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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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slide1

FFR in Diffuse Multivessel Disease

Jie Qian

National Heart Center & FuWai Hospitall

slide2

Different Patients with the same symptom : angina

Angio-based PCI

IVUS –based or FFR –Based PCI ?

slide3

Why do we need functional evaluation ?

  • Limitations of coronary angiography
  • Limitations of noninvasive techniques
  • Cost issues ( Cost / Benefit )
slide4

Limitations of Angiography :

“Lumengram”: Disconnection with function & physiology

slide5

FAME study: (dis)congruence between QCA and FFR

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

slide6

“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)

slide7

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
slide8

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

slide9

75 yrs male,

Hyperlipidemia .Hypertension and diabetes

Typical chest pain on exerction despite optimal medical therapy .

Stress

Rest

Infero-lateral inducible ischemia

slide10

FFR= 0.72

FFR= 0.97

FFR= 0.82

Following stent implantation at prox LCX

slide12

Intermediate Lesion :

Chest pain , without non invasive ischemic test

Simple functional evaluation would provide better management …

slide14
Anatomic Scoring

For Each Lesion Segment

Location

Length

Calcification

Tortuosity

Bifurcation

Diffuse Disease

Occlusion

Thrombus

SYNTAX Score

SYNTAX Score = 41

SYNTAX Score = 18

slide15

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

slide16

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

slide17

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

slide20

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

slide21

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

Total MACE

Death / MI

Fearon WF et al , TCT-MD 2011

slide24

Risk of deferring PCI if FFR < 0.75

%

p<0.05

MACE at 1 year

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

slide25

FFR-Guided PCI in Multivessel Disease

137 patients , non-randomized

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

slide26

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

slide27

FAME study: PRIMARY ENDPOINT

Composite of death, myocardial infarction,

or repeat revascularization (“MACE”)

at 1 year

slide29

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%

slide33

Stent length / Number of stent

&

restenosis – stent thrombosis

slide34

Stent Length is Independent Predictor of Restenosis.

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

%

P<0.001

mm

slide35

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
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
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)
slide38

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
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