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Coronary Stenting: Everyone should be using FFR

Coronary Stenting: Everyone should be using FFR. Morton J. Kern, MD Chief of Medicine, VA Long Beach HCS Professor of Medicine University California Irvine Orange, California. Disclosure: Morton J. Kern, MD

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Coronary Stenting: Everyone should be using FFR

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  1. Coronary Stenting: Everyone should be using FFR Morton J. Kern, MD Chief of Medicine, VA Long Beach HCS Professor of Medicine University California Irvine Orange, California

  2. Disclosure: Morton J. Kern, MD Within the past 12 months, the presenter or their spouse/partner have had a financial interest/arrangement or affiliation with the organization listed below. Company NameRelationship St. Jude Medical Inc. Speakers’ Bureau Volcano Therapeutics Speakers’ Bureau Merit Medical Inc. Consultant Acist Medical Inc. Consultant Opsens Consultant Heartflow Consultant

  3. To treat or not to treat? Is this lesion producing Ischemia? Is PCI appropriate for situation?

  4. Coronary Physiology (FFR as well as FFRCT) is needed because angiography/CTA does not always reflect the functional (i.e. ischemic) impact of a stenosis. LAO, RAO,

  5. Measurement of FFR correlates to the results of stress testing and ischemia out of the lab. FFR is a ‘stress test’ for that artery in the lab at time of cath. Aortic, Pa FFR= Pd/Pa = 65/90 = 0.72 Coronary, Pd Resting pressures Adenosine

  6. Technique Counts: Confounding Factors for FFR • 1. Equipment factors: • Erroneous zero • Incomplete pressure transmission (tubing/connector leaks) • Faulty electric wire connection • Pressure signal drift • Hemodynamic recorder miscalibration • 2. Procedural factors • Guide catheter damping • Incorrect placement pressure sensor • Inadequate or variable hyperemia • 3. Physiological factors • Serial lesion • Reduced myocardial bed • Acute myocardial infarction • Theoretical conditions that might influence FFR • Severe left ventricular hypertrophy • Exuberant collateral supply • Adenosine insensitivity

  7. 5 Steps to Accurate FFR • Zero guide and wire on table to atmosphere • Insert wire into guide and match wire/guide pressures in aorta • Cross lesion 2-3cm distal • Turn on IV adenosine: Use the ‘smart minimum FFR or lowest Pd/Pa • Confirm accuracy with pressure pull back

  8. Rely on FFR – No Guide Catheter Side Holes or Damping From Nico Pijls

  9. Rely on FFR – Avoid Signal Drift Drift Drift True Gradient Notch Notch No notch Notch

  10. Pharmacologic Hyperemia IV Adenosine – 140mcg/kg/min IC Adenosine - LCA = 100-200mcg bolus - RCA = 50-100mcg bolus

  11. When to measure the FFR? Take the lowest value Automated software records the lowest Pd/Pa as the FFR.

  12. Q: Why can we not use IVUS/OCT for functional assessment? A: A single cross-sectional area does not mean the same thing everywhere. 5 < 4 mm² = significant stenosis ? Ref Diam (mm) 4 3 2 50 25 0 % Stenosis for an Cross Sectional Area of 4 mm²

  13. FFR Outcome Studies

  14. 62 yo Man, RCA stent occl 2yr ago with return of CP LAD FFR=0.86, 0.87 Now 1V CAD and new approach

  15. Kaplan–Meier survival curve for clinical events among 3 groups at 5-y follow-up. Sang Hyun Park et al. CircCardiovascInterv. 2015;8:e002442

  16. 71 yo Man with typical angina, pos stress, CAD risk factorsWhat’s your best approach?

  17. FFR CFX FFR CFX=0.88

  18. LAD Xience 3.5x18. 2nd LAD lesion? All done? ? FFR = 0.68

  19. Physiologic Guidance1. Appropriate need for Stents2. Objective info re ischemia3. Eliminates operator uncertainty

  20. MACE Death Myoc Infarct Revascularization FAME – 5yr F/U Nunen LX et al. Lancet, August 30, 2015

  21. FAME 2: Two Year Follow-Up Two year rate of primary endpoint: Death, MI, Urgent Revascularization De Bruyne, et al. NEJM 2014;371:1208-17.

  22. 65 yo M, chest pain at rest and with exertion, ETT (ECG alone) positive at 8’ with minimal ST changes

  23. FFR LAD Ostial Lesion = 0.77

  24. FFR and Appropriate use Criteria. Moving to supported Decisions Prox LAD

  25. iFR vs FFR: The Advise II study - International, Multicenter Study (ADenosine Vasodilator Independent Stenosis Evaluation II Escand J, JACC Interven 2015;8:824-33 IFR 0.85 - 0.94

  26. Should FFR be part of every PCI? Components of PCI indications: Stable Coronary Artery Disease Symptoms of Ischemia Moderate/Severe Stenosis Evidence of ischemia New ECG changes Stress testing or FFR Acute Coronary syndrome - Evidence of ischemia - Stenosis, mild-severe ECG +/- WM abn FFR not needed in culprit, may help in non-culprit

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