jose r rumoroso madrid sept 15 ffr
TRANSCRIPT
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Análisis funcional de las lesiones coronarias en la práctica diaria
José Ramón RumorosoCardiología Intervencionista
Hospital GaldakaoGaldakao.Vizcaya
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Copyright © The American College of Cardiology. All rights reserved.
Integrar la fisiología Coronaria en el Cath Lab
J Am Coll Cardiol. 2010;55(3):173-185. doi:10.1016/j.jacc.2009.06.062
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Decía que el gradiente era insuficiente, pero no podía medir más….
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Copyright © The American College of Cardiology. All rights reserved.
Conceptos clásicos
J Am Coll Cardiol. 2010;55(3):173-185. doi:10.1016/j.jacc.2009.06.062
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FFR
• No es un índice de reposo• A máxima vasodilatación por hiperemia
inducida, que en realidad simula el ejercicio físico, el flujo miocárdico es proporcional a la presión de perfusión miocárdica
• Representa el flujo máximo de sangre que determina la capacidad funcional de un paciente en ejercicio
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En hiperemia máxima
100 70FFR=70/100FFR= 0,70
FFR= PdPa
Q
P
Que significa?Que el máximo flujo de sangre que puede pasar por esa estenosis es el 70% del máximo posible
si no hubiese estenosis
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100
70
70
40
FFR=70/100FFR= 0,70
FFR=40/70FFR=0,58
2 pacientes: Gradiente 30 mmHg y distinto FFR
0
0
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Copyright © The American College of Cardiology. All rights reserved.
J Am Coll Cardiol. 2010;55(3):173-185. doi:10.1016/j.jacc.2009.06.062
Conceptos clásicos
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Es seguro dejar a los pacientes con un FFR >0,75
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N Engl J Med 1996; 334: 1703-6
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N Engl J Med 2009;360:213-24.
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www.thelancet.com Published online August 30, 2015 http://dx.doi.org/10.1016/S0140-6736(15)00057-4
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www.thelancet.com Published online August 30, 2015 http://dx.doi.org/10.1016/S0140-6736(15)00057-4
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Qué Diámetro de estenosis requiere ser interrogada?
Tonino. JACC 2010; 55(25):2816-21
20%
96% 35%
n = 1414 lesiones, 509 pacientes
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FAME 2Stable CAD patients scheduled for 1, 2 or 3 vessel DES-PCI
N = 1220
FFR in all target lesions
When all FFR > 0.80 (n=332)
MT
At least 1 stenosiswith FFR ≤ 0.80 (n=888)
Randomization 1:1
PCI + MT MT
Primary Endpoint: Death, MI or Urgent Revascularization at 2 Yr
Registry
50% randomly assigned to FU27%
Randomized Trial
73%
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Primary Endpoint: Death, MI, Urgent Revasc
De Bruyne, et al. New Engl J Med 2012;367:991-1001
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Primary Endpoint: Death, MI, Urgent Revasc
0
5
10
15
20
25
30
Cum
ulat
ive
inci
denc
e (%
)
166 156 145 133 117 106 93 74 64 52 41 25 13Registry447 414 388 351 308 277 243 212 175 155 117 92 53PCI+MT441 414 370 322 283 253 220 192 162 127 100 70 37MT
No. at risk
0 1 2 3 4 5 6 7 8 9 10 11 12Months after randomization
MT vs. Registry: HR 4.32 (1.75-10.7); p<0.001PCI+MT vs. Registry: HR 1.29 (0.49-3.39); p=0.61
PCI+MT vs. MT: HR 0.32 (0.19-0.53); p<0.001
De Bruyne, et al. New Engl J Med 2012;367:991-1001
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Fractional Flow Reserveparece que es una herramienta indispensable
FAME 1 FAME II 2
1Tonino P., et al. NEJM 20092 de Bruyne B. et al., NEJM 2014
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Curiosidades del FAME II
Adapted from Sechtem U., FAME II Discussant ESC Congress Barcelona 2014
108%
41%
Casi 60% de los pacientes con FFR≤0.80 y OMT
no requirieron revascularización dos años más tarde
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Otra curiosidad del FAME II….
12% de los pacientes con FFR>0.80
requirieron revascularización en los dos años siguientes
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hyperemicflow
baseline
Coronary flow reserve
Coronary flow reserve=
hyperemia
baseline
hyperemia
baseline
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CFR versus test no invasive de isquemia
Meuwissen et al, Intv Cardiol 2009
CFR e Isquemia Umbral más bajo para isquemia: <1.7
El mejor punto de corte para isquemia: 1.7- 2.1 Valor ‘Normal’ >2.8
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Exactitud diagnóstica
Fractional flow reserve
Coronary flow reserve
Meuwissen et al, Intv Cardiol 2009
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Diferir la revascularización
Meuwissen et al, Intv Cardiol 2009
MACE Death (at 1 yr)FFR: 6 % 0 - 1 %CFR: 6 % 0 - 1 %
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FFR/CFR discordanciaFenómeno (In)frecuente?
Johnson et al., J Am Coll Cardiol Img 2012
FFR y CFR son discordantes en 30 – 40% de los casos
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BACK TO BASICS
…., but does it always tell us the whole story?
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La caida de Presión depende del Flujo
Gould KL, Circ Res 1978Van de Hoef TP, et al., Nat Rev Cardiol 2013
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Gould KL, Circ Res 1978Courtesy of Dr. Justin Davies
La caída de Presión incrementa con la velocidad de flujo
Determinado por la función microvascular
Gradientepresión
(mmHg)
FlujoCoronario
(cm/s)
Estenosis Trivial + alto flujo =
significativo gradiente
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MR high CFR FFR
Q
Q
60% DS
Pa Pd
MR low CFR FFR
Q60% DS
Pa Pd
MR
Q
MR
Para una estenosis concretaCambios en la Microcirculación afectan al FFR y CFR de
forma distinta
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FFR/CFVR relationship
van de Hoef et al., Circ Cardiovasc Intv 2014Johnson et al., J Am Coll Cardiol Img 2012
MR low CFR FFR
Q60% DS
Pa Pd
Q
MR
MR high CFR FFR
Q
Q
60% DS
Pa Pd MR
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Presión o Flujo?Que implicaciones clínicas tiene?
Clinical Outcome
Smalling, et al., JACC 1985 / Gould et al. JACC 2014Van de Hoef, et al. Circ Cardiovasc Intv 2014
“Flow is fundamentally more important than pressure for maintaining myocardial function”
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Microvascular resistance
Fractional Flow Reserve
FFR
Microvascular resistance=Distal coronary pressure
Distal coronary flow
Meuwissen, Circulation 2001; van de Hoef, Nat Rev Cardiol 2013
Hyperemic microvascular resistance index (HMR)
Distal coronary pressureDistal flow velocity=
Index of microvascular resistance (IMR)
Distal coronary pressure1/mean transit time=
CFR
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Echavarria-Pinto, et al. Circulation 2013 van de Hoef, et al. Circ intv. 2014
Análisis Multimodal
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Conclusiones FFR is an indispensable tool in contemporary clinical
practice BUT, FAME II and registry data suggest a potential
benefit of looking beyond coronary pressure Although physiologically plausible, there is a need for
novel tools, and a need for clinical data
Escaned J. and Echavarria-Pinto M., Circ Cardiovasc Intv 2014
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Muchas gracias y perdonad