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PCI & AimRadial 2018 | FFR in Left Main Disease - William F. Fearon

1. FFR in Left Main Disease William F. Fearon, MD Professor of Medicine Director, Interventional Cardiology Stanford University Medical Center 2. Disclosure Statement of…
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  • 1. FFR in Left Main Disease William F. Fearon, MD Professor of Medicine Director, Interventional Cardiology Stanford University Medical Center
  • 2. Disclosure Statement of Financial Interest Affiliation/Financial Relationship Company Grant/ Research Support: Abbott, Medtronic, Acist, CathWorks, Edwards LifeSciences Consulting Fees/Honoraria: Boston Scientific Major Stock Shareholder/Equity Interest: Royalty Income: Ownership/Founder: Salary: Intellectual Property Rights: Other Financial Benefit: Minor Stock Options: HeartFlow Within the past 12 months, I or my spouse/partner have had a financial interest /arrangement or affiliation with the organization(s) listed below
  • 3.  82 year old frail woman (4’9”, 90 pounds) with HTN, dyslipidemia presents with chest pain  2 weeks prior to this presentation, patient had NSTEMI with PCI to circumflex. Because of concern regarding aspirin allergy, patient received BMS to proximal circumflex and PTCA to OM. Ejection fraction normal. Case Presentation:
  • 4. Case Presentation:  ECG with nonspecific ST/T wave changes, not significantly different from prior  Initial enzymes negative.  However, because of concerning symptoms and recent history (particularly PTCA), brought to cath lab…
  • 5. What should we do?  Medical Therapy  CABG  PCI LAD  PCI Left Main and LAD  Other suggestions…?
  • 6. Further Interrogation with FFR FFR of LAD and Left Main = 0.64 Resting Hyperemia
  • 7. Further Interrogation with FFR Pullback of Pressure Wire During Maximal Hyperemia Across Mid LAD Across LM
  • 8. Further Interrogation with FFR Pullback of Pressure Wire During Maximal Hyperemia Across Mid LAD Across LM
  • 9. Is this Left Main significant??
  • 10. Effect of Tandem Lesions Myocardium0.84 0.64 Myocardium0.72
  • 11. De Bruyne, et al. Circulation 2000;101:1840-7. Pijls, et al. Circulation 2000;102:2371-7. Scientific Aspects Tandem Lesions
  • 12. The influence of a distal stenosis on the FFR of the LM depends on the extent to which hyperemic flow across the LM stenosis will be decreased by this distal lesion • Severity • Myocardial mass FFR of LM with Downstream Disease
  • 13. The influence of a distal stenosis on the FFR of the LM depends on the extent to which hyperemic flow across the LM stenosis will be decreased by this distal lesion • Severity • Myocardial mass FFR of LM with Downstream Disease Courtesy Bernard De Bruyne, MD, PhD
  • 14. The influence of a distal stenosis on the FFR of the LM depends on the extent to which hyperemic flow across the LM stenosis will be decreased by this distal lesion • Severity • Myocardial mass FFR of LM with Downstream Disease Courtesy Bernard De Bruyne, MD, PhD
  • 15. J Am Coll Cardiol Intv 2015;8:398-403. Human Validation Effect of Downstream Stenosis on LM FFR: FFRapp represents the FFR of the LM and LCx in the presence of LAD balloon inflation FFRtrue represents the FFR of the LM and LCx in the absence of LAD balloon inflation FFRepi represents the FFR of the LM and LAD with the LAD balloon inflated to varying degrees
  • 16. J Am Coll Cardiol Intv 2015;8:398-403.
  • 17. 91 paired measurements obtained in 25 patients Human Validation J Am Coll Cardiol Intv 2015;8:398-403. Effect of Downstream Stenosis on LM FFR:
  • 18. 91 paired measurements obtained in 25 patients When FFRapp >0.85, FFRtrue >0.80 100% of the time. Human Validation JACC CV Intervent 2015;8:398-403. Effect of Downstream Stenosis on LM FFR:
  • 19. What else can we do to assess the left main??
