Fractional Flow Reserve

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1 Fractional Flow Reserve Μηράιεο Φακειόο, MD, PhD, FESC Πανεπιστημιακό Νοσοκομείο Ηρακλείοσ

2 Fractional Flow Reserve (FFR) Η ζηεθαληνγξαθία δε ιέεη πάληα ηελ αιήζεηα όζνλ αθνξά ζηε βαξύηεηα ηωλ ζηελώζεωλ Οη πεξηζζόηεξνη από ηνπο αζζελείο πνπ έξρνληαη ζην εξγαζηήξην δελ έρνπλ ππνβιεζεί ζε κε επεκβαηηθό έιεγρν πξηλ Υπάξρεη ζαθήο αλάγθε ελόο απινύ θαη αμηόπηζηνπ εξγαιείνπ πνπ λα εθηηκά ηελ ζεκαληηθόηεηα κηαο ζηέλωζεο ηελ ώξα ηεο ζηεθαληνγξαθίαο

3 Myocardial Fractional Flow Reserve: Definition Fractional Flow Reserve is a ratio FFR = Q s max max Q N maximal myocardial flow in the stenotic territory normal maximal myocardial flow FFR = extent (%) to which the epicardial stenosis limits maximal myocardial blood flow

4 Myocardial Fractional Flow Reserve: Definition S Q max N Q max = FFR P a P d P v (P d -P v ) / R myo P d -P v FFR = = = S N (P a -P v ) / R myo P a -P v P d P a

5 P a P d + = FFR

6 Threshold Values of FFR to Detect Significant Stenosis FFR non-signif. stenosis significant FFR < 0.75 always ischaemia (specificity 100 %) FFR > 0.80 ischaemia very unlikely (sensitivity 90 %) Pijls et al, NEJM1996

7 Features of FFR Has a normal value = 1.0 for every patient and every artery Is not influenced by changing hemodynamic conditions Accounts for collaterals Is easy to measure (success rate 99 %) and extremely reproducible Pressure measurement has un unequaled spatial resolution

8 Practicalities when Measuring FFR Catheter Guiding catheter without side holes Anticoagulation Heparine, ACT at lest 250 sec Wires WaveWire, Volcano Inc PressureWire, St Jude Medical Hyperaemia Nitrates i.c. Adenosine i.v (140μg/kg/sec)/i.c. (40 μg)

9 FFR and Eyeballing Hamilos et al, submitted

10 FFR and QCA r =-0.51, p<0.001 Hamilos et al, submitted

11 FFR: Κιηληθέο Εθακνγέο

12 FFR for Intermediate Lesion Assessment: The DEFER study Patients scheduled for PCI without Proof of Ischemia (n=325) Randomization deferral of PTCA (167) performance of PTCA (158) FFR 0.75 (91) FFR < 0.75 (76) FFR < 0.75 (68) FFR 0.75 (90) No PTCA PTCA PTCA PTCA DEFER Group REFERENCE Group PERFORM Group Bech et al, Circulation 2001

13 FFR for Intermediate Lesion Assessment: The DEFER study FFR > 0.75 FFR > 0.75 Bech et al, Circulation 2001

14 Cardiac Death and Acute MI after 5 years 20 % P=0.20 P< P< DEFER PERFORM REFERENCE FFR > 0.75 FFR < 0.75 Pijls et al, JACC 2007

15 DEFER: Summary and Conclusions The most important prognostic factor of a stenosis, is its ability of inducing myocardial ischaemia In patients with an FFR < 0.75 incidence of AMI or death is 5 x higher than in a stenosis not associated with inducible ischaemia The prognosis of non-ischaemic stenosis (FFR > 0.75) is excellent and not decreased by stenting

16 FFR for proximal LAD lesions 852 patients with isolated proximal LAD stenosis 730 patients eligible for the study 546 patients with an FFR 0.80, treated medically 166 patients with an FFR<0.80 treated by revascularization Muller et al, JACC Interv 2011

