15 FFR Davidavicius aimradial2017 - Post-PCI FFR
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Post-PCI FFR after long DES - Giedrius Davidavicius
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15 FFR Davidavicius aimradial2017 - Post-PCI FFR
- 1. Post-PCI FFR after long DES Giedrius Davidavicius Vilnius University Hospital ‘Santaros Klinikos’ Lithuania
- 2. Disclosures I have no conflict of interest to declare
- 3. ‘Physiological’ stent implantation • FFR measured post PCI is a strong independent predictor of major adverse cardiovascular events (MACE): – Pijls at al. (750 pts.; Stent length, 17.3±6.4 mm) have shown that the higher the post PCI FFR following BMS implantation, the lower the MACE rate at 6 months follow up – Johnson et al. have shown that the higher the FFR post PCI, the better the prognosis. Pijls NH et al. Circulation. 2002;105:2950-4 Johnson NP et al. J Am Coll Cardiol. 2014;64:1641-54
- 4. FFR post PCI and Outcome Johnson NP et al. J Am Coll Cardiol. 2014;64:1641-54 ‘The absence of a hyperemic residual pressure gradient is a prerequisite for optimum stent deployment’ ‘Measurement of FFR immediately after stenting also shows an inverse gradient of risk, likely from residual diffuse disease’
- 5. MACE according to the stent length in pts with long lesions Honda et al. Catheterization and Cardiovascular Interventions 00:00–00 (2015) <20 mm 20-50 mm >50 mm
- 6. EuroIntervention. 2016 Dec 20;12(12):1473-1480
- 7. The aim: to evaluate the functional result immediately post PCI and at nine-month follow-up, and to ascertain how often a functionally optimal result of >0.95 can be achieved in long coronary lesions treated with long DES
- 9. Clinical characteristics of the patients
- 12. Post PCI result by FFR in pts with long lesions (30-50 mm) and ultra long lesions (>50 mm)
- 13. Functional result at FU in pts with long lesions (30-50 mm) and very long lesions (>50 mm)
- 14. The angiographic in-stent late lumen loss was 0.24 ± 0.41 at 9 months FU
- 15. Clinical Endpoint at 2 years FU at 12 months At 24 months Cardiac Death 2 (2.7%) 3 (4.1%) Myocardial Infarction 5 (6.8%) 7 (9.5%) Periprocedural MI 5 (6.8%) 5 (6.8%) No target vessel related MI 0 2 (2.7%) Target Vessel Revascularization 6 (8.1%) 6 (8.1%) Other Vessel Revascularization 5 (6.8%) 8 (10.8%) Major Adverse Cardiac Events 18 (24.3%) 22(29.7%)
- 16. Discussion • An optimal FFR value of >0.95 was achieved in only 9/74 patients (12.2%). • Only 12/74 (16.2%) had a desirable FFRPOST of 0.91 to 0.95 (inclusive). • Finally, 53/74 (71.6%) had FFR values ≤0.90. • In 8/74 (10.8%) of the patients, the FFR remained haemodynamically significant at ≤0.8 (mean FFRPOST 0.77±0.04, mean stent length 50±15 mm), indicating significant inducible ischaemia • Finally, the rate of functional restenosis at nine-month follow-up was shown to be approximately three times higher than the rate of angiographic restenosis in this cohort.
- 17. Conclusions • In patients with long coronary stenosis (>50mm) Post PCI FFR result >0.95 was not achieved • There is a higher incidence of functional vs angiographic restenosis • A 2 year’s clinical outcome remains satisfactory in all FFR subgroups • Consider LIMA to LAD, particularly if stenosis length exceeds 50 mm
Editor's Notes
- 1. How can we look at the PCI result if it is optimal or not: 2. Using FFR measurement not only prior to but also post PCI we can find a physiological stent implantation. 3. Poststenting FFR was calculated and related to major adverse events. 4. Nijo Pijls in the registry with 750 pts and more recent metaanalysis performed by Johnson showed that the higher the FFR post PCI, the better prognosis. Nico Pijls: Registry: A FFR value >0.95 was achieved in 266 patients (36%), and a value of >0.90 in 507 patients (68%). Specifically, it seems, that the optimal PCI result is achieved when the FFR value post PCI is >0.95, comparable to that found in angiographically normal coronary arteries(4) A recent metaanalysis by Honson et al.
- 1. How can we look at the PCI result if it is optimal or not: 2. Using FFR measurement not only prior to but also post PCI we can find a physiological stent implantation. 3. Poststenting FFR was calculated and related to major adverse events. 4. Nijo Pijls in the registry with 750 pts and more recent metaanalysis performed by Johnson showed that the higher the FFR post PCI, the better prognosis. Nico Pijls: Registry: A FFR value >0.95 was achieved in 266 patients (36%), and a value of >0.90 in 507 patients (68%). Specifically, it seems, that the optimal PCI result is achieved when the FFR value post PCI is >0.95, comparable to that found in angiographically normal coronary arteries(4) A recent metaanalysis by Honson et al.
