FFR in Diffuse Multivessel Disease
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FFR in Diffuse Multivessel Disease. Jie Qian National Heart Center & FuWai Hospitall. Different Patients with the same symptom : angina. Angio-based PCI. IVUS –based or FFR –Based PCI ?. Why do we need functional evaluation ?. Limitations of coronary angiography

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FFR in Diffuse Multivessel Disease

Jie Qian

National Heart Center & FuWai Hospitall


Different Patients with the same symptom : angina

Angio-based PCI

IVUS –based or FFR –Based PCI ?


Why do we need functional evaluation ?

  • Limitations of coronary angiography

  • Limitations of noninvasive techniques

  • Cost issues ( Cost / Benefit )


Limitations of Angiography :

“Lumengram”: Disconnection with function & physiology


FAME study: (dis)congruence between QCA and FFR

Key paper: Tonino et al; JACC 2010; 55: 2816-2821


“I do not stent lesions of 50-70%”

You are under-treating 40% of your patients

“I always stent lesions of 50-70%”

You are over-treating 60% of your patients

“I only stent lesions > 70%”

You are still over-treating 20% of your

patients

IVUS does not solve this problem !

(Key publication: Kang, Park, et al: Circulation Cardiov Interv 2011; 4: 65-71)


  • Limitations of noninvasive techniques

  • Often not performed

  • Can be inaccurate in multivessel disease

  • Generally “territory” specific, but not “vessel” specific

  • Can be “vessel” specific “ but not “lesion “ specific


Limitations of noninvasive techniques

143 patients with angiographically significant 3-vessel disease ( > 70% diameter stenosis)

Tallium Scan Findings

%

Lima et al , J Am Cll Cardiol 2003; 42:63-70


75 yrs male,

Hyperlipidemia .Hypertension and diabetes

Typical chest pain on exerction despite optimal medical therapy .

Stress

Rest

Infero-lateral inducible ischemia


FFR= 0.72

FFR= 0.97

FFR= 0.82

Following stent implantation at prox LCX



Intermediate Lesion :

Chest pain , without non invasive ischemic test

Simple functional evaluation would provide better management …



Anatomic Scoring

For Each Lesion Segment

Location

Length

Calcification

Tortuosity

Bifurcation

Diffuse Disease

Occlusion

Thrombus

SYNTAX Score

SYNTAX Score = 41

SYNTAX Score = 18


CABG(n=171)

TAXUS™ Express2™ Stent (n=181)

40

20

Cumulative Event Rate (%)

0

0

6

12

Months Since Allocation

MACCE to 12 Months by SYNTAX Score™ TercileLow Scores (0-22) 3VD Subset

P=0.66*

17.3%

15.2%

Presenter: See Glossary

Event Rate ± 1.5 SE, *Fisher exact test

Calculated by core laboratory; ITT population


CABG(n=208)

TAXUS™ Express2™ Stent (n=207)

40

20

Cumulative Event Rate (%)

0

0

6

12

Months Since Allocation

MACCE to 12 Months by SYNTAX Score™ TercileIntermediate Scores (23-32) 3VD Subset

P=0.02*

18.6%

10.0%

Presenter: See Glossary

Event Rate ± 1.5 SE, *Fisher exact test

Calculated by core laboratory; ITT population


CABG(n=166)

TAXUS™ Express2™ Stent (n=155)

40

20

Cumulative Event Rate (%)

0

0

6

12

Months Since Allocation

MACCE to 12 Months by SYNTAX Score™ TercileHigh Scores (33) 3VD Subset

P=0.002*

21.5%

8.8%

Presenter: See Glossary

Event Rate ± 1.5 SE, *Fisher exact test

Calculated by core laboratory; ITT population


Stent number and length higher in the syntax trial
Stent Number and Length Higher in the SYNTAX Trial

48% of patients received ≥5 stents

Max #

14 stents!

