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FFR 在多支血管病变介入治疗中的应用

FFR 在多支血管病变介入治疗中的应用. 北京大学第三医院心内科 王贵松. 病变 ≠ 缺血. 冠脉病变的解剖和功能学评价. Fractional Flow Reserve, FFR. Fractional Flow Reserve-FFR 定义和公式假设. FFR 被定义为狭窄存在和正常时 心肌最大血流量（ Q S ， Q N ）的 比值 （ P a － P v ） （ P d － P v ） Q N ＝ , Q S ＝ R R

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FFR 在多支血管病变介入治疗中的应用

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  1. FFR在多支血管病变介入治疗中的应用 北京大学第三医院心内科 王贵松

  2. 病变≠ 缺血 冠脉病变的解剖和功能学评价 Fractional Flow Reserve, FFR

  3. Fractional Flow Reserve-FFR定义和公式假设 FFR被定义为狭窄存在和正常时 心肌最大血流量（ QS，QN）的 比值 （Pa－Pv） （Pd－Pv） QN＝ , QS＝ R R FFR= QS/QN=（Pd-Pv）/（Pa-Pv） ≈ Pd/Pa

  4. FFR的临界值 FFR<0.75提示狭窄有功能意义的特异性100% FFR>0.80提示狭窄无功能意义的敏感性90% ~65% ~20% 需要测量FFR

  5. DEFER STUDYCardiac Death And Acute MI After 5 Years P< 0.03 % 20 P< 0.005 15.7 15 P=0.20 10 7.9 5 3.3 0 DEFER PERFORM REFERENCE FFR > 0.75 FFR < 0.75 Pijls NHJ, et al. J Am Coll Cardiol 2007;49: 2105 - 2111

  6. Patient with stenoses ≥ 50% in at least 2 of the 3 major epicardial vessels 1-year follow-up FLOW CHART Indicate all stenoses ≥ 50% considered for stenting Randomization Angiography-guided PCI FFR-guided PCI Measure FFR in all indicated stenoses Stent all indicated stenoses Stent only those stenoses with FFR ≤ 0.80

  7. FAME study:2-year Event-free Survival p=0.02

  8. FAME: Outcome of Deferred Lesions 513 Deferred Lesions in 509 FFR-Guided Patients 2 Years 22 Peri-procedural 31 Myocardial Infarctions 8 Due to a New Lesion or Stent Related 9 Late Myocardial Infarctions 1 Myocardial Infarction due to an Originally Deferred Lesion Only 1/513 or 0.2% of deferred lesions resulted in a late myocardial infarction Pijls NHP et al JACC 2010

  9. 2011 ACCF/AHA/SCAI Guidelines for PCI

  10. FFR的适应证 所有与无创检查结果不明显匹配的临界狭窄病变，包括左主干病变； 分叉病变主支支架置入后分支口部DS >70% 的所有分支； ACS患者有疑问的非罪犯病变； 多支血管病变或系列和弥散病变时,指导CABG或PCI仅处理有明显血液动力学意义的血管或病变,即功能血管重建； 评价PCI的即刻结果和预测其中远、期预后。

  11. FAME, SYNTAX, COURAGE, ... FAME 研究的主要启示 • In patients with MVD, a revascularisation strategy based on both angiography + FFR compared to a strategy only based on angiography results in a ~ 30% reduction of MACE and detah/MI rate despite a lower number of stents and less contrast medium. • There is no signal to suggest that deferred lesions are likely to be responsible for late myocardial infarctions or to progress and require repeat revascularizations. • FAME challenges two important concepts: • a. The definition of multivessel disease • b. The concept of completeness of revascularisation www.cardio-aalst.be

  12. “多支血管病变（Multi-veseel disease)” “Presence of at least one stenosis > 50% in at least 2 major coronary arteries and/or in the left main stem” RCA: 0.51 LCx: 0.89 LAD: 0.45

  13. 造影所示三支血管病变中 有功能学意义的病变血管的比例 FAME Study 0-VD 9% 3-VD 14% 2-VD 43% 1-VD 34% Angiographic 3-VD (n=115) P. Tonino et al JACC 2010

  14. 不同方法学对多支血管病变界定的差异 ANGIO vs. SPECT vs. FFR SPECT vs. FFR Melikian N, et al. J Am Coll Cardiol Intv 2010;3:307–14

