Tips and tick for left main PCI integrated use of FFR and IVUS

LM Bifurcation Disease Would be Defined as Single Unit of Disease... If Transducer Placed Beyond Bifurcation in both LAD and LCX, Single Unit of Disease Composite FFR still Works.. Func

Tips and Tick for Left Main PCI

Seung-Jung Park, MD, PhD

Professor of Medicine, University of Ulsan College of Medicine

Heart Institute, Asan Medical Center, Seoul, Korea

Integrated Use of FFR and IVUS

Q1,

Why FFR ?

Visual : 80%

FFR : 0.82 Treadmill test : Negative Thallium spect : Normal Stress Echo : Negative

Visual Functional

Mis match

Reverse Mis match

Visual Estimation : 30%

FFR : 0.70

IVUS MLA: 6.2 mm2

Treadmill test: + stage 2

Thallium spect : + large

LAD

How Many

Mismatches ?

Hamilos M et al Circulation 2009;120:1505-1512

Mismatches ?

Different Lesion Morphology

0.61

0.72 0.76

FFR Is Determined By,

• Reference vessel diameter (myocardium)

• Reference vessel diameter (myocardium)

• Many lesion specific local factors influenced

the value of FFR

Park SJ et al, JACC Intv 2012;5:1029 –36

FFR Is Anatomical and Functional Integration of Stenosis

“ Total Lesion Perception ”

FFR Is Determined By,

FFR

Pijls NHJ, NEJM 1996;334:1703-8

Validation with

Non-invasive Stress Test Results

(n=45 patients, intravenous adenosine infusion)

FFR <0.75

FFR Guided Means Ischemia Guided

ESC Guideline, Class I, A

Angiographic % DS is,

Just 2-Dimensional, Single Cut Image

Gould, K L 1974, Animal Study

Physiologic Meaning of 50% DS

Background from Animal Study

Angiographic % DS Is Not Validated for Clinical Ischemia ESC Guideline, Class III.B

FFR vs

Angiographic %DS

They are Totally Different One !

How I Implement FFR

in Real Practice ?

LAD LCX

FFR is Crucial

For the Undetermined, Intermediate

LAD LCX

Possible False Negative

Possible False Positive

Courtesy of Akiko Maehara, MD

It may be Conceptual Problem !

Have Problem to Measure FFR ??

In Reality,

Plaque Distribution by IVUS (n=140)

In 90% plaque extends from LMCA-LAD

1/1,1,1

LCX (1) LAD (1)

LMCA (1/0)

1/0,1,0

LCX (0) LAD (1)

LMCA (1/0)

0/1,1,1

LCX (1) LAD (1)

LMCA (0/1)

0/0,1,0

LCX (0) LAD (1)

LMCA (0/0)

0/0,1,1

LCX (1) LAD (1)

LMCA (0/0)

0/1,0,1

LCX (1) LAD (0)

LMCA (0/1)

Oviedo C et al Circ Cardiovasc Interv 2010;3:105-12

LM Bifurcation Disease Would be Defined as

Single Unit of Disease

If Transducer Placed Beyond Bifurcation

in both LAD and LCX,

Single Unit of Disease

Composite FFR still Works

For the Intermediate LM Bifurcation Lesion,

55/M, Stable angina, TMT (+), Thallium scan (-)

LM Bifurcation Disease

Medina (1,0,0)

0.72

0.78

MLA 3.0mm 2

LAD

LCX

Distal LM, RVD 6.2mm

RVD 5.3mm

Disease Free, LCX

Promus Element 4.0x20

Additional high pressure Inflation with 4.0 mm non-compliant balloon LM-LAD cross over

What Would You Do ?

After Stent Crossover,

Do You Want to Treat Jailed Side Branch ?

Consider FFR, First !

Just Defer ! It’s Safe.

Jailing Issue

Of LCX Ostium ,

Kang et al Circ Cardiovasc Interv 2011;4:355-61

1.Carina shift was mainly due to compressive vessel

deformation, not by plaque gain

2.Lumen jailing is extremely focal, and discrete

Plaque Redistribution

After Cross-Over Before Cross-Over

Functionally Significant LCX Jailing

After Stent Crossover (LCX ostial DS<50%)

Functionally Insignificant, but Significant LCX Jailing,

Just Leave It Alone,

It’s very Safe and Good !