- If we look at the histogram and Caplans Meyers curves below it becomes clear that PCI should aim at the FFR value higher than >0.9, and the aspiration would be 0.95- the level of the normal coronary artery which does not have resistance to the flow at the epicardial level. As if the post FFR result is achieved >0.95 post PCI MACE event rate is significantly lower. Therefore two important messages could be taken for clinical practice: ‘The absence of a hyperemic residual pressure gradient is a prerequisite for optimum stent deployment’ ‘Measurement of FFR immediately after stenting also shows an inverse gradient of risk, likely from residual diffuse disease’
- An estimated 20–25% of patients undergoing PCI has diffuse coronary artery disease and represents a therapeutic challenge. Honda et al.: MACEs at 4yrs: 43 (5.8%)/Short DES; 57 (7.5%)/LongDES; 22 (13.2%)/ultralongDES;p= 0.001 Intravascular ultrasound (IVUS)-guided PCI was attempted to perform for all patients, with the exception of some cases in which delivery of an IVUS catheter was not possible due to severe calcification or tortuosity. Length and diameter of stents were selected based on IVUS findings performed before or after plain old balloon angioplasty. Procedural success of IVUSguided PCI was defined as follows: (1) no malapposition; (2) no residual stenosis; and (3) minimum stent area more than distal reference lumen area, in the presence of thrombolysis in myocardial infarction (MI) flow grade 3. A registry of 3,157 patients undergoing sirolimus and paclitaxel eluting stents demonstrated an increased risk of stent thrombosis in patients with stent lengths >31.5 mm (4 vs. 0.7% in lesions) Successful PCI with second generation DES 1669 pts, 2763 lesions Stent implantation was performed according to current standard techniques. The second DES used included Xience V, Xience Prime, Xience Expedition (Abbott Vascular, Santa Clara, CA), Promus, Promus Element, Promus Premier (Boston Scientific, Natick, MA), Nobori (TERUMO, Tokyo, Japan), and Resolute Integrity (Medtronic, Minneapolis, MN).
- 1. Therefore, we prospectively looked at POST PCI result with FFR in patients with long lesions selected for DES implantation (stent length >30 mm).
- Baseline (FFRPRE) - defined as evaluation of lesion significance prior to PCI, with the pressure wire sensor positioned at the beginning of the distal segment of the artery. 2. Post PCI: – FFRPOST - post PCI the FFR was measured in the same position as FFRPRE. – FFR gradient: - FFR gradient across the stent (GRADSTENT) was defined as the difference between the FFR value just proximal to the stent and the FFR value just distal to the stent. - FFR gradient distal to the stent (GRADDISTAL) was defined as the difference between the FFR value just distal to the stent and the FFR value at the beginning of the distal segment. - Total gradient was defined as the difference between the FFR value just proximal to the stent and the FFR value at the beginning of the distal segment. 3. The same FFR values were obtained at nine-month follow-up (FFRFU, GRADStentFU, GRADDistalFU). All study lesions were treated with Biolimus A9™ (BioMatrix Flex™; Biosensors, Newport Beach, CA, USA), everolimus (XIENCE Xpedition®; Abbott Vascular, Santa Clara, CA, USA) or zotarolimus (Resolute Integrity®; Medtronic Vascular, Santa Rosa, CA, USA) drug-eluting stents. Angiographic success was defined as TIMI 3 flow with a residual angiographic diameter stenosis of ≤10%. The aim was to achieve the optimal result, defined as an FFRPOST ≥0.95. The operators were encouraged to post-dilate in every case; however, where there was an FFRPOST <0.95, further post-dilatation was mandatory. If there was clear evidence of atheroma beyond the stented segment, then the operator was encouraged to try to optimise the functional result further by implanting another stent more distally. All patients had medical therapy optimised (as tolerated), with
- We included 74 pts with long lesions and with a mean age of 67 years old., three vessel disease was noted in 84% of pts, one third of them were admitted due to a unstable angina. They were subdivided into two groups according to the stent length: In a Long DES group a stent length was 30 to 50 mm and in a ultra long group the stent length was >50 mm. The groups were well matched.
- Target vessel LAD was in 82% of cases. Mean stent length was 51 mm, in the long stent group 39 mm and in ultra long stent group 62 mm expressing the presence difuse coronary artery disease. In order to achieve an optimal PCI result by FFR- in 80% of cases the stent implantation was accomplished by postdilatation at 18ATM, in case of residual gradient distal to the stent by FFR another stent was implanted.
- Baseline FFR was increased to 0.88 by PCI, and remained at 0.85 at 9 months follow up time. Post PCI result by FFR was worse in pts with ultra-long lesions. There is a FFR gradient in the stent 0.05 and distal to the stent, and the FFR gradient in the ultra-long stent group is higher. Not surprisingly there is residual gradient distal to the stent.
- There are two important findings : Group (ulra long lesions) PCI result by FFR was suboptimal. The post PCI result >0.9 was achieved only in …% of cases. 11% of pts had FFR result post PCI below 0.8, so they were excluded from further analysis.
- PCI result with FFR values >0.9 at follow up was only seen in 22%. PCI result >0.95 was seen only in 6.6% of pts and none in ultra long stent group.
- 1. Historically, many studies used angiographic assessment for follow-up. 2. In this study, following angiographic assessment at nine months, we found that there was a restenosis rate of 4.7%, in keeping with previous studies that have used second-generation DES16. 3. However, in this study, we also performed a haemodynamic assessment at nine months and found a functional restenotic rate of 15.1%, equating to a threefold to fourfold increase. This suggests that angiographic assessment potentially misses a significant proportion of patients, and therefore we should not be surprised if MACE rates are higher, particularly in cases where PCI has been performed in long diffuse coronary disease using long second-generation DES. Simply believing the angiographic result may not be sufficient in order to avoid MACE; functional restenosis may be a better predictor of MACE. 4. At 2-year follow-up, 6 (8.1%) of the patients had ischemia driven TVR, all within the first 12 months
- Cardiac death 4.1% TVR 8.1% Other vessel revascularization 10.8% MACE 29.7%