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导管室内的即时决策： IVUS\OCT\FFR 的最佳应用时机

导管室内的即时决策： IVUSOCTFFR 的最佳应用时机. 葛 雷 复旦大学附属中山医院 上海市心血管病研究所. 导管室内的即时决策： IVUSOCTFFR 的最佳应用时机. Clinical Indications for IVUS. Left main disease Discordance between symptoms or noninvasive test results and CAG Ambiguous lesions ISR Unsatisfactory angiographic or symptomatic results of PCI

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导管室内的即时决策： IVUS\OCT\FFR 的最佳应用时机

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  1. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 葛 雷 复旦大学附属中山医院 上海市心血管病研究所

  2. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Clinical Indications for IVUS • Left main disease • Discordance between symptoms or noninvasive test results and CAG • Ambiguous lesions • ISR • Unsatisfactory angiographic or symptomatic results of PCI • Transplant vasculopathy Ostial lesion Bifurcation Aneurysm Hazy lesion

  3. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Angio ambiguity Plaque rupture Intracoronary thrombus NSTEMI – normal ECG NSTEMI – normal ECG

  4. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Suggested IVUS Criteria for a ‘Significant’ Stenosis • Most authorities feel that a lumen area less than 4.0 mm2 in a proximal epicardial artery excluding Left Main and SVG lesions is a flow limiting stenosis. • Absolute lumen CSA <6.0mm2 (or MLD <3.0mm) is the suggested criterion for a significant LMCA stenosis.

  5. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Optimal PCI results: LM Bifurcation • LCx ostium lumen area > 4.0 mm2 or plaque burden ≤ 60% indicates acceptable for one stent strategy • Iterative post-dilatation and IVUS to achieve LM MLA > 8.5 mm2 , origin LAD > 5.5 mm2 , and origin LCx >5.5mm2(2 stents) or >4.0mm2(1 stent)

  6. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 The superior resolution of OCT compared to IVUS

  7. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 OCT vs IVUS: Clinical Applications • Plaque characterization • Stent assessment Acute results *MLA, Ref D, Length *stent expansion *tissue prolapse *edge dissection *incomplete stent (strut) apposition Chronic results *neointima hyperplasia

  8. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 The superior resolution of OCT compared to IVUS

  9. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 The superior resolution of OCT compared to IVUS Dissections In-stent Restenosis Stent Malapposition

  10. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 OCT assessment of the acute effects of stent implantation on the vessel wall Intrastent dissection Tissue prolapse Edge dissection Dissection cavity Gonzalo N, et al. Heart 2009;95:1913-9

  11. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 FFR, When ? • When the non-invasive functional study is absent or ambiguous in stable patients with intermediate lesions • Side branch ostia when DS >70% • Multivessel disease • Questionable culprit lesions or vessels

  12. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 M/52, Recent developed chest pain, Hyperlipidemia, Smoker Visual Estimation 85% Park SJ, AMC, 2011

  13. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 IVUS MLA 2.8 mm2

  14. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 No Doubt about Stenting ! Visual estimation: 85% IVUS MLA: 2.8 mm2

  15. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Treadmill test Stage II Stage III Stage IV Stage 4 Negative

  16. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 FFR Intravenous adenosine, 160 µg/kg/min

  17. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Please Don’t touch ! Visual - Functional Mismatch Angiographic DS(%) : 85% IVUS MLA : 2.8 mm2 FFR : 0.84 Treadmill test : Negative What would you do ?

  18. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 How many % of Mismatches are there in daily practice ?

  19. FAME Study 37% FFR >0.80 1329 lesions in the FFR-guided arm 65% 20% 4% (44%) (37%) (18%) 50-70% 71-90% 91-100% Angiographic Diameter Stenosis Tonino et al., JACC 2009

  20. 46% 20% Mismatch is not uncommon Overall 31% of cases are mismatch ! 26% Reverse Mismatch In Reality at AMC 708 lesions (QCA Analysis)

  21. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 New IVUS MLA matched with FFR <0.80 Cut-off =2.42mm2 AUC=0.800 95% CI=0.742-0.848 100 80 60 Sensitivity=90% Specificity=60% PPV=37% NPV=96% Accuracy=68% Sensitivity 40 20 0 0 20 40 60 80 100 AMC data, 2010 100-Specificity

  22. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 New IVUS MLA matched with FFR <0.80 2.4 mm2 Kang SJ, Park SJ, Circ Cardiovasc Interv. 2011;4: 65-71

  23. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Left Main Disease

  24. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 29% of cases are mismatch ! Mismatch in intermediate Left Main Disease 6% 12% 23% 59% Hamilos M, Circulation 2009; 120: 1505-1512

  25. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 9% 35% of cases are mismatch ! 26% Mismatch in Isolated intermediate LM Disease (AMC data, n=47) FFR DS % (QCA)

  26. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 New IVUS MLA Matched with FFR <0.80 in Left Main Disease 4.5 mm2 AMC prospective cohort registry (n=47 lesions), 2011 AMC data, Preliminary

  27. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Long Tandem Lesions

  28. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 FFR guided Spot Stenting A B How can we select the first target lesion ?

  29. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Treat Proximal lesion First ! Rule of Big Delta Tighter Proximal Distal Pa Pm Pd > P1 P2

  30. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Treat Distal lesion First ! Rule of Big Delta Tighter Proximal Distal Pa Pm Pd < P1 P2

  31. Tandem Lesions 67/F, Effort Chest pain for 2 months DM, Hypertension, Hyperlipidemia, Smoking

  32. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 IVUS MLA 2.6 mm2 MLA 1.9 mm2

  33. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 FFR Intravenous adenosine (140ug/kg/min) FFR1=0.12 FFR2=0.16 < FFR2 FFR1 0.88 1.00 0.72

  34. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Dilate Distal First ! Xience V 3.0x28

  35. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 FFR again : 0.82 0.82 avoid unnecessary stent !

  36. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Bifurcation PCI Side Branch FFR vs IVUS Predictors

  37. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Side branch stenting ? Different criteria from different studies…… TIMI flow <3 Dissection > A > 50% stenosis Flow limiting dissection ≥ 75% stenosis Side branch stent (%) TIMI flow <3 Dissection > A > 70% stenosis Threatened closure TIMI flow=0 Circulation 2010 Eur Heart J 2008 Circulation 2009 Circulation 2006

  38. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Angiographic DS (%) of SB after MB stenting can not predict functional significance (FFR<0.75). 27% 73% FFR of the Jailed side branch FFR >0.75 FFR <0.75 75% Koo BK, JACC 2005; 46: 633-7

  39. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Summary • In stable patients with intermediate lesions,FFR guided can make decision: treat or not. • IVUS and or OCT guided can make the outcomes optimized.

  40. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Left Main • In isolated equivocal LM lesions: FFR • In serial lesions I prefer IVUS to determine the isolated LM component • With high likelihood of PCI, I prefer IVUS

  41. 导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机导管室内的即时决策：IVUS\OCT\FFR的最佳应用时机 Never forget the patient and the clinical scenario!

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