tips and tricks for ffr assessment revisited – an update ... · tips and tricks for ffr...
Post on 15-Jul-2020
2 Views
Preview:
TRANSCRIPT
Tips and Tricks for FFR Assessment Revisited –An Update on New Techniques and Devices
Prof. Jacek Legutko, MD, PhDPresident
An Update on New Techniques and Devices
PresidentAssociation of Cardiovascular Interventions, Polish Cardiac Society
Jagiellonian University Medical CollegeUniversity Hospital, Kraków, Poland
Potential conflicts of interest
Speaker's name: Jacek Legutko
Lecture fee (Philips Volcano, St. Jude, Terumo, Balton, Astra Zeneca,Medtronic, Abbott, Procardia)
Fractional Flow Reserve (FFR)ES C GuidelinesR ecom m endationsES C GuidelinesR ecom m endations
Windecker S, et al.Eur Heart J2014; doi:10.1093/eurheartj/ehu278
M ontalescotG,etal.EurHeartJ2013;4,2949– 3003
Fractional Flow Reserve (FFR)M ainlim itationsM ainlim itations
Optimal route and dose of adenosineadministration still remains a subject of debateand investigationand investigation
Difficult deliverability and insufficient durabilityof the pressure wireof the pressure wire
Relatively high incidence of drift
iFR concept still under investigation iFR concept still under investigation
Fractional Flow Reserve (FFR)M ainlim itationsM ainlim itations
Optimal route and dose of adenosineadministration still remains a subject of debateand investigationand investigation
Difficult deliverability and insufficient durabilityof the pressure wireof the pressure wire
Relatively high incidence of drift
iFR concept still under investigation iFR concept still under investigation
Fractional Flow Reserve (FFR)How toprovokem axim um hyperem ia?
A total of 50 patients with 125 coronary artery stenoses (40-90% by visualestimation) were enrolled.
All lesions were assessed with:
How toprovokem axim um hyperem ia?
All lesions were assessed with: Femoral vein adenosine infusion - 140 μg/kg/min (GOLD STANDARD) Femoral vein adenosine infusion - 280 μg/kg/min Antecubital vein adenosine infusion - 140 μg/kg/min Intracoronary adenosine bolus injection - 100 μg, 200 μg, 400 μg, 600 μg. Intracoronary adenosine bolus injection - 100 μg, 200 μg, 400 μg, 600 μg.
Legutko J et al. J Am Coll Cardiol. 2016;68(18S):B214.Legutko J et al. Advances in Interventional Cardiology. 2016; 12, 4 (46).
Fractional Flow Reserve (FFR)How toprovokem axim um hyperem ia?
Femoral versus antecubital vein adenosine infusion (140 µg/kg/min.)
How toprovokem axim um hyperem ia?
ANTECUBITALFEMORAL ANTECUBITAL
Legutko J et al. J Am Coll Cardiol. 2016;68(18S):B214.
Fractional Flow Reserve (FFR)How toprovokem axim um hyperem ia?
Femoral vein adenosine infusion - 140 versus 280 µg/kg/min.
How toprovokem axim um hyperem ia?
Legutko J et al. Advances in Interventional Cardiology. 2016; 12, 4 (46).
Fractional Flow Reserve (FFR)How toprovokem axim um hyperem ia?
Femoral vein adenosine infusion - 140 µg/kg/min.versus intracoronary bolus – 100 µg
How toprovokem axim um hyperem ia?
Legutko J et al. Advances in Interventional Cardiology. 2016; 12, 4 (46).
Fractional Flow Reserve (FFR)How toprovokem axim um hyperem ia?
Femoral vein adenosine infusion - 140 µg/kg/min.versus intracoronary bolus – 600 µg
How toprovokem axim um hyperem ia?
Legutko J et al. Advances in Interventional Cardiology. 2016; 12, 4 (46).
Fractional Flow Reserve (FFR)How toprovokem axim um hyperem ia?
Femoral vein adenosine infusion versus intracoronary boluses
How toprovokem axim um hyperem ia?
Legutko J et al. Advances in Interventional Cardiology. 2016; 12, 4 (46).
Fractional Flow Reserve (FFR)How toprovokem axim um hyperem ia?
Percentage of functionally significant lesions according to differentmethods of adenosine administration
How toprovokem axim um hyperem ia?
Legutko J et al. Advances in Interventional Cardiology. 2016; 12, 4 (46).
Fractional Flow Reserve (FFR)How toprovokem axim um hyperem ia?How toprovokem axim um hyperem ia?
