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Pros and cons of FFR in multivessel disease: from FAME to ACS

Pros and cons of FFR in multivessel disease: from FAME to ACS. Giuseppe Biondi Zoccai University of Modena and Reggio Emilia, Modena, Italy gbiondizoccai@gmail.com. Learning goals. Scope of the problem What are the implications of FAME What about the culprit lesion in ACS

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Pros and cons of FFR in multivessel disease: from FAME to ACS

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  1. Pros and cons of FFR in multivessel disease: from FAME to ACS Giuseppe Biondi Zoccai University of Modena and Reggio Emilia, Modena, Italy gbiondizoccai@gmail.com

  2. Learninggoals • Scope of the problem • What are the implications of FAME • What about the culprit lesion in ACS • What about non-culprit lesions in ACS

  3. The first coronary angioplastybyAndreasGruentzig

  4. Extent of CAD in the VANWISH trial Kerensky et al, J Am Coll Cardiol 2002;39:1456-63

  5. Single culprit, multiple culprits, or no culprit at all? Kerensky et al, J Am Coll Cardiol 2002;39:1456-63

  6. Whatismosttrustworthy? Melikian et al, J Am Coll Cardiol Intv 2010;3:307–14

  7. Is SYNTAX no more such? Nam et al, ACC 2011 (J Am Coll Cardiol 2011;57:E1090)

  8. Learninggoals • Scope of the problem • What are the implications of FAME • What about the culprit lesion in ACS • What about non-culprit lesions in ACS

  9. Visualangiographicassessment vs FFR in the FAME trial Tonino et al, J Am Coll Cardiol 2010;55:2816-21

  10. FAME trial

  11. FAME at 2 years Pijls et al, J Am Coll Cardiol 2010;55:2816-21

  12. FAME: deferredgroup Pijls et al, J Am Coll Cardiol 2010;55:2816-21

  13. Learninggoals • Scope of the problem • What are the implications of FAME • What about the culprit lesion in ACS • What about non-culprit lesions in ACS

  14. Acute microvascular damage in myocardial infarction STEMI Variable degree of reversible microvascular stunning Maximum achievable flow is less Smaller gradient and higher FFR across any given stenosis With time, the microvasculature may recover, maximum achievable flow may increase, and a larger gradient with a lower FFR may be measured across a given stenosis

  15. Similar stenosis but different extent of perfusion area

  16. An identical stenosis, but... • 26 col-schema fcf (figuur) 100 50 0 Pd Poor collaterals low FFR = 0.50

  17. An identical stenosis, but... • 26 col-schema fcf (figuur) 100 75 0 Pd Good collaterals higher FFR = 0.75

  18. Visiblecollaterals on the coronary angiogram (Rentrop) and fractionalcollateralblood flow Qc/Qn

  19. What about serial lesions?

  20. What about severe left ventricular hypertrophy? In severe left ventricular hypertrophy, there is an exaggerated increase of left ventricular mass in comparison to the vascular bed, resulting in the potential for ischemia even in normal or almost normal coronary arteries Thus, specificity may be reduced (cut-off >0.80?) However, sensitivity remains satisfactory

  21. What about lesion length? Brosh et al, Am Heart J 2005;150:338-43

  22. What about culprit lesion FFR?

  23. What about culprit lesion FFR? De Bruyne et al, Circulation 2001;104;157-62.

  24. What about culprit lesion FFR?

  25. What about culprit lesion FFR? Tamita et al, Catheter Cardiovasc Intervent 2002;57:452-9

  26. What about culprit lesion FFR? Beleslin et al, Eur Heart J 2008;29:2617-2624

  27. What about culprit lesion FFR?

  28. What about culprit lesion FFR? Samady et al, J Am Coll Cardiol 2006;47:2187-93

  29. Learninggoals • Scope of the problem • What are the implications of FAME • What about the culprit lesion in ACS • What about non-culprit lesions in ACS

  30. What about non-culprit lesions?

  31. What about non-culprit lesions? Ntalianis et al, Catheter Cardiovasc Intervent 2002;57:452-9

  32. What about non-culprit lesions? Ntalianis et al, Catheter Cardiovasc Intervent 2002;57:452-9

  33. Is it worthwhile?

  34. Take home messages

  35. Take home messages • FFR hasbeenprovedsafe and effective in severalsettings, including 2 RCTswithclinicallyrelevantend-point (DEFER and FAME) • ACS do benefit from FFR aswellasallothers, with the notableexception of acute/subacute culpritlesions • The upcoming FAME 2 trial willhopefullyfurthersupport FFR, and provideusanotherargumentagainst (or better on top of) medicaltherapyfor CAD

  36. Interested in more?

  37. 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

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