FFR= Qs/Qn. Ohm s law R= P/Q Q=P/R
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1 32 ο Πανελλήνιο Καρδιολογικό Συνζδριο, Θεσσαλονίκη 20/10/2011
2 Gould KL et al, JACC CARDIOVASC IMAG 2009
3 Gould KL et al AM J CARDIOL 1974 & JACC CARDIOVASC IMAG 2009
4 Under maximal hyperemia: Rs=Rn FFR= Qs/Qn (1) Qs: maximal flow to the myocardium in the presence of a stenosis Qn: maximal flow to the myocardium without a stenosis Ohm s law R= P/Q Q=P/R (2) (1)& (2)
5 Hodgson J, JACC CARDIOVASC INTERV 2010
6 Eyeballing vs FFR in LMCA K=0.45 (coefficient of concordance) Hamilos M et al CIRCULATION 2010
7 n=63, 2D & 3D QCA vs FFR<0.75 Yong A et al EUR HEART J 2010
8 FFR-guided IVUS for estimating the significance of a stenosis N=267 (intermediate lesions assessed), n=88 with FFR<0.8 Besides proximal and mid-lad, the appropriate MLA to predict the functional significance of lesions could not be found in other segments Koo BK et al JACC CARDIOVASC INTERV 2011
9 Melikian et al. JACC INTERV 2010 Patients n=67, vessels n=201 Sensitivity:76% 30% Ψευδώς αρνητικά 37% Ψευδώς θετικά Specificity:38% PPV:66% NPV:50%
10 Patients n=497, FAME study 1/3 of the pts were reclassified to a lower score Classic SYNTAX score Functional SYNTAX score Nam CW et al JACC 2011
11 Nam CW et al JACC 2011
12 Patients n=167, lesions n=83 FFR-guided and n=94 IVUS-guided 60% less revascularization in the FFR group 1year outcomes Nam CW et al. JACC CARDIOVASC INTERV 2010
13 FAME study: 1-year cost FFR-guided group= 14315$ vs Angio-guided group= 16700$, p<0.001 Fearon W et al CIRCULATION 2010
14 De Bruyne B et al. CIRCULATION 1996 Coefficient of variation: 4.8% for FFR, 10.5% for CFR and 27.7% for IHDVPS (instantaneous hyperemic diastolic velocity pressure slope) total
15 Bech et al. CIRCULATION 2001, Pijls NHJ. Coronary Physiology in the Catheterization Laboratory, Nice 2011 AVERAGE DIFFERENCE BETWEEN THE 2 FFR MEASUREMENTS: 0.03±0.02 DEFER study
16
17 Pijls NHJ et al. JACC 2007 DEFER study n=325, Stable angina
18 FAME study, 24 months n=1005, Stable angina Pijls NHJ et al. JACC 2010
19 Pijls NHJ et al. JACC 2010
20 Pijls NHJ et al. JACC 2010
21 n=213 Hamilos M et al. CIRCULATION 2009
22 Muller O et al. JACC INTERV 2011, in press
23 All lesions included had an FFR 0.75 Revascularization deferred ACS, n= 124: 11 STEMIs, 31 NSTEMIs, 82 UA Stable angina, n= 61 Potvin et al. Am J Cardiol 2006
24 Prospective multicenter study 1.00 FFR December 2007 September 2009 Cardiovascular Center Aalst, Belgium, Catharina Hospital Eindhoven, Vilnius University Hospital, Tokyo Medical University Hospital Inclusion criteria: i) STEMI treated by primary PCI or a NSTEMI scheduled for PCI within 72 hours ii) one non-culprit coronary artery stenosis (>50%) iii) stable hemodynamic condition STEMI: n=75 NSTEMI: n=26 FFR of the non-culprit(s) during the acute phase (after PCI of the culprit) and 35 4 days after ACUTE FOLLOW-UP p=ns Ntalianis et al. JACC CARDIOVASC INTERV 2010
25 FOLLOW UP FOLLOW UP Mean+2SD FFR Average r=0.91, p< A Mean-2SD ACUTE % DS Mean+2SD % Average Mean-2SD r=0.78, p< ACUTE -40 Ntalianis et al. JACC CARDIOVASC INTERV 2010
26 Delta FFR 0.20 TERTILES LVEDP ACUTE * 0.05 *p= LVEDP <15mmHg 15 LVEDP <20mmHg LVEDP 20mmHg Ntalianis et al. unpublished data
27 % % Sensitivity% Specificity% Area=0.64 p=0.05 LVEDP (mmhg) Δ FFR 0.04 Ntalianis et al. unpublished data
28 Patients n=49, vessels n=50 with in-stent restenosis (DES) when only the 15 lesions with diffuse-type restenosis were analyzed, the degree of correlation was no significant (r=0.56, p=0.12) Nam CW et al AJC 2011
29 Pijls NHJ et al. CIRCULATION 2002
30 Patients n=80, vessels n=99, FFR after DES implantation Nam CW et al AJC 2011
31 Glineur et al. J Thorac Cardiovasc Surg 2011 RITA=10, SVG=7
32 Consecutive patients with two coronary angiograms (n=127) Time interval between 2 angiographies 1 year FFR in the same native coronary vessel and segment Ntalianis et al. unpublished data
33 21 (14%) lesions with FFR < 0.75 at FU (from 0.83±0.04 to 0.68±0.06, p<0.01) Ntalianis et al. unpublished data
34 13 (9%) lesions %DS > 50% at FU (from 51±9% to 58±5%, p<0.05) Ntalianis et al. unpublished data
35 FFR is a valuable tool to determine whether or not an intermediate stenotic segment can cause downstream ischaemia in: A) stable patients with MVD B) unstable patients with MVD C) in-stent restenosis D) LM stenosis E) post-mi Wijns W et al. EUR HEART J 2010
