Fractional Flow Reserve and instantaneous wave -free Ratio. Λάμπρος Κ. Μόσιαλος Επεμβατικός Καρδιολόγος ΓΝ Παπαγεωργίου

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1 Fractional Flow Reserve and instantaneous wave -free Ratio Λάμπρος Κ. Μόσιαλος Επεμβατικός Καρδιολόγος ΓΝ Παπαγεωργίου

2 DISCLOSURES There are no financial conflicts of interest relevant to this presentation

3 The functional significance of an angiographic lesion cannot be judged from the classical angiogram

4 Detection of Ischemia Per Patient (Exercise test) Per Territory (SPECT) Per Vessel (FFR-iFR)

5 Pressure Wire positioning

6 Fractional Flow Reserve FFR myo= Maximum myocardial blood flow in the presence of stenosis Normal maximum myocardial blood flow Q N = (P a -P v ) R Q S = (P d -P v ) R FFR myo = (P d -P v ) (P a -P v ) FFR myo = P d P a

7 Induction of Hyperaemia

8 Pressure gradient-velocity curves Gould KL. Circ Res Aug;43(2):

9 Pressure gradient-velocity curves Gould KL. Circ Res Aug;43(2):

10 Pressure gradient-velocity curves Gould KL. Circ Res Aug;43(2):

11 Probability of Ischemia

12 FFR after myocardial infarction B.De Bruyne Circulation 2001;104:

13 DEFER 15 years

14 FAME study

15

16 CTO, chronic total occlusion. Serruys P. Presented at TCT 2016.

17 (Circulation. 2014;129:

18 Results: PRIMARY ENDPOINT Summary Agreement about category of management in 147 out of 200 (74%) ie after FFR management change in 26% of cases Circ Cardiovasc Interv. 2014;7:

19 LAD Cx RCA Circ Cardiovasc Interv. 2014;7:

20 FFR is substantially underutilized

21 Limitations with FFR Requires hyperemic agent Adds time to the procedure Cost considerations Patient symptoms / side effects Unpredictable hyperemia Challenging in diffuse disease & tandem lesions Left main lesions Grafts Low-flow / High-flow situations (endothelial dysfunction/microvascular diseases; large coronary flow reserve)

22 Discordance between CFR and FFR Occurs in 30-40% of all stenoses 1 Only CFR assesses the microvascular function (autoregulation) additionally to the epicardial domain Combined use can reveal predominant or non flow-limiting stenoses and microvascular disease CFR shows strong relationship with ifr 2 1 Van de Hoef et al., Circ. Cardiovascular Interv Petraco R. et al., Circ. Cardiovascular Interv Aug;7(4):

23 Discordance between FFR and CFR occurred in 37% Van de Hoef TP, et al. Circ Cardiovasc Interv Jun;7(3):301-11

24 In general Small perfusion territory, distal stenosis, older patient, moderate long lesion, small artery, microvascular disease: often moderate gradient at rest with little increase at hyperemia Large perfusion territory, proximal stenosis, young patient, short severe lesion, large artery, intact microvasculature: often minimal gradient at rest with large increase at hyperemia

25 Circ Cardiovasc Interv. 2014;7:

26 Basic concept of ifr

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29 ifr FFR studies

30 Study Design ifr-swedeheart

31 ifr-swedeheart Primary Endpoint at 1 year (Death, MI, Unplanned revascularization) Procedural characteristics

32 Chest Discomfort from the procedure

33 DEFINE FLAIR study

34 DEFINE FLAIR study

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36 DEFINE-FLAIR ifr-swedeheart Largest Physiology prospective clinical outcome dataset

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38 Hyperemic Versus Baseline Blood Flow

39 Underestimated LM

40 ifr-scout pullback modality

41 ifr Co-Registration

42 ifr Intensity

43 ifr Intensity

44 Guidelines for FFR ifr

45 Guidelines for FFR ifr

46 Guidelines for FFR ifr 2018 ESC/EACTS myocardial revascularization guidelines on intracoronary diagnostics

47 CONCLUSION The use of coronary physiology to guide revascularization has been found to improve patient outcomes and defer stenting of nonischemic lesions compared with angiographic assessment. FFR-iFR carries a Class 1A recommendation for guiding revascularization in angiographically intermediate coronary stenoses in patients with stable angina. The DEFINE-FLAIR and ifr-swedeheart trials suggest that ifr may be the new evidence-based standard for invasive evaluation of intermediate-severity coronary lesions.

48 ΕΥΧΑΡΙΣΤΩ

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51 Impact of fractional flow reserve (FFR) on treatment decisions in FAMOUS NSTEMI