ffr in diffuse, serial and multiple stenosis · bon-kwon koo, md, phd seoul national university...
TRANSCRIPT
BonBon--Kwon Koo, MD, PhDKwon Koo, MD, PhD
Seoul National University Hospital, Seoul, KoreaSeoul National University Hospital, Seoul, Korea
FFR in diffuse, serial and multiple stenosisFFR in diffuse, serial and multiple stenosis
IPS 2009FFR in Clinical Practice: “Learn from the Cases”
• FFR is the only mean of gaining a per segment functional assessment of the coronary tree
- Stress ECG: Per patient
- Radioisotope scan, CFR Per vessel
- FFR Per segment
Seoul National University Hospital
LA: 2.8mm2
LA: 3.4mm2
LA: 2.6mm2
M/66 Unstable anginaPlanned urgent liver transplantation
Seoul National University Hospital
Pa
B
A
Pm
Pd
FFR(A)pred =Pd - (Pm/Pa) Pw
Pa - Pm + Pd -Pw
FFR(B)pred =(Pa - Pw) (Pm - Pd)
Pa (Pm - Pw)
Pw = Coronary occlusive pressurePijls NHJ et al Circulation 2000
De Bruyne B et al Circulation 2000
FFR in Serial Stenoses
Seoul National University Hospital
FFR in Serial Stenoses: Real world practice
1. Measure FFR of all stenoses together from distal Pd / Pa
2. When FFR is not significant, leave all lesions alone.
3. When it is significant, perform a pressure pullback tracing under steady state hyperemia
PCI the most severe (pressure step-up >10-15mmHg) firstRepeat a pressure pullback tracing
Seoul National University Hospital
LA: 2.8mm2
LA: 3.4mm2
LA: 2.6mm2M/66 Unstable anginaPlanned to urgent liver transplantation
Seoul National University Hospital
M/66 Unstable anginaPlanned to urgent liver transplantation
s/p Vision 3x23mm
Seoul National University Hospital
Diffuse disease without pressure step-up
Multivessel disease
F/52Stable angina, 3VD by CT coronary angiography
Seoul National University Hospital
Extent of Coronary artery diseaseAngiography vs. FFR
Fernando, AJC 2007
1VD1VD
1VD1VD2VD2VD
2VD2VD
3VD3VD
3VD3VD No diseaseNo disease
Multivessel disease
F/52Stable angina, 3VD by CT coronary angiography
1
3
2
4
1 2 3 4
F/52Stable angina, 3VD by CT coronary angiography 1VD by FFR
1
3
2
4
3 4
“3-VD ?”
Proportions of functionally diseased coronary arteries in patients with angiographic 3 vessel disease
3-VD 14%
1-VD 34%
2-VD 43%
0-VD9%
Tonino ESC 2009
Inside the hall of “FAME”
F/52Stable angina, Recent aggravationCT CAG: pLAD 50%, pLCX 70%, RCAos 40%TMT: + at 4min exercise
F/52Stable angina, Recent aggravation
Angiography-guided PCI(N=496)
FFR-guided PCI(N=509)
DES, all indicated stenoses DES, when FFR ≤ 0.80
Randomization
Patient with stenoses ≥ 50% in at least 2 major epicardial vessels
(N=1005)
1-year follow-up
DES: drug-eluting stents
FAME study
Tonino, et al. NEJM 2009
FAME study: Procedural Results
ANGIO-groupN=496
FFR-groupN=509
P-value
No of stents per patient 2.7± 1.2 1.9 ± 1.3 <0.001
Procedure time (min) 70 ± 44 71 ± 43 0.51
Contrast agent used (ml) 302 ± 127 272 ± 133 <0.001
Materials used at procedure (US $)
6007 5332 <0.001
Fearon, et al TCT 2009
FAME study: 2-year outcomes
730 days730 days∆∆4.5%4.5%
AngioAngio--GuidedGuided
FFRFFR--GuidedGuided
AngioAngio--GuidedGuided
FFRFFR--GuidedGuided
730 days730 days∆∆4.3%4.3%
2 Year Death/MI-free Survival2 Year MACE-free Survival
MACE: Death, MI, re-PCI, CABG
513 Deferred Lesions in509 FFR-Guided Patients
2 Years
53 Repeat Revascularizations 37 New or Restenotic lesions
16Originally Deferred Lesions
6 Without FFR or Despite an FFR < 0.80
10Originally Deferred Lesions
with Clear Progression
Only 10/507 or 2.6% of deferred lesions clearly progressed
requiring repeat revascularization
Outcome of Deferred Lesions
Fearon, et al TCT 2009
Inside the hall of “FAME”
513 Deferred Lesions in509 FFR-Guided Patients
2 Years
31 Myocardial Infarctions 22 Peri-procedural
9Late Myocardial Infarctions 8 New Lesion or Stent Related
1MI due to Originally deferred lesion
Only 1/509 or 0.2% of deferred lesions resulted in a late MI
Outcome of Deferred LesionsInside the hall of “FAME”
Fearon, et al TCT 2009
When multiple stenoses:Meaure FFR at distal; If significant, perform a pressure pullback tracing PCI the most severe stenosisRepeat the pressure pullback tracing, ........
When multivessel diseases:Measure FFRPerfrome a pressure pullback tracing in all significant vessels
When diffuse disease and no focal stenosis:Measure FFRPerform a pressure pullback tracingStent only if there is a focal pressure step-up (ΔP>10-15 mm Hg, empiric statement)
Serial, Multiple Stenoses and Diffuse Disease