Ostial / proximal LMCA diseaseOstial / proximal RCA disease
Sequential lesions requiring pull-backSequential lesions requiring pull-back
YES
i.v. infusion (femoral / antecubital)
NO
Intracoronary bolus of adenosine i.v. infusion (femoral / antecubital)of adenosine 140 µg/kg/min
Intracoronary bolus of adenosine100-400 µg
YESYES
FFR 0,81-0,85 FFR 0,81-0,85YES
NO i.v. infusion (femoral / antecubital)of adenosine 280 µg/kg/min
NO
Accept FFR value
Fractional Flow Reserve (FFR)M ainlim itationsM ainlim itations
Optimal route and dose of adenosineadministration still remains a subject of debateand investigationand investigation
Difficult deliverability and insufficient durabilityof the pressure wireof the pressure wire
Relatively high incidence of drift
iFR concept still under investigation iFR concept still under investigation
Fractional Flow Reserve (FFR)L im itationsoftheElectricalP ressureGuidew ire
ElectricalPressure Guidewire
L im itationsoftheElectricalP ressureGuidew ire
Pressure Guidewire
• No current FFR electrical guidewireprovide workhorse wire
• No current FFR electrical guidewireprovide workhorse wireprovide workhorse wirecharacteristics
• Drift
• Moisture sensitive: contrast agents,
provide workhorse wirecharacteristics
• Drift
• Moisture sensitive: contrast agents, 3 electrical• Moisture sensitive: contrast agents,blood and other liquids may result inunreliable connection, hinderingmulti-vessels and post-stent FFRassessment.
• Moisture sensitive: contrast agents,blood and other liquids may result inunreliable connection, hinderingmulti-vessels and post-stent FFRassessment.
3 electricalcables
assessment.assessment.
Small diametercore wire
Fractional Flow Reserve (FFR)AdvantagesoftheO pticalP ressureGuidew ires
OpticalPressure Guidewire
AdvantagesoftheO pticalP ressureGuidew iresOpticalfiber
Laser cutPressure Guidewire
Fiber optic technology enabling
Workhorse pressure guidewire design
Fiber optic technology enabling
Workhorse pressure guidewire design
Laser cutspiralstainlesssteel
• Workhorse pressure guidewire design
• Improved procedural freedom
• Utilize the guidewire as a standard
• Workhorse pressure guidewire design
• Improved procedural freedom
• Utilize the guidewire as a standard3 electrical
Larger diameter Nitinol core –enhanced torque characteristic
steel
Utilize the guidewire as a standardPCI guidewire
• Accurate FFR measurement - minimaldrift *.
Utilize the guidewire as a standardPCI guidewire
• Accurate FFR measurement - minimaldrift *.
3 electricalcables
• Re-connect-disconnect – Quick, reliable,easy – true fluid resistance.
• Re-connect-disconnect – Quick, reliable,easy – true fluid resistance.
Small diametercore wire
in ACCURACY
FFR with Confidence – Zero drift*
Lead with the Light
• Opsens - Accurate FFR measurement showing minimal drift*.
FFR with Confidence – Zero drift*
Extract Specifications OptoWire St. Jude** Volcano***
Zero drift (mmHg / h) < 1 < 7 < 30Zero drift (mmHg / h) < 1 < 7 < 30
**St-Jude documentation # 100018911.*** Extract from NHJP presentation:
Putting it all together: Why FFR works,presented in Stanford CoronaryOpsens tested 20 devices for 8 hours presented in Stanford Coronary
Physiology Conference Oct, 2015.
* Per IEC 60601-2-34 ed3
Opsens tested 20 devices for 8 hours• 18 showed zero drift over 8 hours.• 2 showed less than 1 mmHg over 8 hours.
• 0.014” guidewire compatible,rapid exchangerapid exchange
• Optical pressure sensingtechnologytechnology
• Ultra-thin distal shaft
<3F <2F
Sensor
.026x.020”<3F
<2F
<2F
Marker
.026x.020”
MPS Catheter Distal Tip~10 mm
R .Diletti,etal.Eurointervention2015;11:428-432.
R .Diletti,etal.Eurointervention2015;11:428-432.
