Finet G
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Use of Additional Morphological and Functional Technics by TRA
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Finet G
- 1. Rencontres Interventionnelles - Transradial Approach Prague, Czech Republic, Thursday 29th & Friday 30th September 2011 Use of addi*onal morphological and func*onal technics by TRA Gérard Finet MD PhD! Department of Cardiology and Interventional Cardiology Cardiovascular Hospital - Hospices Civils de Lyon gerard.finet@univ-‐lyon1.fr INSERM Unit 1086 Claude Bernard University Lyon 1 Lyon - France
- 2. Diagnos*c assessment of atherosclero*c coronary artery lesion Morphological assessment Func*onal assessment MLA < 3mm2 %DS > 50% IVUS X-‐ray Angio FFR VH® OCT Gould et al. AJC 1974 Takagi et al. Circula8on 1999 Koo et al. JACC Cardiovasc Interv 2011 Rioufol & Finet JACC Cardiovasc Interv 2011 Thim et al. Circula8on -‐ Cardiovasc Imaging 2010.
- 3. Transradial approaches Morphological assessment Func*onal assessment 6F IVUS X-‐ray Angio 5-‐6F FFR 6F OCT
- 4. Algorithms for the complementary use of FFR and IVUS
- 5. Arguments for morphological approaches IVUS or OCT
- 6. View 1 View 2 (orthogonal to view 1) Coronary angiography reference stenosis Cross-‐sec8onal images IVUS (90 µm @ 30 im/sec) Cross-‐sec8onal images OCT (13 µm @ 5 im/sec)
- 7. ACC/AHA/SCAI 2005 Guideline Update for PCI. Indica*ons for IVUS Circula8on. 2005;113:156-‐175 1-‐ To assess adequacy of coronary stent deployment Class IIa LoE: B 2-‐ To determine the cause of stent restenosis and guide PCI strategy Class IIa LoE: B 3-‐ To evaluate ambiguous coronary obstrucFon Class IIa LoE: C 4-‐ To assess a subopFmal angiographic result aHer PCI Class IIa LoE: C 5-‐ To establish the presence and distribuFon of calcium in case of RA Class IIa LoE: C 6-‐ To determine plaque burden and circumferenFal distribuFon in case of DCA Class IIa LoE: B Acute stent strut Spontaneous intra-‐adven**a haematoma malapposiFon
- 8. Impact of IVUS guidance on long-‐term mortality in sten*ng for unprotected LM coronary artery stenosis Kaplan-‐Meier incidences curves of outcomes following IVUS and angiograpic guidances In 201 propensity-‐matched pairs In 145 propensity-‐matched pairs of the overall populaLon of paLents receiving DES Park SJ et al. Circ Cardiovasc Intervent 2009; 2:167-‐177. Roy et al. EHJ 2008 Hong et al. EHJ 2006 Okabe et al. AJC 2007 Kim et al. AJC 2010
- 9. Arguments for func*onal approach FFR determinaLon by pressure guide
- 10. Complex rela*onships between lesion morphology and fluid dynamics Gould KL. JACC Cardiovasc Imaging 2009;2:1009 Raphael Lancet 1989 Gould JACC 1990 White NEJM 1984 Meijboom JACC 2008 Gould JACC 2009 Erbel EHJ 1996
- 11. Determination of FFR by pressure guide 0.80 0.75 Pijls NHJ. Heart 1998; 80:539-542. Pijls NHJ. Circulation 1995;92:3183-3193. Matsuo H. Circulation 2002;105:1060-1065. Bech GJW. Circulation 2001;103:2928-2934. Bech GJW. J Am Coll Cardiol 1998;31:841-847. Pijls NHJ. N Engl J Med 1996;334:1703-1708.
- 12. Angiographic Versus Func*onal Severity of Coronary Artery Stenoses DEFER Study FAME Study 325 lesions 1329 lesions Bech et al. Circula8on 2001 Tonino et al. JACC 2010
- 13. FFR and mul*-‐vessel disease: FAME study’s backfire angiographic func*onal Tonino et al. JACC 2010
- 14. Mul*vessel disease and diagnosis Spect performances vs FFR Concordance 42% overes*ma*on 22% underes*ma*on 36% 67 pts 2-‐ ou 3-‐vx disease Ragosta et al. Am J Cardiol 2007 Jung et al. Eur Heart J 2008;29:2536 Beleslin et al. J Nucl Cardiol 2010 Melikian et al. JACC Intv 2010;3:307 Förster et al. IJCV 2010
- 15. Topol et al. Circula8on 1993
- 16. Algorithms for the complementary use of FFR and IVUS
- 17. Topol et al. Circula8on 1993 Lin et al. JAMA 2008 No previous stress tes*ng Park et al. Circula8on 2011 Anatomical CA ambiguity ? IVUS (OCT) Physician esFmate of diagnosis CAD For each artery no Func8onal ambiguity yes (%D stenosis 30% -‐ 90%) no yes %D Sténose > 90% %D Sténose < 30% FFR no Consider yes diffuse ATS lesions* “artery effect“ ? FFR Consider No func*onal Consider RevascularisaLon Consider CAD Medical therapy w/o FFR RevascularisaLon IVUS-‐guiding if complex PCI De Bruyne et al. Circula8on 2001*
- 18. Jung et al. EHJ 2008 Melikian et al. JACC Interv 2010 Förster et al. JCI 2009 Previous posi*ve stress tes*ng Beleslin et al. J Nucl Cardiol 2010 Ragosta et al. Am J Cardiol 2007 Vigna et al. IJC 2005 Lewis et al. AHJ 2005 Anatomical CA ambiguity ? IVUS (OCT) Ashley et al. Lancet 2000 Hung et al. JACC 1984 Lima et al. JACC 2003 yes no Single coronary disease? no yes %D Sténose > 50% For each artery %D Stenosis > 30% If discrepency by diffuse ATS lesions yes Func8onal ambiguity no “artery effect“ ? (%D stenosis 30% -‐ 90%) FFR FFR Consider Consider Consider RevascularisaLon Consider RevascularisaLon Medical therapy w/o FFR RevascularisaLon w/o FFR IVUS-‐guiding if complex PCI
- 19. ACS STEMI/NSTEMI Anatomical Cavender et al. Am J Cardiol 2009 CA ambiguity ? IVUS (OCT) yes no Culprit lesion? DetecFon of one or more other lesions (>30%) yes Func8onal ambiguity no (%D stenosis between 30% -‐ 90%) FFR Consider Consider RevascularisaLon Consider RevascularisaLon w/o FFR RevascularisaLon w/o FFR IVUS-‐guiding if complex PCI
- 20. Coronary angiography “firstline“: a provoca*ve strategy?
- 21. A “convenLonal Bayesian strategy“ B “Coronary angiography Firstline“ Clinical Clinical presenta*on Presenta*on* no Intermediate or high probability of CAD *Lipinski et al. AHJ 2002 Stress tesFng yes Stress tesFng (2) **Bugiardini et al. JAMA 2005 CA CA (in case of stable coronary lesion) Class IA FuncFonal ambiguity (%D stenosis 30% -‐ 90%): FFR Class IIa/b (B/C) Anatomical ambiguity : IVUS Angiographically normal arteries : Vascular func*on study** Consider revascularisa*on Consider revascularisa*on or OMT or OMT Finet G & Rioufol G. Arch Cardiovasc Dis 2011 in press
- 22. The “oculo-‐steno*c reflex“ will die in 2001... ... it will be burried in 2011 ! Persan “radialist“ interven8onal cardiologist (280 BC)