FFR and serial lesions - Hitoshi Matsuo

1. FFR and serial lesion
• Hitoshi Matsuo M.D.,
• The Department of Cardiovascular
Medicine,
• Gifu Heart Center
• Japan
PCI workshop 2017

2. Disclosure Statement of Financial Interest
I have no financial conflicts of interest related to this presentation
PCI workshop 2017

3. Treatment strategy using FFR
PCI workshop 2017

4. PCI workshop 2017

5. PCI workshop 2017

6. PCI workshop 2017

7. Saito N, Matsuo H et al. J Invasive Cardiol. 2013 Dec;25(12):642-9..
In Vitro Assessment of Mathematically-Derived FFR
in Coronary Lesions With More Than Two Sequential Stenoses
PCI workshop 2017

8. 2017/10/12 FFR workshop 3/3/2012
PCI workshop 2017

9. FFR oriented intervention to the
tandem lesion in real world
• Step1 : The rule of delta PG
Stenosis A > Stenosis B → Fix stenosis A
Stenosis A < Stensois B → Fix stenosis B
Stenosis A = Stenosis B → Fix proximal stenosis
• Step2 : Re-evaluate PG after fixing the first stenosis
If FFRmyo <0.80 Fix another stenosis
If FFRmyo >=0.80 leave the stenosis without Tx
PCI workshop 2017

10. PCI workshop 2017
Kim HL, Koo BW et al. JACC Cardiol Interv. 2012;110:1578-1584.

11. PCI workshop 2017
Cardiac event occurred very few, if treated by this strategy
during mean follow-up of 501±311 days.
Kim HL, Koo BW et al. JACC Cardiol Interv. 2012;110:1578-1584.
A total of 131 patients (141 vessels and 298 lesions) with multiple intermediate stenoses
within the same coronary artery were assessed by FFR with pullback pressure tracings.

12. Case
ID:138126
 74y.o. Male
 Diagnosis : effort angina
 Risk factor : Dyslipidemia ,DM, CKD stage ⅢA
 Present illness : Pt began to feel chest oppressive
sensation during 5minutes walking about 2 weeks
before the procedure.
PCI workshop 2017

13. MR ID:153893
2012/1/25
PCI workshop 2017

14. PCI workshop 2017

15. PCI workshop 2017
Stenosis A
Stenosis B
Stenosis C
MR ID:153893
2012/1/25

16. MR ID:153893
2012/1/25
PCI workshop 2017
A B C

17. PCI workshop 2017
MR ID:153893
2012/1/25
Stenosis A
Stenosis B
Stenosis C

18. MR ID:153893
2012/1/25
PCI workshop 2017
A B C

19. PCI workshop 2017
MR ID:153893
2012/1/25
Stenosis A
Stenosis B
Stenosis C

20. MR ID:153893
2012/1/25
PCI workshop 2017
A B C

21. Case History
• 78-year-old male
• Dyslipidemia
• Coronary angiography and physiological study using a pressure
wire, followed by LM and LAD PCI (Xience V, Abbott Vascular, CA,
USA) performed 6 years ago
• Presented to our hospital complaining of chest tightness
PCI workshop 2017

22. Coronary Angiography and FFR
• Coronary angiography revealed
tandem lesions: 50% lesion in LAD
and 75% lesion in LMCA
• FFR (Opsens Medical, Quebec,
Canada) in distal LAD within the gray
zone (FFR = 0.76)
• Hyperemic pull back revealed step-
ups over the two lesions of 0.12 and
0.06, respectively
Pre-PCI: tandem lesion in LAD and LMT
PCI workshop 2017

23. Treatment
Lesion with the larger ΔFFR treated first
and then FFR reassessed:
• Drug-eluting stent (Ultimaster, Terumo,
Tokyo, Japan) implanted in the LAD
over the pressure guidewire
• FFR performed immediately after
dilatation
• FFR corrected for drift ≈ 0.83
Park SJ, Ahn JM, Pijls NH, De Bruyne B, Shim EB, Kim YT, et al. Am J Cardiol. 2012;110:1578–84.
FFR correctd for drift ≈ 0.83
PCI workshop 2017

24. Summary
• All procedures in this patient were performed using one pressure guidewire
and no re-normalization was performed until the end of the case
• Device exchange was performed 6 times over the Optowire
• Total procedure time was 53 minutes
• Drift observed after the procedure was 2 mmHg
• The FFR corrected for drift was ≈ 0.83; unnecessary stenting of the lesion in
this patient’s LMCA was avoided
PCI workshop 2017

