tips and tricks for ffr assessment revisited – an update ... · tips and tricks for ffr...

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)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).


Femoral versus antecubital vein adenosine infusion (140 µg/kg/min.)


ANTECUBITALFEMORAL ANTECUBITAL

Legutko J et al. J Am Coll Cardiol. 2016;68(18S):B214.


Femoral vein adenosine infusion - 140 versus 280 µg/kg/min.


Legutko J et al. Advances in Interventional Cardiology. 2016; 12, 4 (46).


Femoral vein adenosine infusion - 140 µg/kg/min.versus intracoronary bolus – 100 µg




Femoral vein adenosine infusion - 140 µg/kg/min.versus intracoronary bolus – 600 µg




Femoral vein adenosine infusion versus intracoronary boluses




Percentage of functionally significant lesions according to differentmethods of adenosine administration



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)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.

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


• 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)


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


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!

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