents farmacoactivos. Todavía hay bastantes incertidumbres respecto a los stents bioabsorbibles (navegan bastante mal, no hay certeza sobre su fuerza radial, sobre el tiempo de desaparición (por lo tanto sobre la duración de la antiagregación), sobre la inflamación secundaria durante el proceso de desaparición en fin muchas incertidumbres todavía. En mi opinión, a día de hoy un buen DES (Resolute Integrity, Promus Element, Xience Prime) sin duda son mi elección a la hora de tratar un paciente. De: E. Garcia [mailto:ejgarcia1@telefonica.net] Enviada em: quarta-feira, 17 de agosto de 2011 Para: 'Costantino Costantini Por cierto, solamente hay datos del stent Bioabsorbible en un número muy limitado de pacientes (alrededor de 100) y en 70 de ellos con un seguimiento menor de 2 años, teniendo en cuenta que la tasa de trombosis en el Resolute All Commers (Resolute vs Xience) es 1% a los 2 años, se necesitarían alrededor de pacientes para demostrar una tasa de trombosis del bioabsorbible menor que la del Xience y Resolute.

52 A Importancia do Stent BOOST APV - 66 yrs Jul10 SXM - 71 yrs Dec10

53 Drug Eluting Balloons in Bifurcations Trial : the DEBIUT Stella R. TCT 2010

54 PCI Evolution..? CASS Balloon BMS work -horse small vessels long lesions SYNTAX DM ISR CTO multi-vessel disease bifurcated lesions IA

55 TULIP DIPOL Gaster RESIST SIPS AVID OPTICUS Combined (RE) Combined (FE) MACE In conclusion, IVUS guidance for bare metal stent implantation improved the acute procedural results (angiographic minimum lumen diameter) and thereby reduced angiographic restenosis and repeat revascularization and major adverse cardiac events, a follow-up period of 6 months to 2.5 years Favors IVUS Odds Ratio Favors Non-IVUS Am J Cardiol 2011;107:

56 SYNTAX Score MACCE!!!! 4 Years!!!!!!!!!!! 3 Vessel disease SYNTAX Score 0-22 SYNTAX Score SYNTAX Score 33 PCI CABG CABG < 10% with IVUS????? CABG TAXUS Presented P. Serryus TEAM 2011, Adapted C. Costantini SBHCI 2011

57 Repeat Revascularization to 3 Years LM Subset < 10% with IVUS????? CABG (n=348) TAXUS (n=357)

58 USIC Preditor de Trombose e de Reestenose na Era dos Stents Farmacológicos. O Stent, a Técnica ou os Dois!!!!!!!! Cypher Taxus Hipoexpansão Biomatrix Mal Aposição Trauma de Bordos Xience Reint. 27% Bifurcações Images Hospital Cardiológico Costantini

59 Conclusions: PCI IN Left main IVUS guidance, reduce the long-term mortality rate for unprotected left main coronary artery stenosis when compared with conventional angiography guidance. Park SJ et al, Circ Cardiovasc Intervent. 2009;2:

60 Patrick Serruys. Circulation. 1995;91: LM: PES LAD: PES Diag: PES LCX: PES Lom: BMS Vision Stents (5x) SES Stents (3x) Vorpahl M, Virmani R. presented ACC 2010

61 Angioplastia de Tronco há 3 meses em outra Instituição JS - 76 Anos Jun11 Stent Stent

62 Angioplastia de Tronco há 3 meses em outra Instituição Sem Utilizar IVUS JS - 76 Anos Jun11 Óstio DA Hipoexpansão 6.12 mm² 3.48 mm² 6.55 mm² 5.64 mm² Mal Aposição

63 JS - 76 Anos Jun11 CX Óstio Balão 2.0 * 15 Balão 3.5 * mm² Pré RePCI Kissing Balloon USIC Pós Balão Stent Xience 3.5 * 23 Stent Boost Desarranjo Óstio Acomodação 3.5 * 23 Resultado Final

