32 ο Πανελλήνιο Καρδιολογικό Συνζδριο, Θεσσαλονίκη 20/10/2011
Gould KL et al, JACC CARDIOVASC IMAG 2009
Gould KL et al AM J CARDIOL 1974 & JACC CARDIOVASC IMAG 2009
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)
Hodgson J, JACC CARDIOVASC INTERV 2010
Eyeballing vs FFR in LMCA K=0.45 (coefficient of concordance) Hamilos M et al CIRCULATION 2010
n=63, 2D & 3D QCA vs FFR<0.75 Yong A et al EUR HEART J 2010
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
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%
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
Nam CW et al JACC 2011
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
FAME study: 1-year cost FFR-guided group= 14315$ vs Angio-guided group= 16700$, p<0.001 Fearon W et al CIRCULATION 2010
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
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
Pijls NHJ et al. JACC 2007 DEFER study n=325, Stable angina
FAME study, 24 months n=1005, Stable angina Pijls NHJ et al. JACC 2010
Pijls NHJ et al. JACC 2010
Pijls NHJ et al. JACC 2010
n=213 Hamilos M et al. CIRCULATION 2009
Muller O et al. JACC INTERV 2011, in press
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
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 0.95 0.90 0.85 0.80 0.75 0.70 0.65 0.60 0.55 0.50 0.45 0.40 0.35 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 0.30 0.25 0.20 ACUTE FOLLOW-UP p=ns Ntalianis et al. JACC CARDIOVASC INTERV 2010
FOLLOW UP FOLLOW UP 0.20 0.15 0.10 Mean+2SD 1.0 0.8 FFR 0.05 0.6-0.00-0.05 0.2 0.4 0.6 0.8 1.0 Average 0.4 0.2 r=0.91, p<0.0001-0.10-0.15-0.20 40 A Mean-2SD 0.0 0.0 0.2 0.4 0.6 0.8 1.0 ACUTE % DS 30 100 20 Mean+2SD 80 10 60 % 0-10 -20-30 20 40 60 80 100 Average Mean-2SD 40 20 r=0.78, p<0.0001 0 0 20 40 60 80 100 ACUTE -40 Ntalianis et al. JACC CARDIOVASC INTERV 2010
Delta FFR 0.20 TERTILES LVEDP ACUTE 0.15 0.10 * 0.05 *p=0.04-0.00-0.05-0.10-0.15 LVEDP <15mmHg 15 LVEDP <20mmHg LVEDP 20mmHg Ntalianis et al. unpublished data
% % 100 90 80 70 60 50 40 30 20 10 0 6.5 9 10.5 11.5 13 14.5 15.5 16.5 17.5 19 20.5 21.5 23.5 26 27.5 29 31 33.5 37.5 100 90 80 70 60 50 40 30 20 10 0 Sensitivity% Specificity% Area=0.64 p=0.05 LVEDP (mmhg) Δ FFR 0.04 Ntalianis et al. unpublished data
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
Pijls NHJ et al. CIRCULATION 2002
Patients n=80, vessels n=99, FFR after DES implantation Nam CW et al AJC 2011
Glineur et al. J Thorac Cardiovasc Surg 2011 RITA=10, SVG=7
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
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
13 (9%) lesions %DS > 50% at FU (from 51±9% to 58±5%, p<0.05) Ntalianis et al. unpublished data
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
FFR IVUS OCT Plaque burden/ Tissue characterization - + + Ischemia burden + - - Vessel size - + ++ Dissection/ Thrombus - + ++ Microcirculation/ Coronary flow (IMR, Absolute coronary flow) ++ - - LV function (dp/dt) ++ - -
FFR IVUS OCT 1VD/MVD + ±? LMCA + +? Proximal LAD +?? Post-stent implantation Acute coronary syndromes True/false lumen (CTOs) Atheromatosis progression + + ++ +? + - ++? + + + Bifurcations + + +
FFR vs IVUS FFR vs OCT http://clinicaltrials.gov/, accessed on 18/10/2011