17 % survival 5 year Survival P = Medical group Revascularization group Months No at risk Medical group Revasc. group Muller et al, JACC Interv 2011

18 % survival Survival in Medical & Control Group P = Medical group Controls Months No at risk Medical group Controls Muller et al, JACC Interv 2011

19 FFR for Multivessel Disease Common finding in angiography Treatment decision is not easy in most of the cases PCI vs medical therapy? (COURAGE) PCI vs CABG? (SYNTAX, BEST)

20 Inaccuracy of Perfusion SPECT imaging in MVD 143 severe 3-vessel disease patients and Tc-SPECT 3 Vessel Pattern 10% 18% No Defect 1 Vessel Pattern 36% 36% 2 Vessel Pattern Lima RS et al, JACC 2003

21 Patient with stenoses 50% in at least 2 of the 3 major epicardial vessels Indicate all stenoses 50% considered for stenting Randomization Angiography-guided PCI N=496 FFR-guided PCI N=509 Measure FFR in all indicated stenoses Stent all indicated stenoses Stent only those stenoses with FFR year follow-up

22 1 Year Results from FAME 1. Improved outcomes 2. Decreased cost Absolute Difference in MACE-Free Survival 3. Less contrast use 4. Similar procedure time FFR-guided PCI Angio FFR Angio-guided PCI 5.3% 360 days p=0.02 $6,007 vs $5,332, p< ml vs 272 ml, p< min vs 71 min, p=0.51 Tonino et al, NEJM 2009

23 FAME: 2 years FU Fearon et al, TCT 2009

24 FFR for Left Main Coronary Artery Significant Left Main Coronary Artery (LMCA) stenosis is an absolute indication for surgical revascularization Incidental LMCA stenosis is a relatively common finding during routine coronary angiography In most of the cases, therapeutic decision for its treatment is based on the angiographic appearance of the lesion

25 FFR for LMCA estimation Total number of patients = 591 Publication Journal Pts Defer Surg FU EFS EFS Surviv Surviv (Def) (Surg) (Def) (Surg) Bech et al Heart Jasti et al Circulation Jiminez et al J Invas Card Legutko et al Kardiol Pol Suemaru et al Heart Vessels Linsdtaedt et al Am Heart J Courtis et al Am J Cardiol Hamilos et al Circulation

26 274 patients with LMCA 26 patients with protected LMCA 10 patients with valvular disease 213 patients enrolled 4 patients requiring surgery but treated medically 21 patients requiring surgery for other vessel disease 138 Nonsurgical group 75 Surgical group 2 patients lost in FU 2 patients lost in FU 136 patients included in the analysis 73 patients included in the analysis Hamilos et al, Circulation 2009

27 % Survival 5-year Survival p=0.48 FFR 0.80 FFR< No at risk Months FFR FFR< Hamilos et al, Circulation 2009

28 % MACE free 5-year MACE p=0.5 FFR 0.80 FFR< No at risk Months FFR FFR< Hamilos et al, Circulation 2009

29 FFR in ACS FFR in Acute STEMI / NSTEMI FFR in Chronic MI FFR in the non culprit during STEMI / NSTEMI

30 FFR after myocardial infarction: Acute phase FFR=0.50 DS=75% Normal Myocardium significant Myocardial Infarction Non significant FFR=0.84 DS=75% Non-viable Stunning Normal Myocardium Microvascular Dysfunction, Thrombi

31 FFR after myocardial infarction: Chronic phase DS=75% FFR=0.50 Normal Myocardium significant Myocardial Infarction Non significant FFR=0.84 DS=75% Scar Normal Myocardium Capillary density Microvascular Dysfunction FFR can be used as in normal myocardium Cut-off values for FFR are the same

32 FFR in non-culprit lesions 101 pts, 75 STEMI, 36 NSTEMI, FFR in 112 lesions at time of PCI and 35 days later FFR=0.77± FFR=0.77± ACUTE FOLLOW-UP p=ns Ntalianis et al. JACC Cardiovasc Intervent 2010

