Declaration of conflict of interest Nothing to disclose
Hong-Seok Lim, Seung-Jea Tahk, Hyoung-Mo Yang, Jin-Woo Kim, Kyoung- Woo Seo, Byoung-Joo Choi, So-Yeon Choi, Myeong-Ho Yoon, Gyo-Seung Hwang, Joon-Han Shin Department of Cardiology Ajou University Medical Center
Intravascular ultrasound (IVUS) provides useful information during stent implantation to optimize stent expansion, extension, and apposition; and to identify and treat possible complications after stent implantation. Mintz GS et al., J Am Coll Cardiol 2001;37:1478-92. Hanekamp CE et al., Circulation 1999;99:1015-1021 MSA 5.0 mm 2 MSA 5.5 mm 2 MSA 6.0 mm 2 Sonoda S, et al., J Am Coll Cardiol 2004;43:1959 63 Hong MK, et al., Eur Heart J 2006;27:1305 1310 E, et al., Am J Cardiol 2005;95:1240 1242
FFR is useful and comparable to IVUS to guide optimal stent implantation. % Adverse Events at 6 Months Hanekamp CE, et al., Circulation 1999;99;1015-1021 300 150 200 150 266 241 130 16% 22% 30% 30 % 20 % No. of patients AE at 6 mo 100 50 N 0.96-1.00 5% 0.91-0.95 6% 0.86-0.90 63 0.81-0.85 10 % 44 % event 0.76-0.80 Pijls NH, et al., Circulation 2002;105;2950-2954
FFR for 1yroutcomes after DES implantation Nam CW, et al., Am J Cardiol 2011;107:1763 1767
In the current era of DES, the relationship between post-pci IVUS or FFR findings and long-term clinical outcomes the comparative value of post-pci IVUS and FFR as a guide to stent optimization related with favorable long-term clinical outcomes
To investigate and compare the predictive value of post-stent FFR and IVUS for longterm clinical outcomes after DES implantation.
Inclusion Criteria Both FFR and IVUS after elective PCI with DES Age 18-80 years Stable angina, unstable angina, silent ischemia de novo coronary artery stenotic lesion ( 30% DS by visual estimation) Reference vessel diameter 2.5 mm by visual estimation Exclusion Criteria Acute MI Infarct-related artery in old MI LM disease In-stent restenosis / Graft vessel disease Low ejection fraction (< 40%) 206 lesions of 188 patients Composite of Cardiac death,tv-mi,tvr @ 2 years
IVUS Galaxy2 and ilab IVUS Imaging System EchoPlaque 3.0 (Indec Systems, Mountain View, CA) Measurement of FFR Intracoronary Pressure Wire, RADI (St. Jude Medical, USA) RADI view 2.2
Baseline Characteristics (n=188) Male sex, n (%) 128 (62%) Age, y 60±10 Hypertension, n (%) 117 (62%) Diabetes, n (%) 55 (29%) Hyperlipidemia, n (%) 143 (76%) Current Smoking, n (%) 33 (18%) Clinical presentation, n (%) Stable angina, n(%) 86 (46%) Unstable angina, n(%) 89 (47%) Silent ischemia, n(%) 13 (7%) Previous MI, n(%) 7 (4%) Previous PCI or CABG, n(%) 18 (10%) Number of diseased vessel, 1 / 2 / 3 92 (49%) / 58 (31%) / 38 (20%) Medications at discharge DAPT / BB / RAS blockers /Statins, % 100 / 34 / 38 / 71
Angiographic and procedural characteristics Treated vessel, LAD / LCx / RCA 172 (84%) / 11 (5%) / 23 (11%) AHA/ACC lesion type B2/C 184 (89%) Reference vessel diameter, mm 3.5±1.7 Minimal lumen diameter, mm Pre-PCI 0.9±0.6 Post-PCI 3.2±1.7 Percent diameter stenosis, % 73±13 Lesion length, mm 25±6 Number of stent used per lesion 1.4±0.6 Stent length, mm 36±16 Mean diameter of stent 3.3±0.3 Types of stent, 1 st gen. / 2 nd gen 152(74%) / 54(26%)
IVUS and FFR findings Proximal reference segment EEM CSA, mm 2 17.3±4.1 Lumen CSA, mm 2 10.4±2.9 Distal reference segment EEM CSA, mm 2 9.0±4.1 Lumen CSA, mm 2 6.3±2.7 Pre-PCI MLA, mm 2 2.8±0.9 Plaque burden, % 77±9 Final minimum stent CSA, mm 2 6.2±1.6 Stent symmetricity index 0.84±0.08 FFR, Pre- / Post-PCI 0.75±0.11 / 0.91±0.05
12 events (6.4%) C-Death, 2 No MI TVR, 11 ROC analysis of MSA by IVUS and FFR for the prediction of clinical events 100 Post-stent FFR 100 Minim al stent area 80 80 60 40 Sensitivity 60 40 20 FFR > 0.92 AUC : 0.643 95% CI [0.570-0.712] 20 MSA > 6.1mm 2 AUC :0.543 95% CI [0.469-0.615] 0 0 20 40 60 80 100 0 0 20 40 60 80 100 100-Specificity 100-Specificity
Diagnostic value of post-pci MSA by IVUS and FFR to predict 2-year clinical outcomes MSA>6.1 mm 2 MSA 6.1 mm 2 FFR > 0.92 FFR 0.92 Cardiac events (+) 3 9 0 12 Cardiac events (-) 80 96 76 100 Sensitivity 75 % 100 % Specificity 46 % 43 % PPV 9 % 11 % NPV 96 % 100 %
Summary In the patients underwent DES implantation optimized by IVUS and FFR after stenting, the rate of cardiac events at 2- year was low. The accuracy of both poststent MSA and FFR for predicting 2- year outcomes after DES implantation were not satisfactory with no difference between the two diagnostic methods. Both poststent MSA and FFR can provide useful information for long-term outcomes with its high NPV.
Limitations Registry data Small number of events Need for prospective randomized comparison between IVUS and FFR
Conclusion Both post-stent FFR and IVUS MSA are useful on-site predictors for long-term outcomes after DES implantation with excellent negative predictive values.
Concordance between the BCV of post-pci MSA and FFR to predict 2-year clinical outcomes MSA>6.1 mm 2 MSA 6.1 mm 2 FFR > 0.92 50 44 FFR 0.92 37 75 Concordance 125/206 (61%)
1 st generation stent only 100 FFR 100 MSA 80 80 Sensitivity 60 40 Sensitivity 60 40 20 20 0 0 20 40 60 80 100 100-Specif icity 0 0 20 40 60 80 100 100-Specif icity 100 80 Sensitivity 60 40 FFR MSA 20 0 0 20 40 60 80 100 100-Specif icity
LAD only 100 FFR 100 MSA 80 80 Sensitivity 60 40 Sensitivity 60 40 20 20 0 0 20 40 60 80 100 100-Specif icity 0 0 20 40 60 80 100 100-Specif icity 100 80 Sensitivity 60 40 FFR MSA 20 0 0 20 40 60 80 100 100-Specif icity