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Fractional Flow Reserve guided

Intervention:

Should it be routine or

individualized according to very

specific need in MVD?

Prof.Dr. Amr Zaki

Alexandria University

The answer is;

it should be individualized

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FFR – guided PCI improves outcomes by

adding functional information to the

anatomic information obtained from the

angiogram.

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DES → ↓↓ TVR

A large and growing number of patients

with MVD are undergoing PCI.

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SS is an anatomic scoring system based

on coronary angiogram;

it

1 - Qualifies lesion complexity

2 - Predicts outcome after PCI in

patients with MVD

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Not all angiographically significant

LESIONS turned to be hemodynamically

significant.

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Thus the clinical guide of FFR helps in

a. Intermediate lesions

b. Serial Lesions

c. Ostial Lesions

d. Side Branch Lesions

e. MVD

f. In stent Restenosis

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Intermediate stenoses (40-60%)

baseline hyperemia

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Serial stenoses

1 2 3 4

By performing a pullback over the stenoses the

”culprit lesion” can be identified.

Left Main Stenosis

LM

LAD

Surgery or not?

Measure pressure and the

patient might avoid CABG

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Side branch lesions

Measurement of FFR in side branch lesions suggests that

most of these lesions do NOT have functional significance,

despite morphologic appearance.

When in doubt, measure FFR.

Koo et al. J Am Coll Cardiol. 2005;46: 633-7

MVD - Multivessel Disease

Measure all suspected lesions

Use long-lasting hyperemic stimulus – time for pullback

Place stents only in stenoses where FFR is below 0.75

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Where to intervene?

LAD D 1

D 2

RCA

Where to intervene?

RCA

FFR = 0.94 >0.75

FFR = 0.89 >0.75

FFR = 0.90 >0.75

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Where to intervene?

RCA

FFR = 0.41 <0.75

Where to intervene?

FFR = 0.67 <0.75

After balloon inflation

3.0 balloon 12 atm (mid-RCA)

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Where to intervene?

After stent 3.5 mm (mid-RCA)

FFR = 0.80 Not optimal post stent result

Where to intervene?

Stent 3.5 mm (mid-RCA) + Stent 3.5 mm

(prox-RCA)

FFR = 0.94 Optimal post stent result

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Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls.

Fractional Flow Reserve

versus

Angiography for

Multivessel

Evaluation

FRACTIONAL FLOW RESERVE

versus ANGIOGRAPHY

FOR GUIDING PCI IN PATIENTS WITH

MULTIVESSEL CORONARY ARTERY DISEASE

Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls.

FAME study: Study Population

The FAME study was designed to reflect daily practice

in performing PCI in patients with multivessel disease

Inclusion criteria:

• ALL patients with multivessel disease

• At least 2 stenoses ≥ 50% in 2 or 3 major epicardial

coronary arteries amenable for stenting

Exclusion criteria:

• Left main disease or previous bypass surgery

• STEMI within last 5 days

• Extremely tortuous or calcific coronaries

Note: patients with previous PCI were not excluded

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Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls.

Angiography-guided PCI

FFR-guided PCI

Measure FFR in all

indicated stenoses

Stent all indicated

stenoses

Stent only those

stenoses with FFR ≤ 0.80

Randomization

Indicate all stenoses ≥ 50%

considered for stenting

Patient with stenoses ≥ 50%

in at least 2 of the 3 major

epicardial vessels

1-year follow-up

FLOW CHART

Ref. NEJM Vol 360, No 3, pp 213-

ANGIO-group

N=496

FFR-group

N=509 P-value

Events at 1 year, No (%)

Death, MI, CABG, or repeat-PCI 91 (18.4) 67 (13.2) 0.02

FAME study: Adverse Events at 1 year

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Ref. NEJM Vol 360, No 3, pp 213-

ANGIO-group

N=496

FFR-group

N=509 P-value

Events at 1 year, No (%)

