Mattias Törnerud, Capio St Görans sjukhus AB, Stockholm. Invasiv tryckmätning FFR

Transcription

1 Namn: Titel: Mattias Törnerud, Capio St Görans sjukhus AB, Stockholm Invasiv tryckmätning FFR Har mo/agit förläsararvoden från St Jude Medical.

2 Intrakoronar tryckmätning, FFR i daglig praxis 1000 angio 450 PCI 100 FFR Mattias Törnerud, Medicinkliniken Capio St Görans sjukhus

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5 Visual Interpretation of Moderate Lesions: Relation to FFR Significant Not Significant FFR > 0.75 A 53% 47% correct B 49% 51% C 56% 44% FFR < 0.75 correct A 80% 20% B 67% 33% C 87% 13% Diagnostic accuracy of visual assessment is 60% Fischer AJC; 2002;90:

6 QCA vs FFR FFR Diameter stenosis%

7 What to do with intermediate lesions 40-80% Treat all of them Treat none of them Treat some of them Or throw the dize

8 65% 25%

9 FFR-interpretation non-signif. stenosis significant Specificity : ~ 100% Sensitivity : ~ 90 % (NEJM 1996; 334: )

10 IMPORTANCE OF PERFUSION TERRITORY: Large perfusion area (myocardium) MLD, cross-sectional area and stenosis resistance are identical. MLD = 1.9 mm CSA = 4.5 mm 2 Small perfusion area (myocardium)

11 IDENTICAL % STENOSIS BUT DIFFERENT PHYSIOLOGIC SIGNIFICANCE. 100 FFR = Large perfusion area (myocardium) 100 FFR = Small perfusion area (myocardium)

12 PREVIOUS MYOCARDIAL INFARCTION (DECREASED PERFUSION TERRITORY): FFR = 0.60 FFR = Normal Myocardium SCAR Normal Myocardium Anatomic stenosis severity remins unchanged but physiologic severity has decreased. FFR accounts for those changes and always gives the right result!

13 Man född -54. Lindrig walk through AP Stresseko (220 W) med ischemi i septum Man född -49. AP vid löpning. Patologiskt a-prov till 240W

14 LAD: 0,82 LCX: 0,96 LAD: 0,88 D1: 0,92

15 Man född -55. AP vid rask promenad eller Uppförsbackar. Patologiskt a-prov till 200 W LAD: 0,68 Slutresultat efter stent

16 Man född -47. BMS (3,75 x 18) i LAD dec-09 I samband med IAP. Nu anginarecidiv vid rask promenad LAD: 0,79 Slutresultat efter DEB 3,5 x 26

17 Sensitivity? Specificity?

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20 Prognostic significance of reversible ischemia at MIBI-Spect Average Annual Hard Events Iskander S, Iskandrian A E JACC 1998

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25 Accuracy of MIBI-SPECT Male, 69-year-old, typical angina CCS 3, positive Mibi-Spect inferior wall, Referred for intervention of severe RCA stenosis

26 MIBI-SPECT Stress Rest Male, 69-year-old, typical angina CCS 3, positive Mibi-Spect inferior wall,

27 Accuracy of MIBI-SPECT

28 Limitations of Noninvasive Imaging: 143 Patients with angiographically significant 3 vessel disease (> 70% diameter stenosis) Thallium Scan Finding % Patients No Defect 18% Single Vessel Pattern 36% Two Vessel Pattern 36% Three Vessel Pattern 10% Lima et al. J Am Coll Cardiol 2003;42:63-70

29 Accuracy of MIBI-SPECT LAD: 0,65 RCA: 0,62 LCX: 0,68 Male, 53-year-old, typical angina at exercise, CCS 3 Persantin-MIBI spect negative re-assured several times. After repeated visits at outpatient clinic: referred for angio

30 Non-ischemic lesions do not need to be treated! The DEFER Study: 5-year Event-free Survival FFR > 0.75 FFR > 0.75 Mortality / AMI per year for non-sign lesion: < 1 % PCI rate per year for non-significant lesion : 4 % Circulation 2001; 103: )

31 20 % P=0.20 P< P< DEFER PERFORM REFERENCE FFR > 0.75 FFR < 0.75

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34 FLOW CHART Patient with stenoses 50% in at least 2 of the 3 major epicardial vessels Indicate all stenoses 50% considered for stenting Randomization Angiography-guided PCI FFR-guided PCI Measure FFR in all indicated stenoses Stent all indicated stenoses Stent only those stenoses with FFR year follow-up

35 ANGIO-group N=496 FFR-group N= ± ± (98%) (63%) (37%) 2.7 ± ± % 94%

36 ANGIO-group N=496 FFR-group N= (18.4) 67 (13.2)

37 ANGIO-group N=496 FFR-group N= (18.4) 67 (13.2) 15 (3.0) 9 (1.8) 55 (11.1) 37 (7.3) 47 (9.5) 33 (6.5) (8.7) 29 (5.7)

38 absolute difference in MACE-free survival FFR-guided Angio-guided 30 days 2.9% 90 days 3.8% 180 days 4.9% 360 days 5.3%

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42 1 Year Economic Evaluation Angio Less Costly Angio Better FFR Less Costly FFR Better QALY USD

43 MACCE in SYNTAX 3VD and FAME similar definition of MACCE, including CVA and excluding CKMB 3-5 x N % SYNTAX UPPER MIDDLE LOWER FAME ALL TERCILE TERCILE TERCILE

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46 Why is the results so good in the FFR group of the FAME study?

47 Intrinsic risk of death and myocardial infarction?

48 Intrinsic risk of death and myocardial infarction? chance to die or have AMI from non-ischemic lesion < 1% / year chance to die or have AMI from ischemic lesion ~ 5 % / year chance to die or have AMI from unnecessary stent ~ 3 % / year

49 stent them all : intrinsic risk 12% 12% stent the ischemic ones : intrinsic risk 12% 8%

50 Outcome of Deferred Lesions

51 Outcome of Deferred Lesions