William Wijns MD PhD The Lambe Institute for …...Tu, Reiber, Wijns et al. JACC CV Interv 2014;7:768-77 & Tu, Reiber, Wijns et al. JACC CV Interv 2016;9:2024-5 • Needs only 2 angio

ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425)

www.escardio.org/guidelines

William Wijns MD PhD

The Lambe Institute for Translational Medicine and Curam

Saolta University Healthcare Group

The Smart Sensors Lab, Director

National University of Ireland Galway, Ireland

Chairman PCR

Institutional Research Grants (to former institution) from Biotronik, MiCell, MicroPort, Terumo

Co-founder of Argonauts, an innovation facilitator

Scientific Advisor Rede Optimus Research

Steering Committee & Honoraria: MicroPort

2020-01-29_HIGH TECHMarseille

Relations of Interest Disclosure



William Wijns MD PhD

2020-01-29_HIGH TECHMarseille

Le futur de la Cardiologie Interventionnelle



SCIENTIFIC ADVANCES & CARDIOVASCULAR MORTALITYNabel and Braunwald. N Engl J Med 2012;366:54-63

1958Coronary

arteriographydeveloped

(Sones)

1977Coronary

angioplastydeveloped(Grüntzig)

1993Superiority of

primary PCI vs. fibrinolysis in

acute MI noted

2002Efficacy of

drug-eluting vs. bare-

metal stents determined

1967First description of CABG(Favaloro)



FIM Percutaneous Coronary Angioplasty 1978

Perfect surgical candidate with a simple to deal with lesion (focal, large vessel, easily

accessible, straight proximal segment)

From “symptomatic” to prognostic indications 2016

Acute Presentations of CAD

• Primary PCI for STEMI

• High-risk unstable angina

Elective PCI / chronic patients

Equipoise with CABG for subsets of patients with left main stenosis

± multivessel disease

CTO no longer a frontier



Primary endpoint

No. at risk Medical therapy 1344 1222 688 559 381 301FFR-guided PCI 1056 980 696 566 406 328

Medical therapy

FFR-guided PCI

Hazard ratio 0.72 (95% CI 0.54-0.96) P=0.024

28% lower (relative)*

4.5% lower (absolute)

Cardiac Death or Myocardial Infarction

Zimmermann et al.

European Heart Journal, Volume 40, Issue 2, 07 January 2019, Pages 180–186 https://doi.org/10.1093/eurheartj/ehy812 *Relative benefit of FFR-guided PCI not different among studies

FAME 2NCT01132495

DANAMI-3-PRIMULTINCT01960933

I

Compare-AcuteNCT01399736



After adjustment for - patient- site-level- procedural factors

FFR-guided revascularization was associated with a 43% lower risk of mortality at 1 year

compared with angiography-only revascularization

1 year all-cause mortality

Hazard Ratio: 0.57

95% confidence interval: 0.45 to 0.71; p < 0.0001)



0

.50

.75

.25

1.0

FFR = 0.74

FFR = 0.74

Q-FR = 0.75

Tu, Reiber, Wijns et al. JACC CV Interv 2014;7:768-77 & Tu, Reiber, Wijns et al. JACC CV Interv 2016;9:2024-5

• Needs only 2 angio runs from biplane or monoplane systems

• Computation speed < 2 min

• Rendering of Q-FR color-coded pullbacks for all branches in the same calculation

• High Diagnostic Accuracy 87% (95%CI 80-94) vs FFR measured by pressure wire after adenosine



No

TA

VI

No

TA

VI

SurgicalRisk

# Patients

TAVISurgery

TATF

A.P. Kappetein, EuroPCR, AYNTK



2019

PARTNER 3

Evolut LOW RISK

Low

>/=

CLINICAL EVIDENCE ACROSS RISK CATEGORIESCLINICAL EVIDENCE ACROSS RISK CATEGORIES

2017

PARTNER 2A

SURTAVI

NOTION I

20162011

PARTNER 1A

2014

CoreValve HR

2012

PARTNER 1B

2014

CoreValve ER



2010 Guidelines on myocardial revascularisation

The Task Force on Myocardial Revascularisation of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)

Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI)

Authors/Task Force Members: William Wijns (Chairperson) (Belgium), Philippe Kolh (Chairperson) (Belgium), Nicolas Danchin (France), Carlo Di Mario (UK), Volkmar Falk (Switzerland), Thierry Folliguet (France), Scott Garg (The Netherlands), Kurt Huber (Austria), Stefan James (Sweden), Juhani Knuuti (Finland), Jose Lopez-

Sendon (Spain), Jean Marco (France), Lorenzo Menicanti (Italy), Miodrag Ostojic (Serbia), Massimo F. Piepoli (Italy), Charles Pirlet (Belgium), Jose L. Pomar (Spain), Nicolaus Reifart (Germany), Flavio L. Ribichini (Italy), Martin J. Schalij (The Netherlands), Paul Sergeant (Belgium), Patrick W. Serruys (The Netherlands), Sigmund

Silber (Germany), Miguel-Sousa Uva (Portugal), David Taggart (UK).

European Heart Journal 2010;31:2501-55



The Heart Team

Task Force composition = 8 clinical cardiologists (non interventional)+ 9 interventional cardiologists + 8 cardiac surgeons

Clinical cardiologist(non interventional)

Cardiac

surgeon

Interventional

cardiologist

The patientwith CAD



2014 ESC/EACTS Guidelines on myocardial revascularisation

The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)

Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Authors/Task Force members: Stephan Windecker (ESC Chairperson) (Switzerland), Philippe Kolh (EACTS Chairperson) (Belgium), Fernando Alfonso (Spain), Jean-Philippe Collet (France), Jochen Cremer

(Germany), Volkmar Falk (Switzerland), Gerasimos Filippatos (Greece), Christian Hamm (Germany), Stuart J. Head (Netherlands), Peter Jüni (Switzerland), A. Pieter Kappetein (Netherlands), Adnan Kastrati

(Germany), Juhani Knuuti (Finland), Ulf Landmesser (Switzerland), Günther Laufer (Austria), Franz-Josef Neumann (Germany), Dimitrios J. Richter (Greece), Patrick Schauerte (Germany), Miguel-Sousa Uva (Portugal), Giulio G. Stefanini (Switzerland), David Paul Taggart (UK), Lucia Torracca (Italy), Marco

Valgimigli (Italy), William Wijns (Belgium), and Adam Witkowski (Poland).

European Heart Journal 2014;35:2541-2619



2018 ESC/EACTS Guidelines on myocardial revascularisation

Authors/Task Force Members: Franz-Josef Neumann (ESC Chairperson) (Germany), Miguel Sousa-Uva (EACTS Chairperson) (Portugal), Anders Ahlsson (Sweden), Fernando Alfonso (Spain), Adrian P.

Banning (UK), Umberto Benedetto (UK), Robert A. Byrne (Germany), Jean-Philippe Collet (France), Volkmar Falk (Germany), Stuart J. Head (The Netherlands), Peter Jüni (Canada), Adnan Kastrati

(Germany), Akos Koller (Hungary), Steen D. Kristensen (Denmark), Josef Niebauer (Austria), Dimitrios J. Richter (Greece), Petar M. Seferovic (Serbia), Dirk Sibbing (Germany), Giulio G. Stefanini (Italy),

Stephan Windecker (Switzerland), Rashmi Yadav (UK), Michael O. Zembala (Poland).

