CNCHG2009

CNCHG2009

CNCHG2009

CNCHG2009

CNCHG2009

CNCHG2009

Operator and Hospital Volume-Outcome Relationship in Patients Undergoing Elective Balloon Angioplasty. Jollis J et al. Circulation 1997;95:2485

Operator Volume Hospital Volume

Outcome from 97,478 Medicare patients treated in 1992

75 cases/year 200 cases/year

CNCHG2009

CNCHG2009

La cardiologie interventionnelle en CHG

• 70 salles de cardiologie interventionnelle (PCI).

• « 444 » Cardiologues interventionnels.

• 41 119 PCI en 2007.

92 ATC/opérateur/an

C e n t r e s H o s p i t a l i e r sN o m b r e d ' a n g i o p l a s t i e s

r é a l i s é e s e n 2 0 0 7

A v ig n o n 1 3 3 6

M e t z 1 2 0 0

L e n s 1 1 0 0

B o u rg e s 1 0 8 5

S t L a u r e n t d u V a r 1 0 0 0

L a g n y 9 7 5

P a u 9 6 7

L e P le s s is R o b in s o n - M a ri e L a n n e lo n g u e 9 5 0

L a R o c h e ll e 9 1 2

A n n e c y 9 0 0

C o lm a r ( P S P H ) 8 7 5

A n g o u le m e ( s t m i c h e l ) 8 4 9

M u lh o u s e 8 2 4

C h a rt r e s 8 0 0

V a l e n c ie n n e s 7 9 0

L y o n S t L u c S t J o s e p h ( P S P H ) 7 8 3

C o m p iè g n e 7 7 0

P e r p i g n a n 7 6 8

F r e j u s 7 6 3

O r le a n s 7 1 5

A ix e n P r o v e n c e 7 0 0

N e v e r s 6 9 9

N io r t 6 6 3

B e l f o r t 6 5 0

To u lo n 6 5 0

Va le n ce 6 0 0

Brive s la Ga illa rde 6 0 0 p rév u s c ar d é bu t aoû t 2 00 8

Va n n es 6 0 0

Ha g ue n e au 5 8 0

Pa ris Mon tso u ris 5 5 1

Mont fe rm e il 5 5 0

Lo rie nt 5 3 5

Au x e rre 5 1 2

Co rbe il E sson e 5 1 2

Ba y o nn e 5 0 0

La Ro ch e /Yon 5 0 0

Ne u illy /S e in e 5 0 0

Po n to ise 5 0 0

Sa in t-Qu e n tin 5 0 0

Pé rigu e u x 4 8 0

Vich y 4 6 4

St B rie uc 4 7 3

Ba s tia 4 5 9

St Den is la Ré u n io n 4 5 0

Le Ha vre 4 2 8

Ro u b aix 4 2 5

Le Ma ns 4 2 0

Villen e u ve S t G eo rg e s 4 2 0

Bo u lo gn e Billa nc o u rt 4 1 7

S t M a lo 4 1 2

D u n k e r q u e 4 1 1

V e rs a il le s ( A n d ré M ig n o t ) 4 0 8

L o m m e 4 0 2

E a u b o n n e 4 0 0

G re n o b l e C lin i q u e M u tu a lis t e (P S P H ) 4 0 0

Q u im p e r 4 0 0

R o d e z 4 0 0

M o n t re u i l 3 9 9

A rg e n te u il 3 8 3

P o is s y S t G e rm a in 3 8 0

L ib o u rn e 3 6 0

S u re s n e s (h ô p i ta l F o c h ) 3 5 0

C a n n e s 3 0 0 ( d é b u t a c t iv i té 2 0 0 7 )

T a rb e s 3 0 0

T ro y e s 2 6 0

A u ln a y s s b o is 2 5 9

G o n e s s e 2 5 8

C o lm a r (C H ) 2 5 0

A ja c c io 2 0 5

T ra c y -le -M o n t (o is e ) 2 0 0

P a p e e t e 1 8 0

M a n t e s la J o li e 1 2 0

L a v a l 1 0 0

N o u m é a ?

Le top Ten

Les « EnVoied’Extinction »

Le down Ten

CH A.MIGNOT

PARLY II

CH POISSY

Centre d’Evecquemont

Port Marly

Trappes

CH MANTES

La situation dans les Yvelines 27

Coronarographies AngioplastiesÉVECQUEMONT, 1 083 493 46%PORT MARLY - CMC de l'Europe 512 246 48%LE CHESNAY - Parly II 1 302 607 47%TRAPPES - CMC Ouest Parisien 461 233 51%POISSY, 810 444 55%VERSAILLES - André Mignot 946 360 38%MANTES LA JOLIE 290 90 31%

Registre Cardio ARHIFYvelines - Activité 2008

Sténose >70%

IVUS sonde 20mHz Lésion de bifurcation du TC

Aujourd’hui, samedi 28 novembre 2009, je suis seul et d’astreinte…..