  15. PCI的临床价值 直接PCI——减少死亡，挽救生命 择期PCI——减轻缺血，缓解症状

  16. Ischemia Reduction Improves Outcomes 1 0.9 0.8 0.7 0.6 Unadjusted p=0.001 Risk-adjusted p=0.082 Cumulative Event-free Survival 0.5 0.4 0.3 >5% reduction in ischemic myocardium (n=68) 0.2 No significant reduction in ischemia (n=37) 0.1 0 1.5 2 2.5 3 3.5 4 4.5 5 Time to Follow-up (in years) COURAGE Nuclear Substudy Shaw LJ, et al. Circulation 2008;117:1283-1291

  17. Why do We Need Ischemia Assessment in the Cath Lab? • < 50% of patients undergo noninvasive stress test prior to coronary angiography • Non invasive stress test unreliable in the presence of multivessel CAD • Generally “territory” specific, but not “vessel” specific • Can be “vessel” specific “ but not “lesion “ specific • Coronary Angiography cannot identify the accurate hemodynamic significance of many coronary stenosis Lin GA et al. JAMA 2008;300:1765-1773 Kern MJ. Cardiol Clin 2011; 29 237–267

  18. FFR-Guided PCI in MVD 74 year old woman with HTN, hyperlipidemia, diabetes and atrial fibrillation Admitted with unstable angina Stress thallium revealed inferior and lateral reversible ischemia

  19. FFR of the RCA FFR= Pd / Pa during hyperemia = 89 / 108 =0.82

  20. FFR Left Circumflex FFR = 0.72

  21. What about serial lesions? 0.72

  22. Pullback in Circumflex Most of gradient occurs across proximal lesion Across proximal lesion Across mid disease

  23. After “spot-stenting” proximal circumflex FFR = 0.97

  24. FFR in Acute Coronary Syndromes Culprit Non-Culprit

  25. PCI: LAD Adenosine i. v. infusion 140 µg/kg/min.

  26. FAME Trial: Substudy: ACS versus Stable Angina FFR,ACS, N= 150 Angio ACS, N=178 Data suggest that like the overall population, a 30% reduction in MACE when FFR is used to guide revascularization in ACS

  27. FAME, SYNTAX, COURAGE, ... Treatment Options for MVD FAME CABG OMT PCI www.cardio-aalst.be SYNTAX COURAGE

  28. FFR-guided SYNTAX Score (FSS) versus Conventional SYNTAX Score (SS) • 497 patients of the FFR-arm of FAME I • Syntax scored re-calculated by 3 incdependant reviewers • Functional ( FFR) Syntax Score : counting only the lesions with FFR < 0.80 • 3 tertiles based on SS HIGH risk 33% LOW risk 33% MEDIUM risk 33% SS FSS HIGH risk 21% LOW risk 59 % MEDIUM risk 21% 32% of patients moved to a lower-risk group Nam, C.W. et al. JACC 2011

  29. Funtctional SYNTAX Score desciminates Risk of Death/MI and Risk of Total MACE Total MACE Death / MI Fearon WF et al , TCT-MD 2011

  30. The use of Functional Evaluation ( FFR ) during MVD PCI reduce the number of stents and MACE SYNTAX Score = 38

  31. Angio-driven procedure = 6 stents CABG is preferd . As altervnative :

  32. FFR-driven procedure = 3 stents Functional SYNTAX Score = 17

  33. 35% 80% 96% 65% 20% 4% P. Tonino, et al, J Am Coll Cardiol 2010;55:2816–21

  34. Functional Evaluation is not mandatory for every patient

  35. Conclusions • FFR assessment in MVD and diffuse disease is technically easy and offers more accurate functional evaluation of coronary stenoses. • FFR the stenoses which are not “critical” on the angio • Defering treatment of intermediate lesions when the FFR>0.80 should be safe and effective • “Functionally Complete Revascularization”, i.e. stenting of ischemic lesions and medical treatment of non-ischemic ones. • Reducing the number and length of stents /vessel and or /patient is translated in less MACE on long term outcome

  36. Thank you!

  37. 诱发最大充血 140ug/kg/min

  38. FFR in Multi-vessel disease FAME Trial • Only 0.2% of deferred lesions resulted in a late myocardial infarction • Only 1.9% of deferred lesions clearly progressed requiring repeat revascularizations Tonino PAL, et al. N Engl J Med 2009;360:213-24 Pijls NHJ, et al. J Am Coll Cardiol 2010;56:177–84 Decrease in the number of multi-vessel disease and increase in the number of single vessel disease – increase in PCI volume Improves outcomes Saves money

  39. FFR Values (Pull-back in LAD) FFR:0.86 FFR:0.73 FFR:0.76 FFR:0.64

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