La FFR quoi d autre: En pratique? Pierre Deharo, CHU TIMONE, Marseille

Transcription

1 La FFR quoi d autre: En pratique? Pierre Deharo, CHU TIMONE, Marseille

2 La FFR quoi d autre: En pratique? How to avoid non reliable results Management of MVD Non Culprit in STEMI Left main Severe AS Post PCI (?)

3 La FFR quoi d autre: En pratique? How to avoid non reliable results

4 How to avoid non reliable results - Guiding catheter ( 5F) - Anticoagulation required - Nitrates before FFR - Flush - calibrate - zero Pa to the system - Equalization FFR wire and Pa pressures when sensor tip is in the aorta - Pressure wire distal to the stenosis - Maximal Hyperhemia: IC Adenosine (> 100 µg) - Check the absence of drift Be systematic

5 How to avoid non reliable results - Guiding catheter ( 5F) - Anticoagulation required - Nitrates before FFR - Flush - calibrate - zero Pa to the system - Equalization FFR wire and Pa pressures when sensor tip is in the aorta - Pressure wire distal to the stenosis - Maximal Hyperhemia: IC Adenosine (> 100 µg) - Check the absence of drift Be systematic

6 How to avoid non reliable results Be systematic - Guiding catheter ( 5F) - Anticoagulation required - Nitrates before FFR - Flush - calibrate - zero Pa to the system - Equalization FFR wire and Pa pressures when sensor tip is in the aorta - Pressure wire distal to the stenosis - Maximal Hyperhemia: IC Adenosine (> 100 µg) - Check the absence of drift P a P d

7 How to avoid non reliable results Tips and tricks Ostial lesions Avoid guiding catheter engagement Check the curve morphology

8 La FFR quoi d autre: En pratique? How to avoid non reliable results Management of MVD

9 Multivessel disease: revascularisation strategy MVD: Angiography vs. FFR Angiography 3 VD Overestimation of complexity and MVD by angiography vs. FFR Tonino et al, JACC 2010

10 Multivessel disease: revascularisation strategy PCI or CABG: FFR helpful! Man 67 years old, Angina, Stress test + 60% LAD, 90% Mg, 99% RCA LAD STRATEGY: FFR LAD: If FFR LAD +: CABG / If - : PCI Mg and RCA Mg

11 La FFR quoi d autre: En pratique? How to avoid non reliable results Management of MVD Non Culprit in STEMI

12 MVD et STEMI Complete revascularisation is the standard for STEMI FFR guided revascularisation > OMT (COMPARE ACUTE / DANAMI) Questions: When to perform FFR (acute vs. staged)? Complete FFR > complete angio?

13 When to perform FFR in Non Culprit Lesion of ACS patients? «Acute FFR» reliable in non culprit vessel of ACS Natalianis et al, JACC Int 2010

14 Complete FFR guided vs. angio guided: FLOWER-MI STEMI patients with successful culprit lesion PCI (primary, rescue or pharmaco-invasive) and 50% stenosis in at least one additional non-culprit lesion Randomization 1: patients 40 centres 2,5 ans Complete revascularisation Angio-guided PCI (during the index hospital admission ) + OMT Complete revascularisation FFR-guided PCI (during the index hospital admission ) + OMT Follow-up : Discharge, 1, 6 and 12 months Primary Efficacy Outcome: death or non-fatal MI or unplanned hospitalization leading to urgent revascularization at 12 months complete revascularization is encouraged to be done during the index procedure but if that is not possible can be performed during another procedure as soon is possible and before 5 days from the index procedure

15 La FFR quoi d autre: En pratique? How to avoid non reliable results Management of MVD Non Culprit in STEMI Left main

16 LMS Angiography vs. FFR in LMS disease Poor Agreement between FFR and angiography for LMS Disease Hamilos et al, Circulation 2009

17 LMS Left Main Stem Algorythm with FFR LMS lesions are rarely isolated Bhavik et al, Eurointervention 2017

18 LMS Clinical value of FFR in LMS Good prognosis of FFR-guided decision Hamilos et al, Circulation 2009

19 La FFR quoi d autre: En pratique? How to avoid non reliable results Management of MVD Non Culprit in STEMI Left main Severe AS

20 AS FFR has some limitations in severe AS Microvascular dysfunction Difficulties in achieving maximal hyperhemia Impaired CFR even in the absence of coronary obstruction Wiegerinck et al, Circ C Int 2015

21 AS FFR reproducible after TAVI 0.89± ±0.13 Pesarini et al, Circ C Int 2016

22 AS Changes for borderline FFR (6%) Pesarini et al, Circ C Int 2016

23 La FFR quoi d autre: En pratique? How to avoid non reliable results Management of MVD Non Culprit in STEMI Left main Severe AS Post PCI (?)

24 Post PCI? Better prognosis if higher post-pci value Piroth et al, Circ C Int 2017

25 Conclusion: en pratique Very useful tool in a cathlab Systematic protocol Management of intermediate lesions and multivessel disease Severe AS, STEMI and post-pci under evaluation