PCI & AimRadial 2018 | FFR in Left Main Disease - William F. Fearon

1. FFR in Left Main Disease
William F. Fearon, MD
Professor of Medicine
Director, Interventional Cardiology
Stanford University Medical Center

2. Disclosure Statement of Financial Interest
Affiliation/Financial Relationship Company
Grant/ Research Support: Abbott, Medtronic, Acist, CathWorks,
Edwards LifeSciences
Consulting Fees/Honoraria: Boston Scientific
Major Stock Shareholder/Equity Interest:
Royalty Income:
Ownership/Founder:
Salary:
Intellectual Property Rights:
Other Financial Benefit: Minor Stock Options: HeartFlow
Within the past 12 months, I or my spouse/partner have had a financial
interest /arrangement or affiliation with the organization(s) listed below

3.  82 year old frail woman (4’9”, 90 pounds) with
HTN, dyslipidemia presents with chest pain
 2 weeks prior to this presentation, patient had
NSTEMI with PCI to circumflex. Because of
concern regarding aspirin allergy, patient
received BMS to proximal circumflex and
PTCA to OM. Ejection fraction normal.
Case Presentation:

4. Case Presentation:
 ECG with nonspecific ST/T wave changes,
not significantly different from prior
 Initial enzymes negative.
 However, because of concerning symptoms
and recent history (particularly PTCA),
brought to cath lab…

10. What should we do?
 Medical Therapy
 CABG
 PCI LAD
 PCI Left Main and LAD
 Other suggestions…?

11. Further Interrogation with FFR
FFR of LAD and Left Main = 0.64
Resting Hyperemia

12. Further Interrogation with FFR
Pullback of Pressure Wire
During Maximal Hyperemia
Across Mid LAD Across LM

13. Further Interrogation with FFR
Pullback of Pressure Wire
During Maximal Hyperemia
Across Mid LAD Across LM

14. Is this Left Main significant??

15. Effect of Tandem Lesions
Myocardium0.84 0.64
Myocardium0.72

16. De Bruyne, et al. Circulation 2000;101:1840-7.
Pijls, et al. Circulation 2000;102:2371-7.
Scientific Aspects
Tandem Lesions

17. The influence of a distal stenosis
on the FFR of the LM depends
on the extent to which
hyperemic flow across the LM
stenosis will be decreased by this
distal lesion
• Severity
• Myocardial mass
FFR of LM with Downstream Disease

18. The influence of a distal stenosis
on the FFR of the LM depends
on the extent to which
hyperemic flow across the LM
stenosis will be decreased by this
distal lesion
• Severity
• Myocardial mass
FFR of LM with Downstream Disease
Courtesy Bernard De Bruyne, MD, PhD

19. The influence of a distal stenosis
on the FFR of the LM depends
on the extent to which
hyperemic flow across the LM
stenosis will be decreased by this
distal lesion
• Severity
• Myocardial mass
FFR of LM with Downstream Disease
Courtesy Bernard De Bruyne, MD, PhD

20. J Am Coll Cardiol Intv 2015;8:398-403.
Human Validation
Effect of Downstream Stenosis on LM FFR:
FFRapp represents the
FFR of the LM and LCx
in the presence of LAD
balloon inflation
FFRtrue represents the
FFR of the LM and LCx
in the absence of LAD
balloon inflation
FFRepi represents the
FFR of the LM and LAD
with the LAD balloon
inflated to varying
degrees

21. J Am Coll Cardiol Intv 2015;8:398-403.

22. 91 paired measurements obtained in 25 patients
Human Validation
J Am Coll Cardiol Intv 2015;8:398-403.
Effect of Downstream Stenosis on LM FFR:

23. 91 paired measurements obtained in 25 patients
When FFRapp >0.85, FFRtrue >0.80 100% of the time.
Human Validation
JACC CV Intervent 2015;8:398-403.
Effect of Downstream Stenosis on LM FFR:

24. What else can we do to
assess the left main??

25. Further Interrogation with IVUS
MLA=2.1mm2MLA=4.9mm2
DistalProximal
Mid LADLeft Main

26. Jasti, et al. Circulation 2004;110:2831-6
55 patients with ambiguous left main disease had IVUS and FFR performed
IVUS Cutoff Value For Significant LM

