TAVOLA ROTONDAQuale Ruolo Clinico e Quale Rimborso

per la Franctional Flow Reserve?

Correlazioni anatomo-funzionaliFFR vs IVUS

Luigi Vignali, Parma

Bologna 21 Aprile 2011

IVUS guidance in PCIIndications

When IVUS? Why IVUS?

Pre Decide strategy Vessel reference and % stenosisPCI and Sizing Length of the lession

Plaque composition

Post Evaluate Stent Final lumenPCI Results Expansion

AppositionDissection or plaque shift

IVUS in evaluation forPost dilatation needs

•Post-dilatation strategy:•With non-compliant balloon shorter than stent in presence of vessel remodelling or uncompleted-apposition

Pre Stent Posdil

Underexpansion

StentMalapposition

IVUS reveals need of postdilatation

IVUS-guided stent implantation may be considered for unprotected left main PCI

CLASS IIb EVIDENCE C

Recommendations for specific percutaneous coronary intervention devices

IVUS in ISRBeware that expected ISR might reveal under expanded stent during previous intervention.

Because the vessel and plaque and stents became visible, IVUS guidance clarify substrate in failure or previous PCI, and frequently discover under expanded stents

IVUS reveals stent underexpansion in ISR

Performance Comparison, OCT vs IVUS

Spazial Resolution 12 - 15 m 100 - 200 m

Acquisition Time 20 mm/s 0.5 - 1 mm/s

Tissue Penetration 1.0 - 2.0 mm 10 mm

Contrast enjection during acquisition

Every images No contrast

IVUSC7XR

Image Comparison

10

• Edge dissection during stent implantation

Neointimal growth on previously implanted stent at follow-up

???

???

Validation of IVUS Assessment of Validation of IVUS Assessment of Ischemia-producing Stenoses (Doppler Ischemia-producing Stenoses (Doppler

FloWire, SPECT, and Pressure Wire)FloWire, SPECT, and Pressure Wire)

443939CFR CFR 2.0 2.0

272722CFR < 2.0CFR < 2.0

IVUS MLA <4.0mm2

IVUS MLA 4.0mm2

Diagnostic accuracy = 92%. Diagnostic accuracy = 92%. Abizaid et al. Abizaid et al. Am J CardiolAm J Cardiol 1998;82:42-8 1998;82:42-8

112020- Spect- Spect

424244+ Spect+ Spect

IVUS MLA <4.0mm2

IVUS MLA 4.0mm2

Diagnostic accuracy = 93%. Diagnostic accuracy = 93%. Nishioka et al. Nishioka et al. J Am Coll CardiolJ Am Coll Cardiol 1999;33:1870-8 1999;33:1870-8

Takagi, et al. Takagi, et al. CirculationCirculation 1999;100:250-51999;100:250-5

IVUS in intermediate assessmentProximal LAD, CX, RCA

Takagi, et al. Circulation 1999;100:250-5Takagi, et al. Circulation 1999;100:250-5

Intermediate stenosis assessment:

If in Proximal LAD, CC or RCA, the stenosis MLA ≤ 4 mm2 then is cause isquemia; and must be treated

IVUS reveals significance of intermediate lesions, with morphological assessment

Clinical follow-up in 357 Intermediate Lesions in 300 Clinical follow-up in 357 Intermediate Lesions in 300 Pts with Deferred Intervention after IVUS ImagingPts with Deferred Intervention after IVUS Imaging

• Death/MI/TLR @ (mean) 13 mos = 8% overall (2% death/MI and 6% TLR)Death/MI/TLR @ (mean) 13 mos = 8% overall (2% death/MI and 6% TLR)• Death/MI/TLR @ (mean) 13 mos = 4.4% in lesions with MLA >4.0mmDeath/MI/TLR @ (mean) 13 mos = 4.4% in lesions with MLA >4.0mm22

• Only independent predictor of death/MI/TLR was IVUS MLA (p=0.0041)Only independent predictor of death/MI/TLR was IVUS MLA (p=0.0041)• Independent predictors of TLR were DM (p=0.0493) and IVUS MLA (p=0.0042)Independent predictors of TLR were DM (p=0.0493) and IVUS MLA (p=0.0042)

IVUS MLD (mm)IVUS MLD (mm)

QCA MLD (mm)QCA MLD (mm)

00

11

22

33

44

00 11 22 33 44

r=0.339r=0.339

IVUS MLA (mm2)IVUS MLA (mm2)

Death/MI/TLRDeath/MI/TLR

2-32-3 3-43-4 4-54-5 550

5

10

15

20

25

30

35

0

5

10

15

20

25

30

35

IVUS MLA (mm2)IVUS MLA (mm2)

TLRTLRDMDM

no-DMno-DM

2-32-3 3-43-4 4-54-5 55

Abizaid et al. Abizaid et al. CirculationCirculation 1999;100:256-61 1999;100:256-61

Confidential information of Boston Scientific Corporation. Do not copy or distribute.

