Physiology (FFR & IFR) is Essential in Daily Pratice. Martine Gilard Brest University - France

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1 Physiology (FFR & IFR) is Essential in Daily Pratice Martine Gilard Brest University - France

2 Background Invasive assessment of atherosclerotic coronary artery lesion Morphological assessment IVUS X-ray Angio Functional assessment FFR/ IFR OCT

3 Gould KL. JACC Cardiovasc Imaging: 2009;2:1009 Coronary angiography and functional impact A significant coronary

4 Tonino et al. N Engl J Med 2009;360: Coronary angiography and functional impact FAME Study 1329 lesions

5 Coronary angiography and functional impact

6 Rational Revascularisation has improved survival in patients with moderate to severe ischemia. Whereas medical treatment resulted in better survival than revascularisation in patients with no or mild ischemia

7 In clinical practice One or multivessel disease Left main of Acute Coronary Syndrome

8 FFR DEFER FAME FAME II

9 Pijls et al. J Am Coll Cardiol 2007;49: CV death and AMI 5-year FU

10 Van Numen et al. Lancet 2017;386: FAME: CV death and AMI 5-year FU

11 Instantaneous wave-free ratio (IFR) 25 % 75 % Without adenosine

12 Davies et al N Engl J Med 2017;376: DEFINE-FLAIR: pts Primary end point: Death, MI, unplanned revascularisation

13 Götberg et al N Engl J Med 2017;376: ifr SWEDEHEART: pts Primary end point: Death, MI, unplanned revascularisation

14 Low risk population in IFR trials FAME FLAIR SWED However Large inferiority margin 1-year MACE (%) 13% 7% 6.7 FFR mean %FFR % 35% 29% Multivessel CAD 100% 42% 35.7% CCS class II-IV 74% 48% 64% Prior MI 37% 30% 33.1% Population Risk HIGH low low

15 Adjedj al. Circulation 2016; 133(5): Berry C et al. Circulation 2017; 36: FU too short However Death & AMI ifr FFR RR (IC) p DEFINE-FLAIR 53 (4.6%) 41 (3.5%) 1.39 ( ) 0.16 SWEDEHEART 37 (3.7%) 29 (2.9%) 1.27 ( ) 0.33 Overall ( ) 0.09

16 Left Main and FFR Elgendy et al Clin. Cardiol.2014; 37:

17 Koo et al., Euro Heart J 2008; 29: Side branch > 2 mm et > 50% Only 26 lesions with FFR> 0.75

18 Koo et al., Euro Heart J 2008; 29: Side branch > 2 mm et > 50%

19 Botman et al. Ann Thorac Surg 2007;83: FFR of lesions and angiographic patency at 1 year 153 patients 525 lesions

20 Layland et al European Heart J 2015;36: Maximal coronary hyperaemia which may be less readily achieved in patients with because of coronary microvascular dysfunction FAMOUS-NSTEMI 350 patients 6 UK centres

21 Layland et al European Heart J 2015;36: n=14 n=11 n=144 n=125 n=18 N=40

22 Zhang et al Heart 2015;101: Pronostic value of FFR Global Death

23 Zhang et al Heart 2015;101: Pronostic value of FFR AMI

24 Economic evaluation of FFR in FAME FFR améliore le pronostic et économise les ressources Fearon et al Circulation 2010;122:

25 Guidelines ESC Guidelines on myocardial revascularization Eur Heart J 2014;35:

26 Take Home Messages We must avoid unnecessary treatment of lesions that are not haemodynamically relevant FFR is the current standart of care for the functional assessment of coronary lesion severity FFR guided PCI, as compared with angiography guidance, improves the outcomes