Mardi 2 décembre, nous serons trois….

En salle, et pour l’astreinte, nous n’avons qu’une auxiliaire et…

que deux lits de SSPI….

Nos anesthésistes ne « veulent » pas venir nous épauler…

Et nous devons débuter le 24/24 en janvier 2010Avec l’appui logistique du SAMU 78 et 27

Mais pour combien de temps…..

Aujourd’hui, samedi 28 novembre 2009, je suis seul et d’astreinte…..

Mardi 2 décembre, nous serons trois….

En salle, et pour l’astreinte, nous n’avons qu’une auxiliaire et…

que deux lits de SSPI….

Nos anesthésistes ne « veulent » pas venir nous épauler…

Et nous devons débuter le 24/24 en janvier 2010Avec l’appui logistique du SAMU 78 et 27

Mais pour combien de temps…..

La VIE du Service de CARDIOLOGIE de Mantes

La VIE du Service de CARDIOLOGIE de Mantes

IVUS, outil indispensable pourcertaines procédures.

CNCHG2009

CNCHG2009

FAME 2 TCT 2009• reduced mortality and myocardial infarction at two years by 34%• reduced MI at two years by 37%

• cost-saving and does not prolong procedure time• decreased amount of contrast agent used

CNCHG2009

CNCHG2009

FAME 2 in TCT 2009• reduced mortality and myocardial infarction at two years by 34%• reduced MI at two years by 37%

• cost-saving and does not prolong procedure time• decreased amount of contrast agent used

•The routine measurement of FFR during PCI with DES in patients with MVD: •is superior to current angiography-guided treatment strategy, in reducing by ~30% the rate of the composite endpoint of death, MI, re-PCI and CABG, at 1 year. This strategy also reduces individual endpoints such as mortality and MI at 1 year. •is cost-saving, greatly reducing the number of stents used •does not prolong the procedure •reduces the number of stents used •decreases the amount of contrast agent used and results in a similar, if not better, functional status

•FAME trial supports the evolving paradigm of “Functionally Complete Revascularisation”, i.e. stenting of ischemic lesions and medical treatment of non-ischemic ones.. •FFR confirms to be a very helpful instrument for more accurate decision making during interventional procedures

CNCHG2009

CNCHG2009

The consensus of the SYNTAX in EuroPCR 2009 session was:

•CABG remains the gold standard of care for patients with three-vessel or LM coronary artery disease, since the use of CABG, as compared with PCI, resulted in lower rates of the combined endpoint of MACCE at 1 year. •Based on a non-significant difference in MACCE at 1 year, the SYNTAX results suggest that 66% of all patients with threevessel or LM coronary artery disease are still best treated with CABG. For the remaining 1/3 of such patients with a low SYNTAX Score (0-22), PCI may be considered as an alternative to surgery (with the exception of insulino-dependent diabetic patients). Again it should be remembered that this statement is based on 1 year data. Longer follow-up results will be presented during the ESC meeting. According to previous studies one can foresee further diverge of MACCE with longer follow-up. •A Heart Team Concept is mandatory for such patients with MVD or LM stenosis. In complex patients, the diagnostic procedure should be separate from the PCI, when eventually indicated. Time is needed in order to discuss management options, allowing for an informed decision.

CNCHG2009

CNCHG2009

CNCHG2009

CNCHG2009

CNCHG2009

CNCHG2009

Assistance mécanique pour le Choc cardiogénique

IABP Impella Tandem Heart

CNCHG2009

CNCHG2009

Hospital Volume-Outcome Relationship in Patients Undergoing Elective PTCA

Hannan E et al. JAMA 1997;19:892-8

Outcome from 62,670 Medicare patients treated between 1991-1994 in NY State

600 cases/year

1.12

0.80.85

0.79

0.95

0.5

0.75

1

1.25

<400

400-

599

600-

799

800-

999

>100

0

Statewide Mortality: 0.9%

CNCHG2009

CNCHG2009

Procedural Complexity and Operator Volume-Outcome Relationship in Patients Undergoing

Elective Balloon Angioplasty. Ellis S et al. Circulation 1997;95:2479

5.9

1.72.4

22.4

0

2

4

6

8

<70 70-99

100-142

143-270

>270

%

P<0.001

Low Risk Lesions(N=12,985 PCI Patients 1993-94)

