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


Functional Evaluation is not mandatory for every patient :


Intermediate Lesion :

Chest pain , without non invasive ischemic test

Simple functional evaluation would provide better management …


The angio-guided approach : is it the optimal approach ?


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

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

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

  • 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 ?


DEFER Study : 5-year Follow-up ( Death / MI )


Risk of deferring PCI if FFR < 0.75

%

p<0.05

MACE at 1 year

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


FFR-Guided PCI in Multivessel Disease

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

Composite of death, myocardial infarction,

or repeat revascularization (“MACE”)

at 1 year


FAME study: Adverse Events at 1 year


FFR-guided

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


FAME study: 2-year Event-free Survival


Stent length / Number of stent

&

restenosis – stent thrombosis


Stent Length is Independent Predictor of Restenosis.

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

%

P<0.001

mm


Non-Q-Wave MI

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

  • 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

  • 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

  • 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!


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