In Intermediate stenosis assessment:Event Free Survival is better for the IVUS Criteria vs. the FFR >0.75 Criteria.

Follow-up of 122 patients with moderate LEFT MAIN disease

Indipendent predictors of MACE @11.7 Months:DM (p=0.004) and IVUS MLD (p=0.005)- but NOT the palque burden

Abizaid, et al. J Am Coll Cardiol 1999;34:707-715

Abizaid, et al. J Am Coll Cardiol 1999;34:707-715

Abizaid, et al. J Am Coll Cardiol 1999;34:707-715

Intermediate Main Left stenosis assessment:

If Main Left MLA ≤ 6 mm2 cause isquemia and must be treated

IVUS in intermediate assessment in Left Main

IVUS assess significance of Main Left lesions, where angio fails

IVUS determinants of LMCA FFR<0.75

Jasti et al Circulation 2004; 110;2831-6

0

25

50

75

100

Months

Cum

ulat

ive

prop

ortio

n su

rviv

ing

0 12 24

Logrank test: p = 0.04

REV 93.4%

DEF 98.1%

Kaplan-Meier survival free from mortality and infarction

331 Patients

179 pt MLA>6 mm2 (DEF group)

152 pt MLA<6 mm2 (REV group) PCI 44%CABG 55%

MULTICENTERDED MULTICENTERDED LITRO STUDYLITRO STUDYINTERMEDIATE LEFT MAIN CORONARY ARTERY LESIONINTERMEDIATE LEFT MAIN CORONARY ARTERY LESION

Jose’ M de la torre Hernandez et al.JACC 2010;vol55

Absolute lumen CSA <5.9 mm2 (or MLD < 2.8 mm) is the suggested criterion for significant LMCA stenosis

IVUS Criteria for a “significant” LMCA stenosis

FFR= 0,70

LA= 5,5

LA= 4,5

LA= 8,0

Chang-Wook Nam et al 2010;JACC interventions vol 3 :812-7

FFR vs IVUS in Intermediate Coronary Lesions 167 consecutive patients

0

25

50

75

100

FFR guided IVUS guided

91.5%

33,7%

The rate of performing PCI according to guiding device

100

90

80

70

60

100 200 300 400

Time to event (days)

Even

t Fre

e Su

rvai

val (

%)

P>0.05

Cutoff value FFR 0.80 Cutoff value IVUS MLA >4mm2

(FFR-guided,83 lesion vs IVUS-guided,94 lesion)

CORRELATION BETWEEN FFR AND IVUS LUMEN AREA IN 150 INTERMEDIATE CORONARY STENOSIS

Itsik Ben-Dior, Ron Waksman et al 2011.JACC

For lesion with vessel reference diameters of 2.5-3 mm, 3-3.5 mm and >3.5 mm, the MLA threshold for FFR <0.8 were 2.5,2.8 and 3.7 mm2 respectively

FFR= 0,74

COMPLEMENTARY ROLE IVUS FFR OCTCOMPLEMENTARY ROLE IVUS FFR OCT

PRE INTERVENTIONPRE INTERVENTION

IVUS vessel size lesion lenghtIVUS vessel size lesion lenght

FFR FFR Severity lesionSeverity lesion

POST INTERVENTIONPOST INTERVENTION ExpansionExpansionAppositionAppositionCoverageCoverageComplicationComplication UnderexpansionUnderexpansion

Edge problemsEdge problems

IVUSIVUS

OCT INDICATIONOCT INDICATION

Immediatelly after stentImmediatelly after stentimplantationimplantation

1 Year after DES1 Year after DES ImplantationImplantation

1 Year after BMS1 Year after BMS ImplantationImplantation

Delayed healing; new intimal growth

Thank you for your attention

For any correspondence: gbiondizoccai@gmail.com

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