36 FFR IVUS OCT Plaque burden/ Tissue characterization Ischemia burden Vessel size Dissection/ Thrombus Microcirculation/ Coronary flow (IMR, Absolute coronary flow) LV function (dp/dt)
37 FFR IVUS OCT 1VD/MVD + ±? LMCA + +? Proximal LAD +?? Post-stent implantation Acute coronary syndromes True/false lumen (CTOs) Atheromatosis progression ? ? Bifurcations + + +
38 FFR vs IVUS FFR vs OCT accessed on 18/10/2011
39
40 Personal communication with B. De Bruyne
41 Personal communication with B. De Bruyne
42 Erglis et al. ESCARDIO 2010
43 Koo et al, EUROPCR 2011
44 Koo et al, EUROPCR 2011
45 Fractional flow reserve is a very accurate and reproducible method to assess hemodynamic severity of coronary artery stenoses FFR adds significant prognostic information in patients with one-vessel or multivessel coronary artery disease, in-stent restenosis, post-stent implantation, left main coronary artery stenosis and post-myocardial infarction The incidence of myocardial infarction and revascularization of coronary artery stenoses with an FFR>0.8 is very low for at least 2 years after FFR measurements
46 Robust data show that FFR is cost-effective since both it improves outcomes and saves resources FFR CT is a very promising non-invasive tool in obtaining similar functional information to invasive FFR FFR should be implemented to decide if PCI is appropriate or not and IVUS or OCT to guide PCI
47 Back up slides
48 FFR and prognosis: Multivessel disease Pijls NHJ. Coronary Physiology in the Catheterization Laboratory, Nice 2011
49 Tonino P et al. NEJM 2010 n=1005, Stable angina FFR and prognosis: Multivessel disease
50 FFR and UA/NSTEMI Pijls NHJ et al. Coronary Physiology in the Catheterization Laboratory, Nice 2011
51 Latest news Accessed on 12/9/2011
52 Koo et al, EUROPCR 2011
53 Koo et al, EUROPCR 2011
54 FFR vs IVUS Ben Dor et al. Eurointervention 2011
55 FFR and cost-effectiveness Hoole S et al CAN J CARDIOL 2011
56 Paradigm shift: from anatomy to physiology Park SJ et al CIRCULATION 2011
57 Myocardial perfusion territory and FFR FFR=0.72 Iqbal M et al CIRCULATION CARDIOVASC INTERV 2010
58 Myocardial perfusion territory and FFR AFTER 2 DES IN THE RCA FFR=0.84 Iqbal M et al CIRCULATION CARDIOVASC INTERV 2010
59 FFR and cost-effectiveness FFR vs MPI Fearon W et al AHJ 2003 Fearon W et al AHJ 2003
60 FFR of the culprit and prognosis Lopez et al. Rev Esp Cardiol 2010
61 Στεφανιαία Εφεδρεία Νεώτερες εξελίξεις Αργύριος Νταλιάνης
62 FFR post-stenting nnnnnnnnnn
63 IU FFR and Non-culprit lesions Index of Microcirculatory resistance 80 n= p=ns 0 ACUTE FOLLOW UP Ntalianis et al. JACC Cardiovasc Intervent 2010
64 FFR and ACS; the culprit lesion and prognosis All lesions included: FFR 0.75 Revascularization deferred ACS: 11 STEMIs, 21 NSTEMIs, 3 UA Fischer et al. CCI 2006
65 FFR other applications Grafts IMR Absolute coronary artery flow measurements LV dp/dt measurements (resynchronization therapy) Renal artery stenosis
66 Latest news Accessed on 12/9/2011
67 Latest news Accessed on 17/10/2011
68 Latest news Accessed on 18/10/2011
69 Latest news Accessed on 18/10/2011
70 Latest news Accessed on 18/10/2011
71 Latest news Accessed on 18/10/2011
72 Latest news Accessed on 18/10/2011
73 Latest news Accessed on 18/10/2011
74 Latest news Accessed on 18/10/2011
75 Latest news Accessed on 18/10/2011
76 Latest news Accessed on 18/10/2011
77 1. dye don t lie Applegate R, JACC dye and decide 3. a coronary artery stenosis is severe if it looks severe even in one projection
78 FFR: basic principle FFR= Qs/Qn (1) Qs: maximal flow to the myocardium in the presence of a stenosis Qn: maximal flow to the myocardium without a stenosis P: pressure, Q: flow, R: resistance Ohm s law R= P/Q Q=P/R (2) (1)& (2) Under maximal hyperemia: Rs=Rn (3)
79 Microvascular resistance in the presence of an epicardial stenosis Jayaweera et al. Am J Physiol 1999
80 De Bruyne B. Heart 2008 FFR: basic principle FFR= Ps/Pn (Pv is negligible)
81 FFR: basic principle De Bruyne B. Heart 2008
82 Latest news Accessed on 12/9/2011
83 Future avenues ; FFR CT Erglis et al. ESCARDIO 2010
84 Chamuleau S et al. AJC 2002 n=107,mvd, MPI NEGATIVE, One intermediate stenosis, FFR<0.75: n=15, FFR 0.75: n=92 30 % 25 26, Relative Risk= 3.1, p=0.04 8,7 FFR< FFR 0.75
85 n=407,revascularization n=136, No Revascularization n=271, MACE: 15,5% vs 6% p=0.01 (non compliance vs compliance group) Legalery P et al. EHJ 2005
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