SHA24/014004

FRACTIONAL FLOW RESERVE FOR LEFT MAIN DISEASE

Saudi Heart Association Rhyadh, February 13th, 2013

Nico H.J.Pijls, MD, PhD Catharina Hospital, Eindhoven The Netherlands,

mortality

FFR in LM

Specific Characteristics of Left Main Stenoses

1. Large myocardial mass depending on the LM 3. Difficult to appreciate angiographically 4. Rarely isolated/often associated with co-morbidities 5. Outcome after FFR-based decision making

ETP, April 2011

www.cardio-aalst.be

2. Difficult to appreciate non-invasively

•Male, 69-year-old , typical angina class 3,

What does the MIBI-Spect show ?

• Male, 69-year-old , typical angina class 3,

• positive Mibi-Spect inferior wall, • referred for intervention of severe RCA stenosis

RCA, hyperemia

• Male, 69-year-old , typical angina class 3,

• positive Mibi-Spect inferior wall, • referred for intervention of severe RCA stenosis

Sensor at ostium LCA

LAD, resting

hyperemia

FFR in LM

Specific Characteristics of Left Main Stenoses

1. Large myocardial mass depending on the LM 3. Difficult to appreciate invasively 4. Rarely isolated/often associated with co-morbidities 5. Outcome after FFR-based decision making

ETP, April 2011

www.cardio-aalst.be

2. Difficult to appreciate non-invasively

FFR in LM

How to assess a LM stenosis Limitations of the Angiogram

1. Overlap of the catheter and LAD/LCx 3. Incomplete mixing of blood and contrast 4. Lack of true ‘normal segment’, 5. Diffuse disease of a short segment 6. Bifurcation 7. Calcifications ++

ETP, April 2011

Underestimation of LM stenosis severity

www.cardio-aalst.be

2. Spillover of contrast medium

New diagnostic strategies in CAD

4-y-o man. Typical angina. Abnormal Exercise stress testing, Nl L

www.cardio-aalst.be

Assessment

by IVUS can be difficult

Aalst, March, 2011

64-y-o man. Typical angina. Abnormal Exercise stress testing, Nl LV

New diagnostic strategies in CAD

64-y-o man. Typical angina. Abnormal Exercise stress testing, Nl LV

LAD

Aalst, March, 2011

LM

www.cardio-aalst.be

Aorta

64-y-o man. Typical angina. Abnormal Exercise stress testing, Nl LV

rest

hyperemia

FFR = 0.65

FFR = 0.68

FFR in LM

Specific Characteristics of Left Main Stenoses

1. Large myocardial mass depending on the LM 3. Difficult to appreciate invasively 4. Rarely isolated/often associated with co-morbidities 5. Outcome after FFR-based decision making

ETP, April 2011

www.cardio-aalst.be

2. Difficult to appreciate non-invasively

FFR in LM

Left Main Stem Stenoses are Rarely Isolated

www.cardio-aalst.be

FAQ: When there is a stenosis in the LAD, can we put the sensor in the LCx to assess the true severity of the left main stenosis ?

NO !

ETP, April 2011

FFR in LM

Left Main Stem Stenoses are Rarely Isolated

• Severity • Myocardial mass

ETP, April 2011

www.cardio-aalst.be

The influence of a distal stenosis on the FFR of the LM depends on:

FFR in LM

Left Main Stem Stenoses are Rarely Isolated

• Severity • Myocardial mass

ETP, April 2011

www.cardio-aalst.be

The influence of a distal stenosis on the FFR of the LM depends on:

FFR in LM

Specific Characteristics of Left Main Stenoses

1. Large myocardial mass depending on the LM 3. Difficult to appreciate invasively 4. Rarely isolated/often associated with co-morbidities 5. Outcome after FFR-based decision making 6. Practicalities

ETP, April 2011

www.cardio-aalst.be

2. Difficult to appreciate non-invasively

FFR in LM

Clinical Outcome Data after FFR-Guided Revascularization in Patients with LM Equivocal LM Stenosis

R = 0.38, p<0.001 Î&#x161; = 0.27

ETP, April 2011

www.cardio-aalst.be

Angio versus FFR (N=209)

Hamilos M, Muller O et al. Circulation 2009

FFR in LM

Clinical Outcome Data after FFR-Guided Revascularization in Patients with LM Equivocal LM Stenosis (N=209)

SURVIVAL RATE

www.cardio-aalst.be

FFR â&#x2030;Ľ 0.80 No CABG FFR < 0.80 CABG

Deferring revascularization of 30-70% LM stenosis based upon FFR > 0.80, is extremely safe !!

