: evolving from pci to cabg
TRANSCRIPT
FFR Digest : Evolving from PCI to CABG
Bon-Kwon Koo, MD, PhD
Seoul National University Hospital, Seoul, Korea
Seoul National University Hospital
Cardiovascular Center
TCTAP 2014
Expanding Role of FFR at CathLab
FFR has become the gold standard to detect the ischemia-related lesion in a catheterization lab.
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FFR =
• Functional evaluation for multi-vessel disease
• FFR-guided bypass surgery: Clinical evidences
• Functional evaluation for graft stenoses
• Non-invasive FFR
FFR Digest : Evolving from PCI to CABG
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• FFR is the only mean of gaining a per segment
functional assessment of the coronary tree
- Stress ECG: per patient
- Radioisotope scan, CFR per vessel
- FFR per segment
FFR in Multi-vessel disease and Multiple lesions
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“3-VD ?”
Proportions of functionally diseased coronary arteries in patients with angiographic 3 vessel disease
3-VD
14%
1-VD
34%
2-VD
43%
0-VD
9%
From FAME study, Tonino P, et al.
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Multivessel disease
F/52
Stable angina
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8
7
9
1
2
3 4
5
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Multivessel disease
F/52
Stable angina
6
8
7
9
6 7 8 9 1
2
3 4
5
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F/52
Stable angina
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3VD, 9 lesions by coronary angiography
5-6 stents? Bypass surgery?
After FFR, 1VD, single lesion Treated with 1 DES
• Functional evaluation for multi-vessel disease
• FFR-guided bypass surgery: Clinical evidences
• Functional evaluation for graft stenoses
• Non-invasive FFR
FFR Digest : Evolving from PCI to CABG
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Cardiovascular Center 10
FFR 0.83
Why is a graft to RCA occluded?
• LITA to LAD, SVG Y-graft to D2
• RITA+SVG Y-graft to D1, PDA
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Botman CJ, et al. Ann Thorac Surg 2007
21.9% 21% 21.4%
13.6%
6%
9%
0
5
10
15
20
25
30
Arterial graft Venous graft All graft
FFR>0.75 FFR≤0.75
• Prospective study
• 164 patients with ≥ 1 intermediate stenosis
• FFR was measured, but the surgeon was blinded to the results of FFR
• 1 year angiography to assess the graft patency
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% o
cclu
sion
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Cardiovascular Center
• Retrospective registry, 627 patients with bypass surgery
• ≥ 1 intermediate stenosis
• 429 patients with angio-guided surgery vs. 198 FFR-guided surgery
Toth G, et al. Circulation 2013
Before FFR
After FFR
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Toth G, et al. Circulation 2013
FFR-guided group: Significantly lower rate of angina (CCS II–IV angina, 31% vs. 47%; P<0.001)
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• Functional evaluation for multi-vessel disease
• FFR-guided bypass surgery: Clinical evidences
• Functional evaluation for graft stenoses
• Non-invasive FFR
FFR Digest : Evolving from PCI to CABG
Seoul National University Hospital
Cardiovascular Center 15
F/73
CABG 10 years ago (LITA-SVG to LAD, RITA Y-graft to OM)
Recurred chest pain
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What happened to the graft?
F/73
CABG 10 years ago (LITA-SVG to LAD, RITA Y-graft to OM)
Recurred chest pain
What happened to the graft?
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Is perfusion to PL branch enough? M/61 Asymptomatic, routine 1 year f/u angiography after bypass surgery
: LITA-LAD, Saphenous vein Y-graft to Dg-OM-LCX-PL)
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Cardiovascular Center 18
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Flow competition
– from OM
and from LITA- SVG
Is perfusion to PL branch enough? M/61 Asymptomatic, routine 1 year f/u angiography after bypass surgery
: LITA-LAD, Saphenous vein Y-graft to Dg-OM-LCX-PL)
• Functional evaluation for multi-vessel disease
• FFR-guided bypass surgery: Clinical evidences
• Functional evaluation for graft stenoses
• Non-invasive FFR
FFR Digest : Evolving from PCI to CABG
Seoul National University Hospital
Cardiovascular Center 20
FFR without invasive procedure, without pressure wire…
Computational Model
based on CCTA
3-D anatomic model from CCTA
Blood flow equations solved
on supercomputer
Blood Flow Solution
Physiologic models -Myocardial demand
-Morphometry-based boundary condition
-Effect of adenosine on microcirculation
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0.81
Ambiguous left main lesions (Case #77 from SNUH, Korea)
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Virtual bypass surgery FFRCT after virtual CABG with LIMA + 2SVGs
FFR 0.92
FFR 0.89 FFR 0.94
Koo BK, EuroPCR 2012
Ambiguous left main lesions (Case #77 from SNUH, Korea)
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•Functional significance of a stenosis is a key element in the
assessment of the patients with coronary artery stenosis.
•FFR is the gold standard invasive method to define ischemia-
causing stenosis.
•FFR is still evolving. More adoption of “ischemia-guided revascularization” using FFR will improve the patients’
outcomes.
Conclusion
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