64 JS - 76 Anos Jun11 Resultado Final Stent Xience 3.5 * 23 - TC > CX mm² 8.52 mm² 9.01 mm² mm²

65 PCI vs. CABG Surgery in Left Main Coronary Artery Disease Meta-analysis of 4 randomized trials involving 1,611 pts. LEMANS (n = 105), SYNTAX LM (n = 705), Boudriot et al (n = 201), PRECOMBAT (n = 600) 20 p= 0.11 PCI (n=809) CABG (n=802) p= 0.29 p= 0.95 p= p= < ,5 11,8 11, ,1 3,0 2,8 2,9 0,1 1,7 5,4 Primary Endpoint Death MI Stroke TVR Capodanno D, et al. J Am Coll Cardiol. 2011;58:

66 Indications for CABG versus PCI in stable patients with lesions suitable for both procedures and low predicted surgical mortality In the most severe patterns of CAD, CABG appears to offer a survival advantage as well as a marked reduction in the need for repeat revascularisation. Joint 2010 ESC - EACTS Guidelines on Myocardial Revascularisation

67 The First Brazilian Registry UPLM PCI Costantini et al. RBCI; Junho, 2011;19(2): 153-9

68 Costantini Experince in UPLM Clinical Follow up 917 ± 743 days 142 patients % BIFURCATION = 79% MULTIVESSEL = 87% SYNTAX SCORE >33 = 44.5% EUROSCORE > 6 = 51% 92% IVUS CABG Results (F/U mortality) Cleveland: 11,3 (1 year) NYS Database: 9,6 (2 years) Duke Database: 10,29 (2 years) Stroke AMI Thrombosis Death Revasc. MACCE Costantini et al. RBCI; Junho, 2011;19(2): 153-9

69

70 Abbott Vascular EXCEL Study Enrollment Update October 2011 We are pleased to announce that current enrollment is now 128 subjects enrolled in the Randomized Clinical Trial and 183 patients in the Universal Registry Brazil Centros: Dante Pazanezze; Incor e Hospital Costantini 183 patients in the Universal Registry 128 Randomized

71 Revascularization of Patients with ULMCAD The 2011 / 2012??? ACC/AHA/SCAI Guidelines???????????????????????? I IIa IIb III I IIa IIb III A?? CABG for ULMCAD PCI for ULMCAD

72 Fractional Flow Reserve The Wave of The Moment..

73 Fractional Flow Reserve

74 First Validation of FFR Comparison with 3 non-invasive functional studies N = 45 patients Sensitivity 88%, Specificity 100%, PPV 100%, NPV 88% N Engl J Med 1996;334:1703-8

75 Maio 1997 à Fevereiro PACIENTES LESÃO < 70% Angiografia(QCA) % ESTENOSE 64% DLM 1,7 ± 0,3 D. REF 3,15 ± 0.5 IVUS % ESTENOSE 60% DLM 2,2 ± 0,4 D. REF 3,48 ± 0.48 FFR > ,5% PROVA FUNCIONAL + 71,4% COSTANTINI. SOLACI 1998

76 Fractional Flow Reserve Metodologia O que Mudou???? (LAD) during adenosine infusion of 0.14 mg/kg per minute. Jhon Kane et al;circulation. 1995;92: ADENOSINE: 24 mcg Left Coronary, 18 mcg Right Coronary Costantino Costantini; SOLACI1998 Continuous infusion (240 g/min) of adenosine. Bon-Kwon Koo et al. J Am Coll Cardiol 2005;46:633 7 (140 g/kg/min) or intracoronary (15 mg in the right or 20 mg in the left coronary artery). DEFER Study // J Am Coll Cardiol 2007;49: After complete hyperemia has been achieved with intravenous adenosine, administered at 140 μg/(kgd min) via a central vein. FAME Study // Am Heart J 2007;154:632-6

