The Future of Coronary Physiology

Transcription

1 The Future of Coronary Physiology Morton J. Kern, MD Chief of Medicine, VA Long Beach HCS Professor of Medicine University California Irvine Orange, California

2 Disclosure: Morton J. Kern, MD Within the past 12 months, the presenter or their spouse/partner have had a financial interest/arrangement or affiliation with the organization listed below. Company Name St. Jude Medical Inc. Volcano Therapeutics Merit Medical Inc. Acist Medical Inc. Opsens Relationship Speakers Bureau Speakers Bureau Consultant Consultant Consultant

3 The Birth of Interventional Physiology

4 The Landscape Serial lesions bifurcation ostial LAD Left main CTO jailed side branch

5 The Tools 100 mm Hg FFR = mm Hg Flush Off FFR 0 mm Hg IMR=Pa*Tmn [(Pd Pw)/(Pa Pw)] FFR=0.78 CVR ifr HSRv=Pa-Pv/APVhyper IC Doppler Flow velocity

6 The Math Index Variables comment Coronary Flow Reserve, CFR, CVR, CFVR APV Hyper /APV base Resistance Sum, epicardial,microvasc Relative CFR, rcfr CFR target /CFR ref Qs/Qn (?) Resting translesional Pressure Ratio Pd/Pa Epicardial only Instantaneous wave free pressure ratio, ifr Hyperemic translesion Pressure Ratio, FFR Hyperemic Stenosis Resistance, HSR Hyperemic Myocardial Resistance, HMR Index of Microcirculatory Resistance, IMR Pd/Pa, wf period Pd/Pa, hyperemia (Pd-Pa )/APV hyperemic P d /APV hyperemic P a *Tmn * [(P d P w )/(P a P w )] Epicardial only Epicardial only Epi+Micro Myocardial Resistance Microcirculatory resistance

7 The Future Technical Advances P-Q combowires Opitcal Fiber Pressure Microcatheters Co-registration Absolute Blood Flow CT FFR Outcome Studies STEMI/NSTEMI Side Branch Microvascular Dz Cardiomyopathy TAVR PVD Conceptual Advances CFC/iFR/IMR/etc.

8 Microcatheter Monorail Pressure system Courtesy of ACIST Medical, Inc. Rxi System

9 FFR of LAD w microcatheter

10 FFR of Diagonal branch

11 FFR (Optical Fiber) with Co-Registration Co-Reg Toggle off Co-Reg if desired AUC Courtesy of Boston Scientific

12 Pre-Angioplasty ifr Pullback Provides Virtual Intervention and Predicts Hemodynamic Outcome for Serial Lesions and Diffuse CAD J Am Coll Cardiol Intv. 2014;7(12):

13 Using ifr to perform Virtual PCI PRE-PCI (MEASURED) VIRTUAL PCI POST-PCI (PREDICTED) (MEASURED) ifr intensity overlaid onto angiogram ifr Angiographic stenosis corresponds to region with highest

14 Functional Lesion Assessment of Intermediate stenosis to guide Revascularisation Intermediate lesion requiring physiological assessment In ACS : intermediate non-culprit lesion N=2500, 1:1 Randomisation FFR guided PCI ifr guided PCI FFR>0.8 Defer PCI FFR 0.8 Perform PCI ifr 0.9 Defer PCI ifr<0.9 Perform PCI 30 day, 1, 2 and 5yr followup

15 FAME 2: Two Year Follow-Up Two year rate of primary endpoint: Death, MI, Urgent Revascularization De Bruyne, et al. NEJM 2014;371:

16 1 year MACE Rates Where do we go from here? % SYNTAX FAME FAME 3

17 True Ischemia? Pressure (FFR) vs Flow (CFR? Nl CFR Abn FFR N,N Study: Define Flow treat microvascc Johnson N et al. J Am Coll Cardiol Img. 2012;5(2):

18 ΔP (mm Hg) Rationale Prognostic value of discordance 50 S3 40 S2 30 MR v up FFR < 0.80 S1 20 MR v down 10 CFVR baseline velocity v cm/sec Van de Hoef et al. Circ Cardiovasc Interv 2014

19 Postulated Physiologic Changes after TAVR for Lesion Assessment Aortic Stenosis CFR Aortic Stenosis TAVR Post TAVR IMR Dia Suction Wave LV Relax FFR

20 Patients with and without microvascular injury after primary PCI in anteroseptal myocardial infarction without microvascular injury. Low HMR with microvascular injury. High HMR Paul F.A. Teunissen et al. Circ Cardiovasc Interv. 2015;8:e001786

21 The Future of STEMI IRA-only? PRAMI and Culprit, Treat culprit and FFR rest? Major Issue for STEMI Approach Achieve complete revascularization for ischemia. Culprit only approach: Potentially leaves non-culprit stenosis untreated MV all apppoach: Potentially over treats non-culprit lesions which are not ischemic FFR can identify ischemic lesions. Question about threshold for negative FFR in some patients.

22 Contemporary Randomized STEMI MVD Trials Do All now Do All, stage Do All now, use FFR

23 FFR CT Superior to All Methods to Date Non-Invasive Gold Standard LAD FFRCT 0.96 RCA FFRCT 0.60 Source: Koo et al. JACC 2011; Min JK et al. JAMA 2012; Norgaard BL et al. JACC 2014

24 CFC Coronary Flow Capacity CFR hapv T. Van de Hoef et al, Circ Interven, In press 2015

25 T. Van de Hoef et al, Circ Interven, In press 2015

26 The Future of Coronary Physiology 2016