Fractional Flow Reserve (FFR)M ainlim itationsM ainlim itations
Optimal route and dose of adenosineadministration still remains a subject of debateand investigationand investigation
Difficult deliverability and insufficient durabilityof the pressure wireof the pressure wire
Relatively high incidence of drift
iFR concept still under investigation iFR concept still under investigation
Physiological Lesion AssessmentiFR versusFFR (R ES O LVES tudy)iFR versusFFR (R ES O LVES tudy)
Conclusions This comprehensive core laboratory analysis comparing iFR andPd/Pa with FFR demonstrated an overall accuracy of 80% for both nonhyperemicindices, which can be improved to 90% in a subset of lesions. Clinical outcome
JAm CollCardiol2014;63:1253-1261.
indices, which can be improved to 90% in a subset of lesions. Clinical outcomestudies are required to determine whether the use of iFR or Pd/Pa mightobviate the need for hyperemia in selected patients.
iFR outcome data late breaking
clinical trial sessionsclinical trial sessions
Saturday, March 18
10:45 am – 12:00 pm10:45 am – 12:00 pm
The DEFINE FLAIR study
1 year outcome data1 year outcome data
Justin Davies, MD, PhD
Imperial College of London, UK
iFR Swedeheart study
1 year outcome data
Matthias Götberg, MD, PhD
Lund University, Sweden
Fractional Flow Reserve (FFR)How toassesssequentiallesions?
• Hyperemic Flow (FFR)How toassesssequentiallesions?
Proximal Distal
• The proximal lesion limits themaximum blood flow into the distal
Distal
maximum blood flow into the distallesion, while the distal lesion limitsthe maximum blood flow across theproximal lesionproximal lesion
• When one lesion is removed, theFFR value of the remaining lesion ischangedchanged
Nijjer S, et al. “Pre-Angioplasty Instantaneous Wave-Free Ratio (iFR) Pullback Provides Virtual Intervention and Predicts HemodynamicOutcome for Serial Lesions and Diffuse Coronary Artery Disease. JACC: Cardiovascular Interventions 2014; 12: 1386-1396.
P uriR ,etal.JAm CollCardiolIntv2012;5:697– 707
Physiological Lesion AssessmentN ew concept-iFR = instantaneousw ave-freeratio
Definition:Instantaneous120
N ew concept-iFR = instantaneousw ave-freeratio
Definition:Instantaneous
pressure ratio, across astenosis during the wave-freeperiod, when resistance is
Pre
ss
ure
(mm
Hg
)
Wave-free period
period, when resistance isnaturally constant andminimised in the cardiac cycle Pa
Pre
ss
ure
(mm
Hg
)
Pd70
Pre
ss
ure
(mm
Hg
)
0 100 200 300 400 500 600 700 800 900
70
Time (ms)
During the Wave Free period
Time (ms)
Sen S et al. J Am Coll Cardiol. 2012 Apr 10;59(15):1392-402
Fractional Flow Reserve (FFR)How toassesssequentiallesions?
• Hyperemic Flow (FFR) • Baseline Flow (iFR)
How toassesssequentiallesions?
Proximal Distal Proximal Distal
• The proximal lesion limits the • The microvasculature maintains the
Distal Distal
• The proximal lesion limits themaximum blood flow into the distallesion, while the distal lesion limitsthe maximum blood flow across theproximal lesion
• The microvasculature maintains thebaseline distal flow (autoregulation)
• When a lesion is removed, flow doesnot change substantially
proximal lesion
• When one lesion is removed, theFFR value of the remaining lesion ischanged
not change substantially
• The iFR value of the remaininglesion remains constant
changed
Nijjer S, et al. “Pre-Angioplasty Instantaneous Wave-Free Ratio (iFR) Pullback Provides Virtual Intervention and Predicts HemodynamicOutcome for Serial Lesions and Diffuse Coronary Artery Disease. JACC: Cardiovascular Interventions 2014; 12: 1386-1396.
0.92 (post PCI)
Fractional Flow Reserve (FFR)How toassesssequentiallesions?
iFR Co-RegistrationWith iFR co-registration there is no need for hyperemic drugs,no need for time consuming pullback devices and no need for guesswork
How toassesssequentiallesions?
no need for time consuming pullback devices and no need for guesswork
• Make lengthmeasurementswithout awithout acumbersomepullbackdevice
• Plan yourprocedure withphysiologicphysiologicguidance
Fractional Flow Reserve (FFR)How toassesssequentiallesions?
Get the complete picture of vessel physiology and lesion morphologywith iFR and IVUS Tri-registered with the angiogram
iFR and IVUS Tri-RegistrationHow toassesssequentiallesions?
with iFR and IVUS Tri-registered with the angiogram
Thank you for your attention!
top related