77 J Am Coll Cardiol Intv 2011;4:

78 Critério de Inclusão Am Heart J 2007;154:632-6 Oral presentation Ed. Training Program; Nico Pijls April 2011

79 FAME Características Angiográficas N Engl J Med 2009;360:

80 *FAME Results 1 Year Vs. HCC **Taxus Experience Events at 1 year, No (%) *ANGIO-group N=496 *FFR-group N=509 ** HCC TAXUS N= 643 MACE (18.3) (13.2) (5.3) MI (8.7) (5.7) (0.2) Death (3.0) (1.8) (1.3) Death or MI (11.1) (7.3) (1.2) CABG or repeat PCI (9.5) (6.5) (3.5) *FAME study: Adverse Events at 1 year ; NEJM 2009;360: ** HCC TAXUS: Adverse Events at 1 year

81 MACE FAME vs. Others Studies at 1 year (MACE FFR Group = 13,2 % pts) SINTAX SCORE 15!!!!!!!! % ,3 13,5 9,7 8,7 10,7 FAME FAME Angio SYNTAX Syntax Xience XIENCE V Resolute Leaders HCC HCC Low Score Low Score Score? Score? Score? Inter. Score 65% 5,3

82 Conclusions Routine measurement of FFR in patients with multivessel CAD undergoing PCI with drug-eluting stents significantly reduces mortality and myocardial infarction at 2 years when compared with standard angiography-guided PCI. Jam Coll Cardiol 2010;56:177 84

83 Two-year Outcome End Point Events at 2 year % Angiography Group (N = 496) FFR Group (N = 509) P Value Composite of death, MI, and repeat vascularization Death Myocardial infarction Repeat vascularization Death or myocardial infarction Events per patient no ± ± Jam Coll Cardiol 2010;56:177 84

84 /09/ /09/11 Promus El * μg Inμf. Continua Resultado Final 2.96 mm² 2.94 mm² 6.42 mm² RFD - 68 Anos

85 LAD Angiography vs. FFR vs. IVUS FFR= 0.94 MLA= 1.22 mm² 140 Microgramas/kg 30 ampolas BI LKB - 70 yrs Feb11

86 EAH - 55 Yrs Mar11 FFR 0.84??? FFR 0.92??? Left Main LCx LAD 2.84 mm² 4.02 mm² 3.86 mm²

87 FAME or INFAMOUS Study? A total of 1329 lesions assessed in the FFR arm, 620 (47%) had < 70% stenosis as visually graded by FAME Study operators. From the remaining 709 lesions (>70% stenosis) only 15% (111 lesions) had an FFR >0,80. What are Europeans and North Americans treating????? Treating 50 to 70% stenotic lesions without any functional test?????? What can we learn from FAME???? 1) Don't have a cath done in Europe or USA 2)Do not treat lesions that are not severe because they are not severe (is this a new concept?) 3) FFR has 15% of false negative Is this at NEW gold standard????? 4) Actually as my teachers (good ones) thought me, Clinical presentation is sovereign. J Am Coll Cardiol Intv 2011;4:665 71

88 ???????????????????????????????????????? Oral Presentation William F. Fearon,. Left Main and Bifurcation Summit, NY June 4th, 2009 Slide 38/Available in

89 Olhe bem e Conclua Existe alguma Diferença???? (SO..DUAS!!!!!) /Available in

90 SJ Park Evaluation

91 Intervencionismo Hoje... Experience Technology IVUS Stent Boost OCT FFR Judgment Honesty

92 Professionalism at Mayo Clinic Historical perspective The best interest of the patient is the only interest to be considered and in order that the sick may benefit from advancing knowledge a Union of Forces is necessary William J. Mayo, MD June 1910

93 Cardiologists and Intervencionists We Have an Important Mission: To improve our patients life quality... For that we neeed: o Profissionals with competency o High judgment level o High improvement level o And Mainly... Honesty... Frans van Mieris, 1657 Kunsthistorisches Museum, Viena J.L. Pomar, (TEAM 2010)

94 Cath Lab Team Hospital Costantini MUITO OBRIGADO

95 de Novembro de Curitiba.PR.Brasil