25. 102 lesions from 95 patients
Total procedure time (min) 98±29 min
Total contrast volume (ml) 110±43
Device exchange (times） 6±2
Max pressure (atm) 21±4
Rotablator/Jailed wire
(case）
10/13
Drift in FFR value 0.013±0.013 [-0.07 – 0.02]
Drift in mmHg 1.2±1.1 [-5.0 – 2.0]
Optic sensor Pressure wire use as the workhorse wire
(2016/1/20-2016/10/12)
Kawase Y, Matsuo H et al. Cardiovasc Interv Ther. 2017 Jul 3.
doi: 10.1007/s12928-017-0481-x. [Epub ahead of print]
PCI workshop 2017

26. 102 lesions from 95 patients
Total procedure time (min) 98±29 min
Total contrast volume (ml) 110±43
Device exchange (times） 6±2
Max pressure (atm) 21±4
Rotablator/Jailed wire
(case）
10/13
Drift in FFR value 0.013±0.013 [-0.07 – 0.02]
Drift in mmHg 1.2±1.1 [-5.0 – 2.0]
Optic fiber pressure wire
Pressure drift>3.0mmHg (4/102=4%)
FFR drift>0.03 (6/102=6%)
Assessed after whole procedure
Optic sensor Pressure wire use as the workhorse wire
(2016/1/20-2016/10/12)
Kawase Y, Matsuo H et al. Cardiovasc Interv Ther. 2017 Jul 3.
doi: 10.1007/s12928-017-0481-x. [Epub ahead of print]
PCI workshop 2017

27. Treatment strategy using iFR
PCI workshop 2017

28. PCI workshop 2017

29. Justify PCI study
Nijjer SS et al. JACC Cardiol Interv. 2015;8:E001765.
PCI workshop 2017

30. In Vitro Assessment of Mathematically-Derived FFR
in Coronary Lesions With More Than Two Sequential Stenoses
iFR(X-)=iFRpre+ΔiFR(X)
iFR（X)Pred＝１－ΔiFR(X)PCI workshop 2017

31. iFR Scout™ Pullback Software
• Significant
Features
– Live display of
single-cycle iFR
value
– Pullback
assessment of
multiple lesions
– Highlighting of
the Wave-Free
Period
601-0103.181/001
Internal Use Only. Do Not Distribute
PCI workshop 2017

32. Case: M.M. ID: 334928 74 y.o. female
Coronary risk factors: HTN (-), DM (+), HL (+), Family Hx (+), Smoking (+)
PH: none, FH: Brother (cardiac death)
PI: The patient was referred to our hospital due to the suspicion
of angina pectoris. Coronary angiogram performed on 2016/2/12 showed
severe coronary stenosis in her coronary artery showed diffuse calcified coronary stenosis
both in RCA and LCA.(#1: 90%, #2 90%, #3 75%, #6, #14 90%.

33. PCI workshop 2017

34. A
B
C
PCI workshop 2017

35. PCI workshop 2017

36. A B
C
far distal iFR 0.50
Step-up 0.32
Step-up 0.09
Step-up 0.03
PCI workshop 2017

37. PCI workshop 2017

38. A
B
C
PCI workshop 2017

39. PCI workshop 2017

40. A
B C
far distal iFR 0.92
Step-up 0.06
Step-up 0.01
Step-up 0.00
PCI workshop 2017

41. PCI workshop 2017

42. FOCAL
DIFFUSED
(low pressure drop intensity)
iFR pullback mapping to identify focal and diffuse
disease
FOCAL
(high pressure drop intensity)
PCI workshop 2017

43. Case presentation
 75 years old male
 Effort Angina
 PI: The patient was referred to our hospital due to the
exaggerated chest pain during effort.
 Risk factors : past smoker, HT,DM,Dyslipidemia
 No prior intervention
 LVEF 60% CKD class 2
 Transient perfusion defect in anteroseptal wall by
SPECT
 Angiography showed LAD proximal and mid stenosis.

46. Predicted iFR
0.78
Just click and drag
for length measurement and iFR drop
within that lesion

47. Predicted iFR
0.50

48. Predicted iFR
0.91

49. 3.0mm*28mm length EES
3.0mm*24mm length EES

51. post iFR
0.91
Predicted iFR
0.91

52. Take home message
• In serial lesion assessment, Physiological pullback recording is very
important to identify the lesions where stenting is necessary.
• Delta FFR theory is practically helpful for the routine clinical
practice.
• New generation pressure wire system using optical-fiber sensor
may be useful to the repeat assessment of FFR in serial stenosis
because of less chance of pressure drift during procedures.
• iFR pullback curve with syncvision angiocoregistration system may
have large potentials for identifying lesions most likely to lead to an
improvement in coronary physiology and deferring those of lesser
importance, and could assist lesion selection and PCI planning in
the presence of multiple lesions.
PCI workshop 2017

53. Thank you for your attention.
PCI workshop 2017