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Bologna 21 Aprile 2011. TAVOLA ROTONDA Quale Ruolo Clinico e Quale Rimborso per la Franctional Flow Reserve?. Correlazioni a natomo-funzionali FFR vs IVUS. Luigi Vignali , Parma. IVUS guidance in PCI Indications. Stent Mal apposition. IVUS in evaluation for Post dilatation needs.

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tavola rotonda quale ruolo clinico e quale rimborso per la franctional flow reserve

Bologna 21 Aprile 2011

TAVOLA ROTONDAQuale Ruolo Clinico e Quale Rimborso per la Franctional Flow Reserve?

Correlazioni anatomo-funzionali

FFR vs IVUS

Luigi Vignali, Parma

ivus in evaluation for post dilatation needs

Stent

Mal

apposition

IVUS in evaluation forPost dilatation needs

Posdil

Pre

Stent

  • Post-dilatation strategy:
  • With non-compliant balloon shorter than stent in presence of vessel remodelling or uncompleted-apposition

Under

expansion

IVUS reveals need of postdilatation

slide4

Recommendations for specific percutaneous coronary intervention devices

IVUS-guided stent implantation may be considered for unprotected left main PCI

EVIDENCE C

CLASS IIb

ivus in isr beware that expected isr might reveal under expanded stent during previous intervention
IVUS in ISRBeware that expected ISR might reveal under expanded stent during previous intervention.

Because the vessel and plaque and stents became visible, IVUS guidance clarify substrate in failure or previous PCI, and frequently discover under expanded stents

IVUS reveals stent underexpansion in ISR

image comparison
Image Comparison

Edge dissection during stent implantation

???

  • Neointimal growth on previously implanted stent at follow-up

???

10

slide11
Validation of IVUS Assessment of Ischemia-producing Stenoses (Doppler FloWire, SPECT, and Pressure Wire)

IVUS MLA

4.0mm2

IVUS MLA <4.0mm2

CFR < 2.0

2

27

CFR  2.0

39

4

Diagnostic accuracy = 92%.

Abizaid et al. Am J Cardiol 1998;82:42-8

IVUS MLA

4.0mm2

IVUS MLA <4.0mm2

+ Spect

4

42

Takagi, et al. Circulation 1999;100:250-5

- Spect

20

1

Diagnostic accuracy = 93%.

Nishioka et al. J Am Coll Cardiol 1999;33:1870-8

ivus in intermediate assessment proximal lad cx rca
IVUS in intermediate assessmentProximal LAD, CX, RCA

Intermediate stenosis assessment:

If in Proximal LAD, CC or RCA, the stenosis

MLA ≤ 4 mm2

then is cause isquemia; and must be treated

Takagi, et al. Circulation 1999;100:250-5

IVUS reveals significance of intermediate lesions,

with morphological assessment

slide13
Clinical follow-up in 357 Intermediate Lesions in 300 Pts with Deferred Intervention after IVUS Imaging

DM

no-DM

IVUS MLD (mm)

Death/MI/TLR

TLR

4

3

2

1

r=0.339

0

0

1

2

3

4

2-3

3-4

4-5

5

2-3

3-4

4-5

5

QCA MLD (mm)

IVUS MLA (mm2)

IVUS MLA (mm2)

  • Death/MI/TLR @ (mean) 13 mos = 8% overall (2% death/MI and 6% TLR)
  • Death/MI/TLR @ (mean) 13 mos = 4.4% in lesions with MLA >4.0mm2
  • Only independent predictor of death/MI/TLR was IVUS MLA (p=0.0041)
  • Independent predictors of TLR were DM (p=0.0493) and IVUS MLA (p=0.0042)

Abizaid et al. Circulation 1999;100:256-61

slide14

In Intermediate stenosis assessment:

Event Free Survival is better for the IVUS Criteria

vs. the FFR >0.75 Criteria.

slide15

Follow-up of 122 patients with moderate LEFT MAIN disease

Indipendent predictors of MACE @11.7

Months:DM (p=0.004) and IVUS MLD

(p=0.005)- but NOT the palque burden

Abizaid, et al. J Am Coll Cardiol 1999;34:707-715

slide17

IVUS in intermediate assessment in Left Main

Intermediate Main Left stenosis assessment:

If Main Left MLA ≤ 6 mm2 cause isquemia and must be treated

Abizaid, et al. J Am Coll Cardiol 1999;34:707-715

IVUS assess significance of Main Left lesions, where angio fails

slide18

IVUS determinants of LMCA FFR<0.75

Jasti et al Circulation 2004; 110;2831-6

slide21

MULTICENTERDED LITRO STUDY

INTERMEDIATE LEFT MAIN CORONARY ARTERY LESION

Kaplan-Meier survival free from mortality and infarction

DEF 98.1%

REV 93.4%

Logrank test: p = 0.04

Cumulative proportion surviving

179 pt MLA>6 mm2 (DEF group)

331 Patients

152 pt MLA<6 mm2 (REV group)

PCI 44%

CABG 55%

0

12

24

Months

Jose’ M de la torre Hernandez et al.JACC 2010;vol55

slide22

IVUS Criteria for a “significant” LMCA stenosis

Absolute lumen CSA <5.9 mm2 (or MLD < 2.8 mm) is the

suggested criterion for significant LMCA stenosis

slide23

LA= 5,5

LA= 4,5

LA= 8,0

FFR= 0,70

slide24

FFR vs IVUS in Intermediate Coronary Lesions

167 consecutive patients

(FFR-guided,83 lesion vs IVUS-guided,94 lesion)

100

100

90

75

91.5%

Event Free Survaival (%)

80

50

P>0.05

70

33,7%

25

60

0

FFR guided

IVUS guided

400

100

200

300

The rate of performing PCI according to guiding device

Time to event (days)

Cutoff value FFR 0.80 Cutoff value IVUS MLA >4mm2

Chang-Wook Nam et al 2010;JACC interventions vol 3 :812-7

slide25

CORRELATION BETWEEN FFR AND IVUS LUMEN

AREA IN 150 INTERMEDIATE CORONARY STENOSIS

For lesion with vessel reference diameters of 2.5-3 mm, 3-3.5 mm and >3.5 mm, the MLA threshold for FFR <0.8 were 2.5,2.8 and 3.7 mm2 respectively

Itsik Ben-Dior, Ron Waksman et al 2011.JACC

slide28

COMPLEMENTARY ROLE IVUS FFR OCT

PRE INTERVENTION

IVUS vessel size lesion lenght

FFR Severity lesion

POST INTERVENTION

Expansion

Apposition

Coverage

Complication

IVUS

Underexpansion

Edge problems

OCT INDICATION

1 Year after DES

Implantation

1 Year after BMS

Implantation

Immediatelly after stent

implantation

Delayed healing; new intimal growth

slide29

Thank you for your attentionFor any correspondence: gbiondizoccai@gmail.comFor these and further slides on these topics feel free to visit the metcardio.org website:http://www.metcardio.org/slides.html