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Are significant SB lesions really significant?: Insight from FFR

This study focuses on the physiological evaluation and treatment strategies for jailed side branch lesions using Fractional Flow Reserve (FFR) measurement. The study evaluates the relationship between FFR and percent stenosis, as well as the outcomes of FFR-guided jailed side branch interventions. It also discusses the relevance of angiographic criteria in assessing jailed side branch lesions.

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Are significant SB lesions really significant?: Insight from FFR

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  1. Are significant SB lesions really significant?: Insight from FFR Bon-Kwon Koo, MD, PhD Seoul National University Hospital, Seoul, Korea

  2. To treat ? or Not ? • Reference vessel diameter ≥ 2mm • Percent stenosis ≥ 75% • Significant myocardial territory?

  3. PART 1Physiologic Evaluation of Jailed Side Branches

  4. RADI4 pressure wire: Successful FFR measurement: 94/97 lesions (97%) Initial Post-stent

  5. Characteristics of lesions(n=94) Koo BK, et al. JACC 2005

  6. QCA vs. FFRin Jailed side branch lesions (n=94) r = - 0.464 p < 0.001 Fractional Flow Reserve Functionally significant stenosis Percent Stenosis (%)

  7. FFR vs. Percent stenosis by QCA

  8. - All Lesions (n=94) - FFR (< 0.75) vs. QCA (% stenosis) Sensitivity 1 - specificity Best Cut-off Value AUC: 0.85 (95% CI: 0.76 - 0.94)

  9. How to Assess? FFR: 0.93 FFR: 0.61 FFR: 0.84 FFR: 0.58

  10. How to Treat? FFR: 0.61 Balloon artery ratio? Goal of treatment? FFR: 0.58

  11. PART 2FFR in Side Branch Intervention

  12. Hypothesis • The treatment goal of jailed side branch lesion may be to maintain < 75-85% stenosis. • Therefore, balloon inflation with a relatively small size balloon would be enough, if the gain could be maintained during follow-up.

  13. Functional Outcomes of FFR–Guided Jailed SB Intervention Strategy Inclusion criteria De novo, bifurcation lesion Main branches • Successful DES implantation • No significant stenosis proximal to the stented segment Jailed side branches • Stenosis > 50%, diameter > 2 mm • Lesion length < 10 mm • Side branch length > 30 mm Exclusion criteria • Side branch slow flow after stenting • Left main disease, CTO lesions • Infarct related artery, thrombus • Diffuse or distal lesion at SB • RWMA at stented segments • Myocardial disease, valvular disease • Renal insufficiency

  14. FFR-guided Jailed SB Intervention • Stenting the main branch with DES • Measure FFR in jailed SB • Side branch intervention, when FFR<0.75 • Kissing balloon technique with a relatively small balloon at side branch • If FFR < 0.75 after kissing balloon, • use larger balloon, or stent implantation

  15. FFR-guided Jailed SB intervention • Jun, 2004 ~ Jan, 2006 110 patients, 114 lesions • FFR not measured (n=19) • Slow flow: 8 • Fail to GW passage: 4 • Protocol violation: 6 • AV block: 1 91 patients, 95 lesions • FFR < 0.75: 29 lesions • 26 lesions: Kissing Bln • 3 lesions: No SB PCI • FFR ≥ 0.75: 66 lesions • All lesions: No SB PCI

  16. FFR-guided Jailed SB intervention Feasibility • FFR measurement failure • 4/99 lesions (4%) • Achievement of FFR>0.75 after kissing balloon inflation • 24/26 lesions (92%) • No procedure related major complications

  17. FFR-guided Jailed SB intervention Serial changes in SB-FFR in Kissing group Side branch balloon/artery ratio: 0.85±0.14 SB-FFR 0.85±0.06 0.83±0.11 0.65±0.08 P<0.001 P=0.57

  18. FFR-guided Jailed SB intervention Changes of FFR during 6M follow-up (67 lesions) P>0.05 • *Adjusted side branch FFR; SB-FFRadj = [side branch FFR] / [main branch FFR]

  19. FFR-guided Jailed SB intervention Changes in Functional Stenosis of Jailed SB Kissingvs. No-Kissing Balloon Inflation P=0.13 0.01±0.04 Kissing ΔSB-FFRadj No-Kissing -0.02±0.10

  20. PART 3Evaluation of Jailed SB at F/U Angiograms

  21. FFR in Jailed SB lesions: at F/U Angiographic restenosis criteria for jailed side branch lesions: Are these relevant?

  22. FFR in Jailed SB lesions: at F/U Angiographic restenosis criteria for jailed side branch lesions: Are these relevant?

  23. FFR in Bifurcation lesions Insights from FFR studies • QCA overestimates the functional significance of jailed SB lesions. • Kissing balloon with relatively small sized balloon results in significant increment of SB FFR. • Functional significance of jailed SB lesion after DES implantation do not change significantly during 6 month follow-up.

  24. FFR in Bifurcation lesions Significant lesions requiring further intervention - Angiographic vs. Functional criteria -

  25. CONCLUSION In bifurcation lesions with relatively short side branch lesions…. More strict angiographic evaluation criteria and less aggressive SB interventionstrategy should be applied.

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