33 FFR in diffuse coronary artery disease Atherosclerosis is diffuse in nature This diffuse disease is often reponsible for a marked pressure gradient In 8% of arteries without any focal stenosis, FFR<0.75 FFR of all stenoses together can be calculated from the ratio Pd / Pa during maximal hyperemia The severity of one stenosis can be unmasked by PCI of a second stenosis

34 FFR post-stenting Multicenter FFR post-stent Registry / 750 patients 40% 30% 20% %MACE at 6 month follow-up 37% 28% 19% 10% 7% 4% 0% FFR post stenting Piljs et al, Circulation 2002

35 FFR in Bifurcation and Coronary Artery Bypass Graft Lesions FFR can guide bifurcation PCI (Koo et al, JACC 2007, EHJ 2008) FFR for vein grafts and mammary artery has not been extensively studied. Only 1 small study exists (Aqel et al CCI 2008) It is reasonable to use FFR for grafts as in native lesions This should be done with caution until more data are available, since SVG lesions may have a different natural history

36 FAME II study 1832 patients With Stable CAD At least 1 stenosis 50% Measure FFR in all indicated stenoses Randomization Stenting + OMT OMT alone 2-year follow-up

37 Σπκπεξάζκαηα Τν FFR είλαη έλα θαιά κειεηεκέλν, απιό θαη αμηόπηζην κέζν γηα ηελ εθηίκεζε ηεο ζνβαξόηεηαο ηωλ ζηελώζεωλ ζην αηκνδπλακηθό εξγαζηήξην Τν FFR καδί κε ηηο αλαηνκηθέο πιεξνθνξίεο πνπ πξνθύπηνπλ από ηελ αγγεηνγξαθία επηηξέπνπλ ηελ πιήξε εθηίκεζε ηωλ ζηελώζεωλ κέζα ζην εξγαζηήξην Όια ηα παξαπάλω θάλνπλ ην FFR έλα αλαληηθαηάζηαην θιηληθό εξγαιείν γηα ηνλ επεκβαηηθό θαξδηνιόγν

38 BACK UP SLIDES

39 FFR FFR and Angiography Appropriate decision Based on angiography = 65 % Inappropriate decision Based on angiography = 35% r=-0.53, p< STENOSIS% Hamilos et al ESC 2008

40 FFR vs Myocardial Perfusion Imaging Agreement of the 2 methods is only 42% Melikian et al, JACC Interv 2010

41 Adverse Events at 2 Years Angio- Guided n = 496 FFR- Guided n = 509 P Value Total no. of MACE Individual Endpoints Death 19 (3.8) 13 (2.6) 0.25 Myocardial Infarction 48 (9.7) 31 (6.1) 0.03 CABG or repeat PCI 61 (12.3) 53 (10.4) 0.35 Composite Endpoints Death or Myocardial Infarction 63 (12.7) 43 (8.4) 0.03 Death, MI, CABG, or re-pci 110 (22.2) 90 (17.7) 0.07 Fearon et al, TCT 2009

42 FFR and QCA Hamilos et al, submitted

43 5 year Survival free from MACE (Death-MI-TVR) Muller et al, JACC Interv 2011

44 IU FFR in non-culprit lesions Index of Microcirculatory resistance 80 n= p=ns 0 ACUTE FOLLOW UP Ntalianis et al. JACC Cardiovasc Intervent 2010

45 Value of MPI for LMCA stenosis detection 101 patients with angiographic left main CAD (>50%stenosis) Berman et al, J Nucl Cardiology 2007

46 The Reality patients underwent elective PCI Only 44.5% underwent a stress test before! The more experienced the physician the less the stress test was used! Lin et al JAMA 2008

47 FFR in diffuse coronary artery disease When 2 focal stenoses: Treat the most severe stenosis or the distal stenosis Repeat hyperemic pressure pullback afterwards When diffuse disease and no focal stenosis: Place the sensor very distal Induce steady state hyperemia (adenosine iv) Pull back manually under hyperemia and under fluoro Stent when focal hyperemic ΔP>10-15 mm Hg (empiric statement)

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