Physiology (FFR & IFR) is Essential in Daily Pratice
Martine GilardBrest University - France
Background
Functional assessment
FFR/ IFR
Invasive assessment of atherosclerotic coronary artery lesionMorphological assessment
IVUS
OCT
X-ray Angio
Coronary angiography and functional impact
Gould KL. JACC Cardiovasc Imaging: 2009;2:1009
A “significant“ coronary stenosis
Coronary angiography and functional impact
Tonino et al. N Engl J Med 2009;360:213-24
FAME Study
1329 lesions
Coronary angiography and functional impact
Rational
Revascularisation has improved survival in patients with moderate to severe ischemia. Whereas medical treatment resulted in better survival than revascularisation in patients with no or mild ischemia
In clinical practice
One or multivessel disease
Left main stenosis
Lesions of bifurcation
CABG stenosis
Acute Coronary Syndrome
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
DEFER
2007
FAME
2009
FAME II
2012
FFR
Pijls et al. J Am Coll Cardiol 2007;49:2105–11
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
CV death and AMI 5-year FU
Van Numen et al. Lancet 2017;386:1853-60
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
FAME: CV death and AMI 5-year FU
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
Instantaneous wave-free ratio (IFR)
75 %25 %Without adenosine
Davies et al N Engl J Med 2017;376:1824-34
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
DEFINE-FLAIR: 2 492 ptsPrimary end point: Death, MI, unplanned revascularisation
Götberg et al N Engl J Med 2017;376:1813-23
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
iFR SWEDEHEART: 2 037 ptsPrimary end point: Death, MI, unplanned revascularisation
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
However
FAME FLAIR SWED
1-year MACE (%) 13% 7% 6.7
FFR mean 0.71 0.83 0.82
%FFR≤0.8 63% 35% 29%
Multivessel CAD 100% 42% 35.7%
CCS class II-IV 74% 48% 64%
Prior MI 37% 30% 33.1%
Population Risk HIGH low low
Low risk population in IFR trials Large inferiority margin
Adjedj al. Circulation 2016; 133(5): 502-508.
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
However
FU too short
Death & AMI
iFR FFR RR (IC) p
DEFINE-FLAIR 53 (4.6%) 41 (3.5%) 1.39 (0.89-1.98) 0.16
SWEDEHEART 37 (3.7%) 29 (2.9%) 1.27 (0.79-2.05) 0.33
Overall 90 70 1.30 (0.96-1.76) 0.09
Berry C et al. Circulation 2017; 36:2389–2391.
Elgendy et al Clin. Cardiol.2014; 37: 371–380
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
Left Main and FFR
Koo et al., Euro Heart J 2008; 29:726-732
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
Side branch > 2 mm et > 50% stenosis
Only 26 lesionswith FFR> 0.75
Koo et al., Euro Heart J 2008; 29:726-732
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
Side branch > 2 mm et > 50% stenosis
Botman et al. Ann Thorac Surg 2007;83:2093–7
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
153 patients525 lesions
FFR of lesions and angiographic CABG patency at 1 year
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
Maximal coronary hyperaemia which may be less readily achieved in patients with ACS because of coronary microvascular dysfunction
Layland et al European Heart J 2015;36:100-11
350 patients6 UK centres
FAMOUS-NSTEMI
Layland et al European Heart J 2015;36:100-11
Mono or MVDLM
stenosisLesions
bifurcationCABG
stenosisACS
n=14
n=144
n=18
n=11
n=125
N=40
Pronostic value of FFR
Zhang et al Heart 2015;101:455-62
Global Death
Pronostic value of FFR
Zhang et al Heart 2015;101:455-62
AMI
Economic evaluation of FFR in FAME
Fearon et al Circulation 2010;122:2545-50
FFR améliore le pronostic et économise les ressources
Guidelines ESC
Guidelines on myocardial revascularization Eur Heart J 2014;35:2541-2619
Take Home Messages
We must avoid unnecessary treatment of lesionsthat are not haemodynamically relevant
FFR is the current standart of care for the functionalassessment of coronary lesion severity
FFR guided PCI, as compared with angiographyguidance, improves the outcomes
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