Death, MI, CABG, or repeat-PCI 91 (18.4) 67 (13.2) 0.02

Death 15 (3.0) 9 (1.8) 0.19

Death or myocardial infarction 55 (11.1) 37 (7.3) 0.04

CABG or repeat PCI 47 (9.5) 33 (6.5) 0.08

FAME study: Adverse Events at 1 year

Ref. NEJM Vol 360, No 3, pp 213-

ANGIO-group

N=496

FFR-group

N=509 P-value

Events at 1 year, No (%)

Death, MI, CABG, or repeat-PCI 91 (18.4) 67 (13.2) 0.02

Death 15 (3.0) 9 (1.8) 0.19

Death or myocardial infarction 55 (11.1) 37 (7.3) 0.04

CABG or repeat PCI 47 (9.5) 33 (6.5) 0.08

Total no. of MACE 113 76 0.02

FAME study: Adverse Events at 1 year

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Ref. NEJM Vol 360, No 3, pp 213-

ANGIO-group

N=496

FFR-group

N=509 P-value

Events at 1 year, No (%)

Death, MI, CABG, or repeat-PCI 91 (18.4) 67 (13.2) 0.02

Death 15 (3.0) 9 (1.8) 0.19

Death or myocardial infarction 55 (11.1) 37 (7.3) 0.04

CABG or repeat PCI 47 (9.5) 33 (6.5) 0.08

Total no. of MACE 113 76 0.02

Myocardial infarction, specified

All myocardial infarctions 43 (8.7) 29 (5.7) 0.07

Small periprocedural CK-MB 3-5 x N 16 12

Other infarctions (“late or large”) 27 17

FAME study: Adverse Events at 1 year

Ref. NEJM Vol 360, No 3, pp 213-

FFR-guided

30 days

2.9% 90 days

3.8%

180 days

4.9%

360 days

5.3%

Angio-guided

absolute difference in MACE-free survival

FAME study: Event-free Survival

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Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls.

FAME study: CONCLUSIONS (1)

Routine measurement of FFR during PCI with DES

in patients with multivessel disease, when

compared to current angiography guided strategy

• reduces the rate of the composite endpoint of

death, myocardial infarction, re-PCI and CABG

at 1 year by ~ 30%

• reduces mortality and myocardial infarction at

1 year by ~ 35 %

Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls.

FAME study: CONCLUSIONS (2)

Routine measurement of FFR during PCI with DES

in patients with multivessel disease, when

compared to current angiography guided strategy,

furthermore:

• is cost-saving and does not prolong the procedure

• reduces the number of stents used

• decreases the amount of contrast agent used

• results in a similar, if not better, functional status

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Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls.

Routine measurement of FFR during DES-stenting

in patients with multivessel disease is superior

to current angiography guided treatment.

It improves outcome of PCI significantly

It supports the evolving paradigm of

“Functionally Complete Revascularization”,

i.e. stenting of ischemic lesions and

medical treatment of non-ischemic ones.

FAME study: CONCLUSIONS (3)

Functional SYNTAX score for Risk

Assessment in Multivessel coronary

artery disease

JACC volume 58,Issue 12 ,Sept 2011

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Aim of FSS Study

To determine whether an FFR- guided

SYNTAX score (FSS) and defined as a

recalculated SS counting only ischemia-

producing lesions as assessed by FFR is a

better predictor of 1 Year clinical outcome in

patients with MVD undergoing PCI ?

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The major findings in the current study are

that FSS:

1) Decreases the number of highest – risk

patients as assessed by the classic SS

2) Is better descimintor risk for MACE in

patients with MVD undergoing PCI

3) FSS is an independent predictor of a 1 year

MACE in these patients

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Conclusions

Compared with the classic SS, the FSS, which

is obtained by counting only ischemia – Providing

lesions, has better reproducability, has better

prognostic value , and increases the proportion of

patients with MVD who fall into the lowest risk for

adverse events after PCI

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Why should it be individualized ?

Is not a clinical scoring

The study included patients with 2-Vessel

disease beside 3-Vessel disease

This trial was not head to head comparison

with CABG

FFR is time consuming

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THANK YOU

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