P<0.001

High Risk Lesions(N=12,985 PCI Patients 1993-94)

8.4

5.8

7.8

4.9

2.7

0

2

4

6

8

<70 70-99

100-142

143-270

>270

%

Operator Volume per Year Operator Volume per Year

CNCHG2009

CNCHG2009

Operator and Hospital Volume-Outcome Relationship With the Use of Coronary Stents

McGrath P et al. JAMA 2000;284:3139-44

3.52 3.33 3.19

5.665.24

4.5

0

2

4

6

8

<30 30-60 >60

Death Death or CABG

%

P<0.001

Operator Volume per Year(N=167,208 PCI Patients in 1997)

4.88

3.86

3.11

6.88

5.94 5.87

0

2

4

6

8

<80 80-160 >160

Death Death or CABG

P<0.001

Hospital Volume per Year(N=167,208 PCI Patients in 1997)

%

CNCHG2009

CNCHG2009

Operator and Hospital Volume-Outcome Relationship With the Use of Coronary Stents

McGrath P et al. JAMA 2000;284:3139-44

6.13 6.05 5.96

6.06 5.715.17

5.1 4.9 4.6

0

2

4

6

8

<30 30-60 >60

>160

80-160

<80

%

Operator Volume per Year Hospit

al Volu

me

per Y

ear

CNCHG2009

CNCHG2009

Operator and Hospital Volume-Outcome Relationship With the Use of Coronary Stents

Kastrati A et al. JACC 1998;32:970-6

Overall Operator Volume Annual Operator Volume

Outcome of 3,409 PCI patients treated between 1992-1997

CNCHG2009

CNCHG2009

Volume-Outcome Relationship With the Use of Coronary Stents Stratified for Lesion Complexity

Kastrati A et al. JACC 1998;32:970-6

Outcome of 3,409 PCI patients treated between 1992-1997

CNCHG2009

CNCHG2009

Operator and Hospital Volume-Outcome Relationship in Contemporary PCI

Moscucci M et al. JACC 2005;46:625-32

2.041.66 1.51

1.11 1.42

7.38

6.13

4.974.15 4.15

0

2

4

6

8

1-33 34-89 90-139 140-206 207-582

Death MACE

%

P<0.001

18,504 PCI Patients treated in 2002

CNCHG2009

CNCHG2009

199 197189

170

0

50

100

150

200

5-11 12-20 21-33 >33

Hospital Volume and Mortality for Patients With Acute MI Undergoing PCI

Canto J et al. N Engl J Med 2000;342:1573

7.7 7.57

5.7

0

2

4

6

8

5-11 12-20 21-33 >33

%

P<0.01

In-Hospital Death(N=36,535 Primary PCI Patients)

P<0.001

Door-to-Ballon Times(N=36,535 Primary PCI Patients)

Min

utes

Hospital Volume per Year Hospital Volume per Year

CNCHG2009

CNCHG2009

Hospital Volume and Mortality for Patients With Acute MI Undergoing PCI

Magid DJ et al. JAMA 2000;284:3131

6.2

4.5

3.4

5.9 5.95.4

0

2

4

6

8

Low Intermediate High

Primary PCI Thrombolysis

P=0.58 P<0.001 P<0.001NRMI-Registry-62,299 patients with acute MI treated from 1994-1999

-446 acute care hospitalslow PCI volume:<16 cases/yearintermediate: 17-48 cases/yearhigh PCI volume: >49 cases/year

10,144 1,423 21,577 8,817 8605 11,733

%

CNCHG2009

CNCHG2009

Operator and Hospital Volume-Outcome Relationship in Primary PCI

Vakili B et al. Circulation 2001;104:2171-6

7.1

3.8

0

2

4

6

8

Low (1-10) High (>10)

In-h

ospi

talM

orta

lity

% RR=0.43(0.21-0.83)

P=0.01

Operator Volume Hospital Volume

5.8

4

0

2

4

6

8

Low (1-56) High (>56)

1,342 STEMI patients from New York State in 1995

In-h

ospi

talM

orta

lity

% RR=0.56(0.29-1.1)

P=0.11

CNCHG2009

CNCHG2009

3

4.2

5.7

7.4

0

2

4

6

8

<90 90-120 121-150

>150

In-h

ospi

tal M

orta

lity

(%)

Door-to-balloon Time(Minutes)

Door-to-Balloon Time And Mortality in Patients With AMI Undergoing PCI

McNamara R et al. JACC 2006;47:2180-6

NRMI 3-4 Registry (1999-2004) 29,222 primary PCI patients

CNCHG2009

CNCHG2009

Resténose clinique après PCI répétées avec DES