Download Diapositiva 1

Pros and cons of FFR
in multivessel disease:
from FAME to ACS
Giuseppe Biondi Zoccai
University of Modena and Reggio Emilia, Modena, Italy
[email protected]
Learning goals
• Scope of the problem
• What are the implications of FAME
• What about the culprit lesion in ACS
• What about non-culprit lesions in ACS
The first coronary angioplasty by
Andreas Gruentzig
Extent of CAD in the VANWISH trial
Kerensky et al, J Am Coll Cardiol 2002;39:1456-63
Single culprit, multiple culprits, or no
culprit at all?
Kerensky et al, J Am Coll Cardiol 2002;39:1456-63
What is most trustworthy?
Melikian et al, J Am Coll Cardiol Intv 2010;3:307–14
Is SYNTAX no more such?
Nam et al, ACC 2011 (J Am Coll Cardiol 2011;57:E1090)
Learning goals
• Scope of the problem
• What are the implications of FAME
• What about the culprit lesion in ACS
• What about non-culprit lesions in ACS
Visual angiographic assessment vs
FFR in the FAME trial
Tonino et al, J Am Coll Cardiol 2010;55:2816-21
FAME trial
FAME at 2 years
Pijls et al, J Am Coll Cardiol 2010;55:2816-21
FAME: deferred group
Pijls et al, J Am Coll Cardiol 2010;55:2816-21
Learning goals
• Scope of the problem
• What are the implications of FAME
• What about the culprit lesion in ACS
• What about non-culprit lesions in ACS
Acute microvascular damage in
myocardial infarction
STEMI
Variable degree of
reversible microvascular
stunning
Maximum achievable
flow is less
Smaller gradient and
higher FFR across any
given stenosis
With time, the microvasculature may recover, maximum
achievable flow may increase, and a larger gradient with a
lower FFR may be measured across a given stenosis
Similar stenosis but different extent
of perfusion area
An identical stenosis, but...
• 26 col-schema fcf (figuur)
100
50
0
Pd
Poor collaterals
low FFR = 0.50
An identical stenosis, but...
• 26 col-schema fcf (figuur)
100
75
0
Pd
Good collaterals
higher FFR = 0.75
Visible collaterals on the coronary
angiogram (Rentrop) and fractional
collateral blood flow Qc/Qn
What about serial lesions?
What about severe left ventricular
hypertrophy?
In severe left ventricular hypertrophy, there is an exaggerated increase of
left ventricular mass in comparison to the vascular bed, resulting in the
potential for ischemia even in normal or almost normal coronary arteries
Thus, specificity may be reduced (cut-off >0.80?)
However, sensitivity remains satisfactory
What about lesion length?
Brosh et al, Am Heart J 2005;150:338-43
What about culprit lesion FFR?
What about culprit lesion FFR?
De Bruyne et al, Circulation 2001;104;157-62.
What about culprit lesion FFR?
What about culprit lesion FFR?
Tamita et al, Catheter Cardiovasc Intervent 2002;57:452-9
What about culprit lesion FFR?
Beleslin et al, Eur Heart J 2008;29:2617-2624
What about culprit lesion FFR?
What about culprit lesion FFR?
Samady et al, J Am Coll Cardiol 2006;47:2187-93
Learning goals
• Scope of the problem
• What are the implications of FAME
• What about the culprit lesion in ACS
• What about non-culprit lesions in ACS
What about non-culprit lesions?
What about non-culprit lesions?
Ntalianis et al, Catheter Cardiovasc Intervent 2002;57:452-9
What about non-culprit lesions?
Ntalianis et al, Catheter Cardiovasc Intervent 2002;57:452-9
Is it worthwhile?
Take home messages
Take home messages
• FFR has been proved safe and effective in
several settings, including 2 RCTs with
clinically relevant end-point (DEFER and
FAME)
• ACS do benefit from FFR as well as all
others, with the notable exception of
acute/subacute culprit lesions
• The upcoming FAME 2 trial will hopefully
further support FFR, and provide us another
argument against (or better on top of)
medical therapy for CAD
Interested in more?
Thank you for your attention
For any correspondence:
[email protected]
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feel free to visit the metcardio.org website:
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