STEMI (N=27)

CABG (N=1086) Medication (N=320)

No-FKB

N = 318

AMC New Data, 2014

No-FKB FKB

Days Since Procedure

No-FKB FKB

Days Since Procedure

Adjusted Hazard Ratio for Clinical Outcomes at 2 years

FKB (N=95)

Non-FKB (N=318) Adjusted HR (95% CI)

*Derived from Kaplan-Meier estimate

† Adjusted for age, DM, clinical presentation, stent number, preprocedural LCX DS, post-stenting LCX DS

‡ MACE defined as the composite of death, MI, or LM TLR

Q1,

Why FFR ?

1 Angiographic Assessment is Not Always Enough !

Decision Making To Treat or Not To Treat for Intermediate

LM Stenosis, FFR is Crucial !

2 Decision Making To Treat or Not To Treat for Side Brach

Jailing after Main Stent Crossover, FFR Should Be

Considered First ! Routine Kissing Balloon Inflation is Not Always Good

Q2,

Why IVUS too ?

Procedural Impact

Of IVUS,

Single Stent Crossover

Two Stent Crush

Pooled Analysis in 403 Patients with LM PCI Using SES

Kang et al Circ Cardiovasc Interv 2011;4:1168-74

Single Stent Crossover Is Clearly Better !

• T-stent, modified T-stent or TAP

• Culotte

2 Stent Techniques

Effective IVUS Stent Area (Rule of 5,6,7,8)

Can Reduce Restenosis Rate

LM IVUS MLA

Can Predict FFR ?

Jasti V et al Circulation 2004;110:2831-6

2.8mm 5.9mm 2

67% 50%

IVUS MLA < 6.0 mm2

Matched with FFR <0.75

Murray’s Finet’s

LAD LCX LM LM

4.0 4.0 6.35 7.35 4.0 3.9 6.27 7.26 4.0 3.8 6.19 7.17 4.0 3.7 6.11 7.08 4.0 3.6 6.04 6.98 4.0 3.5 5.96 6.89

New IVUS MLA

Matched with FFR <0.80 Ostial and Shaft LM Disease (N=112)

Park SJ et al JACC Interv, 2014;7(8):868-874

New IVUS MLA

With Geometric Assumption (Murray’s Law) !

Q2,

Why IVUS too ?

1 Saves Lives

2 Assessment of Reference Vessel Diameter, Pattern of

Remodeling, and Plaque Vulnerability

3 Simplified the Procedure as Single Stent Cross-Over

Depending on Whether or LCX Disease

4 IVUS Guided Stent Optimization, Effective Stent CSA

(5,6,7,8 mm2) Can Make a Good Clinical Outcomes

5 New IVUS MLA 4.5 mm 2 Can Predict Functional

Significance of LM Stenosis

Outcome Changes,

After Routine Use of IVUS (98%) and

FFR (52%) For LM and 3 VD Treatment ,

AMC Data 2014

CABG Decreased After FFR

Left Main Disease CABG PCI DEFER

P<0.01

29%

Before Routine

Use of FFR

After Routine Use of FFR

Distal LM Stent Technique

Stent Crossover Increased

Treated Vessel Territory

RCA or LCX Are Not So Frequently

Treated Anymore !

Before Routine Use

After Routine Use

New Data from AMC LM and 3 VD Registry, 2014

Death, MI, Stroke or Repeat Revascularization

20 Years Temporal Changes,

Of CABG and PCI For LM Disease

AMC Data 2014

P for Interaction = 0.002

HR (95% CI) P value BMS

New Data from ASAN MAIN registry, 2014

Adjusted Hazard Ratios of MACCE

Between CABG and PCI for LM Disease (N=2360)

P for Interaction = 0.017

HR (95% CI) P

value 1.49 (0.67-3.31) 0.33 0.80 (0.43-1.50) 0.49 0.44 (0.23-0.85) 0.015

P for Interaction = 0.20

HR (95% CI) P value 6.88 (3.21-14.7) <0.001 5.26 (2.73-10.1) <0.001 5.07 (2.12-12.1) <0.001

PCI better CABG better

Death, MI or Stroke Revascularization Repeat

0.1 1 10

PCI better CABG better

100

New Data from ASAN MAIN registry, 2014

Adjusted Hazard Ratios of MACCE

Between CABG and PCI for LM Disease (N=2360)

Outcomes of PCI Is Getting Better Over time !

1 Better Concept ; Integrated use of FFR and IVUS Can

Simplify The Procedures (Single Stent Crossover, Less

Routine Kissing, Less Stent, Less Surgery), Which Can Make

a Good Clinical Outcomes of PCI

Years, and is Comparable with CABG, Even Better Survival !

Summary

Thank You !!

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