27. Limitation of Absolute MLA Cutoff
6
6 mm2
6 mm2
6

28. Kang, et al. J Am Coll Cardiol Intv 2011;4:1168-74
Variability of IVUS Cutoff Values
55 patients with 30-80% LM and FFR and IVUS

29. Factors impacting ischemic potential of a stenosis
Kern MJ, et al. J Am Coll Cardiol 2010;55:173-85

30. Decision Process
 Based on FFR and IVUS, LAD and LM may be
significant. SYNTAX score = 23.
 Stopped procedure and discussed options with
patient and family.
 Presented case to other cardiologists and cardiac
surgeons at cath conference. No aspirin allergy.
No enthusiasm by surgeons…

31. After rotational atherectomy and 2.5x28 mm DES,
post-dilated to 3.0 mm

32. Further Interrogation with FFR
Pullback of Pressure Wire
During Maximal Hyperemia
Across Mid LAD Across LM

33. Further Interrogation with FFR
FFR of Left Main = 0.72
(In absence of LAD lesion)
Proximal to
LAD stent
Across LM

34. After 3.0x18 DES to LM/prox LAD, post-dilated to 3.5 mm

35. Safety of Deferring LM Revascularization
Bech, et al. Heart 2001;86:547-552
FFR measured in 54 patients with equivocal left main
p = NS
FFR≥0.75
FFR<0.75
FreedomfromDeath

36. Bech, et al. Heart 2001;86:547-552
FFR measured in 54 patients with equivocal left main
p = NS
FFR≥0.75
FFR<0.75
FreedomfromMACE
Safety of Deferring LM Revascularization

37. Jasti, et al. Circulation 2004;110:2831-6
55 patients with ambiguous left main disease
Safety of Deferring LM Revascularization

38. Hamilos, et al. Circulation 2009;120:1505
FFR of LM to Guide Revascularization

39. FFR for Assessing LM Significance
Hamilos, et al. Circulation 2009;120:1505
Poor correlation between “eyeball” and FFR

40. FFR of LM to Guide Revascularization
Hamilos, et al. Circulation 2009;120:1505
Survival Rate

41. FFR of LM to Guide Revascularization
Hamilos, et al. Circulation 2009;120:1505
MACE Rate

42. FU @ 8 mo
Courtesy of Chang-Wook Nam, MD
Pre Stent Post Stent

43. FFR of “Jailed” Left Circumflex
Nam CW, et al. Korean Circ J 2011;41:304-7.
29 patients with LM/LAD crossover stenting with FFR of “jailed” Cx

44. PCI group
n = 5
Defer group
n = 24
Death, n
Myocardial Infarction, n
TLR, n
Stent Thrombosis, n
Total Events, n
0
0
3
0
3
1
0
1
0
2
FFR of “jailed” Circumflex
Mean 20 month follow-up
Nam CW, et al. Korean Circ J 2011;41:304-7.

45. FFR of “jailed” Circumflex
Kang SJ, et al. Catheter Cardiovasc Intervent 2014;83:545-52.
43 patients with cross-over LM to LAD PCI and post PCI FFR of L Cx

46. An Approach to the Equivocal LM
 First measure FFR in the least diseased
vessel, preferably the LAD
 If FFR < 0.80, then revascularize
 If FFR >0.85, then treat medically
 If FFR between 0.80 and 0.85 and there is
significant downstream epicardial disease in the
other epicardial vessel, then IVUS/OCT
 If willing to stent LM, can treat downstream
disease and remeasure FFR
 Never forget the patient and the clinical
scenario

47. Practical Aspects
 Intravenous adenosine is the ideal hyperemic
agent because it allows time to pull the guide
catheter out of the ostium.
 If possible, confirm pressure gradient across left
main by checking FFR in both the LAD and
Circumflex.
 A physiologic evaluation of left main disease,
compared to an anatomic evaluation alone, is
safe and appropriate, just as it is in non-left main
CAD.