The Task Force on myocardial revascularisation of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery

(EACTS)

Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI)

European Heart Journal 2018. Published online August 25 doi.org/10.1093/eurheartj/ehy 394



• Choice of procedural MI definition

• The MI definition in the protocol was modified during the course of the study

• The rates of procedural MI according to Universal Definition have been deliberately withheld

• The all cause mortality data from EXCEL were not strongly enough emphasized

• The DSMC raised concerns that were not considered

• The ESC / EACTS GL are unsafe

EACTS Public Criticism following the publication of EXCEL at 5-year follow-up


www.escardio.org/guidelineswww.escardio.org/guidelines

Type of revascularization in patients with stable

three-vessel or left main coronary artery disease

Windecker S et al., Eur Heart J 2019;40:204-12



The future of Interventional Cardiology / MedicineDiagnosis and Treatment of Cardiovascular Diseases

Best of Medical Care

LifestyleDiet

Pharmacology

Coronary, Valvular, Structural& Peripheral Interventions

CABGValve surgery

Incremental improvement in Best of CareOn behalf of Heart Team 2.0

« By and For » the individual patient

Blue Ocean Strategy



10.7%

11.2%

Days334 313 295 289 279 277 268

454 442 433 422 407 399 391

15.1%

13.2%

HR 0.93 (95% CI 0.60-1.43) p=0.73P <0.001 for non-inferiority*

HR 0.85 (95% CI 0.58-1.25)p=0.42

SYNTAX I CABG

SYNTAX II PCI

Pat

ien

ts (

%)

SYNTAX I CABGSYNTAX II PCI

up to 2 years

Exploratory endpointMACCE PCI vs CABG for 3 vessel disease

Components of the SYNTAX II « Best of PCI Practice » strategy

1. Risk stratification tool: SYNTAX Score II (incorporating clinical and anatomical

variables) to guide Heart Team decisions

2. Physiology-based revascularization

3. Second generation DES (thin strut, biodegradable polymer, everolimus-eluting

Synergy™ stent)

4. IVUS-guided optimisation of stent deployment

5. Contemporary CTO revascularization techniques

6. Guideline-directed medical therapy (LDL cholesterol ≤1.8 mmol/L)

Escaned et al. Eur Heart J. 2017;38:3124-34 – Modolo et al. Ann CardioThoracic Surg 2018;7:470-82

Clinical outcomes of state-of-the-art PCIin patients with de novo 3 VD


www.escardio.org/guidelines 19

Adoption of Interventional ProceduresAdoption of Interventional Procedures

PROM



From S.W. Windecker







MSCT Assessment3D - Maximum Intensity Projection (MIP)

Calcification of the Aorta

Calcified plaque in the LAD

Mid LAD obstructive lesion

LCX/OM bifurcation lesion

Proximal RCA obstructive lesion

Ostial lesion RCA (?)



Left Main / LADSegment 7 = 5 points

Segment 7 >20 mm = 6 points

2nd

Dg

1st

Dg

Multiplanar Reconstruction (MPR)



Engaging the new era of Coronary Computed Tomography - facilitated PCI

Access: femoral-radial

Aorta ascendens / descendens

Coronary arteriesOstiaAberrant arteriesDominance, vessel lengthCoronary calcificationCoronary physiology (CT-FFR)Vessel size, diameter, tortuosityPlaque severity and remodelling Plaque compositionCollateral flow

CTO: length of occlusion, degree of calcification

Risk assessment / stratification by calculation of scores

Procedure planningstent size, length and diameterimpact on FFR

Best views for imaging/procedure

Reduced procedure duration, radiation and use of contrast

Think of changes in training, capacity and care delivery !



Multidistrict Diagnosis and Treatment

1. Cardiac targets: coronary arteries, valves, other structural interventions

2. Peripheral vascular targets: PAD, hypertension, critical limb ischemia

3. Stroke prevention and treatment: LAAC, carotid stenting, acute stroke

4. Pulmonary disease: PAH, pulmonary embolism

5. Acute and chronic heart failure: implanted sensors, assist devices, ECMO



• Multidistrict diagnosis & intervention requires 2 or 3 dedicated rooms: a single equipment does not allow an optimal head-to-toe workflow

The CathLab of the (near) Future

• Coronary diagnosis of the (near) future requires state-of-the-art coronary CT angiography (super-fast CT volume imaging in a single heart cycle)

