Case Review: Borderline LM with IVUS and FFR. Ravi Ramana, DO Heart Care Centers of Illinois SCAI Annual Conference 2010

Transcription

1 Case Review: Borderline LM with IVUS and FFR Ravi Ramana, DO Heart Care Centers of Illinois SCAI Annual Conference 2010

2 Disclosures No relevant disclosures.

3 Borderline Left Main Disease Significant LMS carries a very poor clinical prognosis esp. with LMS >60%, stenosis dominant RCA, low EF Appropriate revascularization improves angina, CHF and survival. Therefore, identification of significant LMS is crucial. The accuracy of angiography of intermediate LM is limited. Therefore, other modalities can/should be used to aid in the diagnosis and planned therapy in this clinical setting.

4 Borderline Left Main Disease Additional modalities include IVUS, FFR (CFR) IVUS versus FFR used complimentary for LMS IVUS Anatomic Significance FFR Physiologic/Functional Significance

5 Case Review History of Present Illness: 52yo presents to clinic with c/o exertional CP. Cardiac RFs: HL, Current Smoker, +FamHx Seen by his PCP who ordered a Cardiac CTA.

6 Cardiac CTA

7 Conventional Angiography

8 Decision Making Time 1. Trust your eyeball PCI RCA vs. CABG 2. Further testing with IVUS/FFR

9 IVUS Left Main

10 FFR - Left Main: Technique Give IV anticoagulation Normalize pressure-wire outside of guide in Aortic Root Engage catheter to LM Administer IC Nitroglycerin ( mcg) Pass pressure-wire distal to stenosis and disengage guide catheter Ostial LMS: measure (P d ) from distal LM Distal LMS: measure (P d ) from LAD and LCx Record Baseline FFR Give IV Adenosine Protocol ~2-4 minutes Record Hyperemic FFR

11 FFR - Left Main:

12 Summary: 1. Borderline LMS on Cardiac CTA and Angiography 2. Significant LMS by IVUS and FFR Therefore, the patient underwent CABG

13 Current Role of IVUS & FFR Evaluate intermediate lesions Assessment of post-pci results Assessment of ostial side-branch lesions Assessment of LM stenosis Appropriate referral for CABG Proceed with PCI of non-lm lesions No revascularization needed

14 IVUS-Guided LM Therapy Abizaid et al. (1999) reported IVUS parameters that may predict clinical events (no ~ physiologic measurements) IVUS MLD >3.0mm had a very low 1 year event rate (3%) Fassa (2005) reported MLA>7.5mm 2 as cut-off value 3 year event rates of CABG vs. deferred were the same

15 IVUS-Guided LM Therapy As FFR 0.75 as gold standard : Jasti 2004

16 IVUS-Guided LM Therapy Cardiac Death Cardiac Event Jasti 2004

17 FFR-Guided LM Therapy: DEFER & FAME Results FFRguided

18 FFR-Guided LM Therapy : FFR versus Clinical Outcome Reference n FFR<0.75 FFR>0.75 (Defer) F/U (months) Mortality in deferred group Bech et al Heart Jimenez- Navarro et al Jasti et al Suemaru et al Legutko et al Lindstaedt et al J Inv Cardiol 2004 Circulation 2004 Heart Vessels 2005 Kardiol Pol 2005 Am Heart J (all non-cardiac)

19 FFR-Guided LM Therapy 274 consecutive pts with indeterminate LMS All underwent FFR of LM: If FFR >0.80 medical or PCI non-lm lesions If FFR <0.80 CABG Average 3 year F/U: all-cause death, MI, CABG/PCI Hamilos 2009

20 Long-term outcomes of patients with LMS in whom CABG was deferred due to FFR >0.80 is favorable and similar to that of patients in whom CABG was done based on FFR <0.80. Hamilos 2009

21 Cons of LM IVUS/FFR IVUS: IVUS catheter difficult to keep co-axial during pullback IVUS catheter may damage lesion/vessel Images may be difficult to assess due to severe Ca ++ IVUS measurements are not indexed for patient body size FFR: Does not differentiate between >50% and >60% stenosis Inaccurate in setting of AMI (2 microvasculature dysfunction) May add time and cost to the procedure

22 Important Reminders Give IC NTG and IV anticoagulant prior to either test Use IV (not IC) adenosine for FFR If distal LMS: must FFR LM LAD and LM LCx When assessing LMS disengage guide catheter

23 Guiding Catheter in Ostium = Stenosis 8F Area Stenosis 64% 3 mm 2.4 mm 7F 49 % 3 mm 2.1 mm 6F 36 % 3 mm 1.8 mm

24 Assessment of Borderline Left Main: You may defer revascularization for LMS if IVUS MLD > 2.8mm FFR > MLA > 5.9mm 2

25 Borderline LM with IVUS and FFR Significant LM disease carries a poor clinical prognosis and the accuracy of standard angiography for LMS is limited IVUS/FFR are valid and objective measures of LMS severity May identify patients who should undergo CABG/PCI LM IVUS: anatomy, plaque position/composition LM FFR: determines functional significance