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Jie Qian National Heart Center & FuWai Hospitall

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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Jie Qian National Heart Center & FuWai Hospitall

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  1. FFR in Diffuse Multivessel Disease Jie Qian National Heart Center & FuWai Hospitall

  2. Different Patients with the same symptom : angina Angio-based PCI IVUS –based or FFR –Based PCI ?

  3. Why do we need functional evaluation ? • Limitations of coronary angiography • Limitations of noninvasive techniques • Cost issues ( Cost / Benefit )

  4. Limitations of Angiography : “Lumengram”: Disconnection with function & physiology

  5. FAME study: (dis)congruence between QCA and FFR Key paper: Tonino et al; JACC 2010; 55: 2816-2821

  6. “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)

  7. 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

  8. 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

  9. 75 yrs male, Hyperlipidemia .Hypertension and diabetes Typical chest pain on exerction despite optimal medical therapy . Stress Rest Infero-lateral inducible ischemia

  10. FFR= 0.72 FFR= 0.97 FFR= 0.82 Following stent implantation at prox LCX

  11. Functional Evaluation is not mandatory for every patient :

  12. Intermediate Lesion : Chest pain , without non invasive ischemic test Simple functional evaluation would provide better management …

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

  14. Anatomic Scoring For Each Lesion Segment Location Length Calcification Tortuosity Bifurcation Diffuse Disease Occlusion Thrombus SYNTAX Score SYNTAX Score = 41 SYNTAX Score = 18

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

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

  22. Is it safe to defer treatment ?

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

  24. Risk of deferring PCI if FFR < 0.75 % p<0.05 MACE at 1 year Chamuleau et al , AJC 2002;89:377-80

  25. FFR-Guided PCI in Multivessel Disease 137 patients , non-randomized Wongpraparut et al , AJC 2005; 96:877-884

  26. 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

  27. FAME study: PRIMARY ENDPOINT Composite of death, myocardial infarction, or repeat revascularization (“MACE”) at 1 year

  28. FAME study: Adverse Events at 1 year

  29. 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%

  30. Adverse Events at 2 Years

  31. FAME study: 2-year Event-free Survival

  32. Stent length / Number of stent & restenosis – stent thrombosis

  33. Stent Length is Independent Predictor of Restenosis. Lee CW et al. Am J Cardiol 2006;97:506-511 % P<0.001 mm

  34. 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

  35. 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).

  36. 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)

  37. 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

  38. THANKS!

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