http://clinicaltrials.gov/ct2/show/study/nct01132495?show_locs=y#locn
Personal communication with B. De Bruyne
Personal communication with B. De Bruyne
Erglis et al. ESCARDIO 2010
Koo et al, EUROPCR 2011
Koo et al, EUROPCR 2011
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
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
Back up slides
FFR and prognosis: Multivessel disease Pijls NHJ. Coronary Physiology in the Catheterization Laboratory, Nice 2011
Tonino P et al. NEJM 2010 n=1005, Stable angina FFR and prognosis: Multivessel disease
FFR and UA/NSTEMI Pijls NHJ et al. Coronary Physiology in the Catheterization Laboratory, Nice 2011
Latest news http://www.tctmd.com, Accessed on 12/9/2011
Koo et al, EUROPCR 2011
Koo et al, EUROPCR 2011
FFR vs IVUS Ben Dor et al. Eurointervention 2011
FFR and cost-effectiveness Hoole S et al CAN J CARDIOL 2011
Paradigm shift: from anatomy to physiology Park SJ et al CIRCULATION 2011
Myocardial perfusion territory and FFR FFR=0.72 Iqbal M et al CIRCULATION CARDIOVASC INTERV 2010
Myocardial perfusion territory and FFR AFTER 2 DES IN THE RCA FFR=0.84 Iqbal M et al CIRCULATION CARDIOVASC INTERV 2010
FFR and cost-effectiveness FFR vs MPI Fearon W et al AHJ 2003 Fearon W et al AHJ 2003
FFR of the culprit and prognosis Lopez et al. Rev Esp Cardiol 2010
Στεφανιαία Εφεδρεία Νεώτερες εξελίξεις Αργύριος Νταλιάνης
FFR post-stenting nnnnnnnnnn
IU FFR and Non-culprit lesions Index of Microcirculatory resistance 80 n=14 70 60 50 40 30 20 10 p=ns 0 ACUTE FOLLOW UP Ntalianis et al. JACC Cardiovasc Intervent 2010
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
FFR other applications Grafts IMR Absolute coronary artery flow measurements LV dp/dt measurements (resynchronization therapy) Renal artery stenosis
Latest news http://www.tctmd.com, Accessed on 12/9/2011
Latest news http://www.clinicaltrials.gov, Accessed on 17/10/2011
Latest news http://www.clinicaltrials.gov, Accessed on 18/10/2011
Latest news http://www.clinicaltrials.gov, Accessed on 18/10/2011
Latest news http://www.clinicaltrials.gov, Accessed on 18/10/2011
Latest news http://www.clinicaltrials.gov, Accessed on 18/10/2011
Latest news http://www.clinicaltrials.gov, Accessed on 18/10/2011
Latest news http://www.clinicaltrials.gov, Accessed on 18/10/2011
Latest news http://www.clinicaltrials.gov, Accessed on 18/10/2011
Latest news http://www.clinicaltrials.gov, Accessed on 18/10/2011
Latest news http://www.clinicaltrials.gov, Accessed on 18/10/2011
1. dye don t lie Applegate R, JACC 2010 2. dye and decide 3. a coronary artery stenosis is severe if it looks severe even in one projection
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)
Microvascular resistance in the presence of an epicardial stenosis Jayaweera et al. Am J Physiol 1999
De Bruyne B. Heart 2008 FFR: basic principle FFR= Ps/Pn (Pv is negligible)
FFR: basic principle De Bruyne B. Heart 2008
Latest news http://www.tctmd.com, Accessed on 12/9/2011
Future avenues ; FFR CT Erglis et al. ESCARDIO 2010
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 26,7 20 15 10 Relative Risk= 3.1, p=0.04 8,7 FFR<0.75 5 0 FFR 0.75
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