• Valvular (TAVI) and other structural interventions (LAAC) require Computed Tomography (CT) and echo imaging, both fused with LIVE imaging in the cathlab

CT equipment is best integrated in the cathlab environment but

with access and workflow also suitable for outpatient service



• Enforcing healthy lifestyle and diet

• Mitral and tricuspid intervention

• Implementing interventional treatment of stroke

• Reducing hospital stay

• Eliminating drug incompatibilities

• Preventing sudden cardiac death

• Anticipating acute atherothrombotic events

• Fighting arterial hypertension

• Diagnosing paroxysmal atrial fibrillation

• Distributing health care to the poor

• . . . / . . .

What is your most frustrating unmet need ?



The mobile phone : Rwanda’s weapon for distance surveillance of high-risk pregnancy

Rwanda 's hospitals use drones to deliver medical supplies

http://flyzipline.com/press/

Transformative impact of technology on care delivery

Prof J. Marescaux (IRCAD) to establish a digital training center for endoscopic surgery in Kigali

1. Computing power2. Data analytics3. Artificial intelligence4. Electroceuticals (electrons as a drug)5. Communication technology (sensors)6. Power (batteries)7. Gene sequencing (responders vs non)8. 3D-printing9. New materials (cell protection)10. Social networks11. Robotics

What does the future hold ?

Areas of Strategic Investment Horizon 2025

S. Oesterlee, Dublin 2016

The synchrony of imaging and catheter movement… practice, plan and perfect…

No lead, no radiation &less X-rays and contrastfor patients …



e-health solutions are relevant if they impact patient care &save money with a good business model

Decrease repeated Decrease repeated hospitalization needs hospitalization needs for heart failure for heart failure patientspatients

Prevent episodes of Prevent episodes of hypoglycemia in hypoglycemia in diabetic patientsdiabetic patients

Decrease ER visits Decrease ER visits for childhood asthma for childhood asthma exacerbationsexacerbations

PJ Fitzgerald@EuroPCR 2016

Value and limitations of connected health



VERILY Life Sciences

SENSORS

https://verily.com/projects/

• Mini CGM (Dexcom)• Smart Lens (Novartis)• Study Watch

INTERVENTIONS

HEALTH PLATFORMS

PRECISION MEDICINE

• Debug• Bioelectronic Medicines (GSK)• Liftware• Retinal Imaging (Nikon)• Verb Surgical (Ethicon - J&J)

• Healthcare Performance (3M)• NHS Testbed Early Intervention

(NHS & MSD)• Onduo (Sanofi)

• Immunoscape (Gilead)• MS Study (Biogen & Brigham)• One Brave Idea (NIH & AZ)• Personnalized Parkinson • Precision Medicine (NIH)• Project Baseline (Duke & Stanford)



IBM Watson

A. Grosse, Cognitive Health Leader EuropeMedTech Strategist, Dublin 2018

Multiple products and services

•IoT Solutions

•Medical Language

•Drug Discovery

•Medical Imaging

•Oncology

•Sepsis (real time)

•Open Health Platform

•. . . / . . .

We have spent the last 50 years or so teaching people to operate computers.Cognitive computing is about teaching computers to understand people.

Rob High – VP and CTO IBM Watson

Symposium en l’honneur du Professeur Legrand



The 10 Commandments of Graeme Codrington



The 10 Commandments of Graeme Codrington

1. Switch on your radar2. Be curious and ask better questions3. Change where you look for information4. Why are we doing it this way?5. Experience more, but wisely6. Embrace different opinions7. Look East8. Learn from your mistakes, and from the

mistakes of others9. Confront your limiting orthodoxies10. Learn, unlearn, and relearn

Documents

William Wijns MD PhD The Lambe Institute for …...Tu, Reiber, Wijns et al. JACC CV Interv 2014;7:768-77 & Tu, Reiber, Wijns et al. JACC CV Interv 2016;9:2024-5 • Needs only 2 angio