  • 20. Further Interrogation with IVUS MLA=2.1mm2MLA=4.9mm2 DistalProximal Mid LADLeft Main
  • 21. Jasti, et al. Circulation 2004;110:2831-6 55 patients with ambiguous left main disease had IVUS and FFR performed IVUS Cutoff Value For Significant LM
  • 22. Limitation of Absolute MLA Cutoff 6 6 mm2 6 mm2 6
  • 23. Kang, et al. J Am Coll Cardiol Intv 2011;4:1168-74 Variability of IVUS Cutoff Values 55 patients with 30-80% LM and FFR and IVUS
  • 24. Factors impacting ischemic potential of a stenosis Kern MJ, et al. J Am Coll Cardiol 2010;55:173-85
  • 25. Decision Process  Based on FFR and IVUS, LAD and LM may be significant. SYNTAX score = 23.  Stopped procedure and discussed options with patient and family.  Presented case to other cardiologists and cardiac surgeons at cath conference. No aspirin allergy. No enthusiasm by surgeons…
  • 26. After rotational atherectomy and 2.5x28 mm DES, post-dilated to 3.0 mm
  • 27. Further Interrogation with FFR Pullback of Pressure Wire During Maximal Hyperemia Across Mid LAD Across LM
  • 28. Further Interrogation with FFR FFR of Left Main = 0.72 (In absence of LAD lesion) Proximal to LAD stent Across LM
  • 29. After 3.0x18 DES to LM/prox LAD, post-dilated to 3.5 mm
  • 30. Safety of Deferring LM Revascularization Bech, et al. Heart 2001;86:547-552 FFR measured in 54 patients with equivocal left main p = NS FFR≥0.75 FFR<0.75 FreedomfromDeath
  • 31. Bech, et al. Heart 2001;86:547-552 FFR measured in 54 patients with equivocal left main p = NS FFR≥0.75 FFR<0.75 FreedomfromMACE Safety of Deferring LM Revascularization
  • 32. Jasti, et al. Circulation 2004;110:2831-6 55 patients with ambiguous left main disease Safety of Deferring LM Revascularization
  • 33. Hamilos, et al. Circulation 2009;120:1505 FFR of LM to Guide Revascularization
  • 34. FFR for Assessing LM Significance Hamilos, et al. Circulation 2009;120:1505 Poor correlation between “eyeball” and FFR
  • 35. FFR of LM to Guide Revascularization Hamilos, et al. Circulation 2009;120:1505 Survival Rate
  • 36. FFR of LM to Guide Revascularization Hamilos, et al. Circulation 2009;120:1505 MACE Rate
  • 37. FU @ 8 mo Courtesy of Chang-Wook Nam, MD Pre Stent Post Stent
  • 38. FFR of “Jailed” Left Circumflex Nam CW, et al. Korean Circ J 2011;41:304-7. 29 patients with LM/LAD crossover stenting with FFR of “jailed” Cx
  • 39. PCI group n = 5 Defer group n = 24 Death, n Myocardial Infarction, n TLR, n Stent Thrombosis, n Total Events, n 0 0 3 0 3 1 0 1 0 2 FFR of “jailed” Circumflex Mean 20 month follow-up Nam CW, et al. Korean Circ J 2011;41:304-7.
  • 40. FFR of “jailed” Circumflex Kang SJ, et al. Catheter Cardiovasc Intervent 2014;83:545-52. 43 patients with cross-over LM to LAD PCI and post PCI FFR of L Cx
  • 41. An Approach to the Equivocal LM  First measure FFR in the least diseased vessel, preferably the LAD  If FFR < 0.80, then revascularize  If FFR >0.85, then treat medically  If FFR between 0.80 and 0.85 and there is significant downstream epicardial disease in the other epicardial vessel, then IVUS/OCT  If willing to stent LM, can treat downstream disease and remeasure FFR  Never forget the patient and the clinical scenario
  • 42. Practical Aspects  Intravenous adenosine is the ideal hyperemic agent because it allows time to pull the guide catheter out of the ostium.  If possible, confirm pressure gradient across left main by checking FFR in both the LAD and Circumflex.  A physiologic evaluation of left main disease, compared to an anatomic evaluation alone, is safe and appropriate, just as it is in non-left main CAD.
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