Multivessel disease:96.2%*

3-vessel disease: 90.8%

Avg. stents per patient:4.6 ± 2.3

Avg. stented length: 86.1 mm

Patients (%)

Total Number of Stents Implanted per Patient

*3VD+LM/3VD+LM/2VD+LM/1VD


Linear increase in macce by number of stentsin the syntax trial
Linear Increase in MACCE by Number of Stentsin the SYNTAX Trial

1.5 Stents“Typical” Real

World Average

Avg. in pts with

5-8+ stents

in SYNTAX19.6%

4.6 StentsSYNTAX Average

17.8%

1 stent

5.6%

12m MACCE Probability

12m MACCE Rate

12m MACCE in TAXUS Arm

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8+

Number of Stents Implanted


  • Functional SYNTAX Score Trial

  • 497 patients , FFR-guided arm of FAME Study

  • 2-3 vessel disease

  • Angio Syntax Score : Conventional fashion

  • Functional ( FFR) Syntax Score : counting only the lesions with FFR < 0.80

Functional ( FFR ) SYNTAX

Angio SYNTAX

FFR reclassifies > 30% !

Fearon WF et al , TCT-MD 2011


Funtctional SYNTAX Score desciminates Risk of Death/MI and Risk of Total MACE

Total MACE

Death / MI

Fearon WF et al , TCT-MD 2011


Is it safe to defer treatment ? and Risk of Total MACE



Risk of deferring PCI if FFR < 0.75 and Risk of Total MACE

%

p<0.05

MACE at 1 year

Chamuleau et al , AJC 2002;89:377-80


FFR-Guided PCI in Multivessel Disease and Risk of Total MACE

137 patients , non-randomized

Wongpraparut et al , AJC 2005; 96:877-884


Patient with stenoses ≥ 50% in at least 2 of the 3 major epicardial vessels

Indicate all stenoses ≥ 50% considered for stenting

Randomization

FFR-guided PCI

Angiography-guided PCI

Measure FFR in all indicated stenoses

Stent only those stenoses with FFR ≤ 0.80

Stent all indicated stenoses

1-year follow-up

FLOW CHART


FAME study: PRIMARY ENDPOINT epicardial vessels

Composite of death, myocardial infarction,

or repeat revascularization (“MACE”)

at 1 year



FFR-guided epicardial vessels

FAME study: Event-free Survival

absolute difference in MACE-free survival

30 days

2.9%

90 days

3.8%

Angio-guided

180 days

4.9%

360 days

5.3%


Adverse events at 2 years
Adverse Events at 2 Years epicardial vessels



Stent length / Number of stent epicardial vessels

&

restenosis – stent thrombosis


Stent Length is Independent Predictor of Restenosis. epicardial vessels

Lee CW et al. Am J Cardiol 2006;97:506-511

%

P<0.001

mm


Non-Q-Wave MI epicardial vessels

Data from DES studies suggest Non-Q-Wave MI rates increase as total stented length increases.

25mm

30mm

40 mm

TAXUS stent

Cyphert stent

TAXUS V

Multiple

stents

7.3

Non Q wave MI

15 mm Mean Stent length ( mm) 65 mm


Full metal jacket ielasi colombo et al ital j inv cardiol 2009 3 suppl 111
Full Metal Jacket. epicardial vesselsIelasi, Colombo et al. Ital J Inv Cardiol 2009; 3 Suppl: 111

  • 658 full metal jacket lesions (≥60mm) in 617 patients.

  • 33% DM, 33 had prior PCI, 33% CTO.

  • 39 months mean follow up (2 yr in 91% pts).

  • Mortality 7.3%

  • MI during follow up: 3.5%

  • TLR: 23.4%

  • Stent thrombosis (Def or Probable): 2.6% (10/17 while on DAP).


Longer stents have more thrombosis roy et al ajc 2009 803 801 5
Longer Stents have more Thrombosis. epicardial vessels Roy et al. AJC 2009; 803:801-5

  • Independent Predictors of Cumulative ST.

    • ISRS (OR 2.7, p<0.001)

    • Number of stents (OR 1.7, p<0.001)

    • Clopridogrel Cessation (OR 1.7, p<0.001)

    • Diabetes (OR 1.5, p 0.2)

    • Renal Insufficiency (OR 1.4, p 0.4)


Conclusions epicardial vessels

  • Pressure wire assessment in MVD and diffuse disease is technically easy and offers more accurate functional evaluation of coronary stenoses.

  • Defering treatment of intermediate lesions when the FFR>0.80 seems safe and effective

  • Reducing the number and length of stents /vessel and or /patient is translated in less MACE on long term outcome


Thanks
THANKS! epicardial vessels


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