Hamilos M, Muller O et al. Circulation 2009

FFR in LM

Clinical Outcome Data after FFR-Guided Revascularization in Patients with LM Equivocal LM Stenosis (N = 209) Some catch-up of CABG due to progression of disease No CABG CABG

ETP, April 2011

www.cardio-aalst.be

MACE RATE

Hamilos M, Muller O et al. Circulation 2009

FFR in LM

Specific Characteristics of Left Main Stenoses

1. Large myocardial mass depending on the LM 3. Difficult to appreciate invasively 4. Rarely isolated/often associated with co-morbidities 5. Outcome after FFR-based decision making 6. Practicalities

ETP, April 2011

www.cardio-aalst.be

2. Difficult to appreciate non-invasively

FFR in LM

Practicalities/Caveats

ETP, April 2011

www.cardio-aalst.be

FFR in Left Main Stenoses

FFR in LM

www.cardio-aalst.be

“Equalization” within the guiding or at least with guiding dislodged

ETP, April 2011

FFR in LM

www.cardio-aalst.be

Partial obstruction of ostium by guiding catheter  less hyperemic flow  less gradient and higher FFR

ETP, April 2011

Guiding Engaged in the LM

Guiding Disengaged from the LM

Influence of guiding catheter on FFR in case of narrow ostium vdP13-04-48

engagement of guiding into ostium

CASE PRACTICAL EXAMPLE HOW TO ASSESS LEFT MAIN LESION BY FFR

suspicion of left main ostial stenosis

PressureWire in LAD, induce hyperemia by i.v. adenosine (mandatory) and dis-engage guiding catheter

hyperemic pressure pull â&#x20AC;&#x201C; back curve ( i.v. adenosine, guiding out of ostium)

left main

ostium LM

Conclusions (1)

. The precise assessement of LM stenoses remains difficult, though critically important, as significant LM stenoses should be revascularized

. The clinical outcome of patients with hemodynamically non-significant (FFR > 0.80) stenoses is favorable without revascularization procedure

. Both the angiogram and non-invasive testing underestimate the true severity of the LM stenoses

Conclusions (2)

4. FFR can be applied in LM stenosis as usual, with similar cut-off value of 0.80

5. At least 6 retrospective and 2 prospective studies with a total of >700 patients have been performed to the safety of deferring LM stenosis with FFR > 0.80 In none of those studies (follow up 1-5 years, any patient ever died in the deferred group due to LM-AMI

6. Revascularization occurred in about 20 % of the patients over time, due to progression of disease

Wedging of the Guiding Catheter: Importance of Flow 7 F Guiding Catheter

3 mm RCA 50% Area Stenosis

FFR and Guidings with Sideholes

Pa Pc

Pc Pd

=

Pa

Pressure recorded by guiding

When wedging of the catheter, withdraw guiding from ostium BDB 98/064 For flow or pressure measurements: NO SIDE-HOLES

Guiding Catheter With Sides Holes

Side Holes

Sensor proximal to side holes

Guiding Catheter With Sides Holes Side Holes

Sensor in the proximal RCA

Guiding Catheter With Sides Holes Side Holes

Sensor in the proximal RCA in the proximal RCA + Papaverine Sensor

FFR in LM

www.cardio-aalst.be

4-y-o man. Typical angina. Abnormal Exercise stress testing, Nl L

ETP, April 2011

FFR in LM

Left Main Stem Stenoses are Rarely Isolated

www.cardio-aalst.be

Left Main Stem and/or Ostial LAD ?

ETP, April 2011

FFR in LM

Limitations of Non-Invasive Testing in LM Stenosis Ischemic Cascade Angina

Stress ECG

Poor spatial resolution

Systolic Dysfunction Stress Echo/MRI

FFR

Detects systolic dysfunction

Diastolic Dysfunction

Perfusion Abnormalities

Nuclear Imaging

Duration and severity of ischemia

ETP, April 2011

Homogeneous flow maldistribution

www.cardio-aalst.be

Î&#x201D; ECG

FFR in LM

Clinical Outcome Data after FFR-Guided Revascularization in Patients with LM Equivocal LM Stenosis

SURVIVAL RATE

FFR ≥0.80  No CABG FFR <0.80  CABG

ETP, April 2011

“Pure” LM Stenoses

www.cardio-aalst.be

All LM Stenoses

FFR ≥0.80  No CABG FFR <0.80  CABG

Hamilos M, Muller O et al. Circulation 2009

FFR in LM

Left Main Stem Stenoses are Rarely Isolated

+ 2 other arteries

10 + 3 other arteries

32 + 1 other arteries

35 LM Only

ETP, April 2011

www.cardio-aalst.be

23

Erglis et al JACC 2007