case-based presentation: ffr optowire and bio active stent

Case-based presentation: FFR OptoWire and bio active stent Optimax to make the difference in multi-

vessel coronary artery disease

Pim A.L. Tonino

24th May 2018

12:18-12:43

Speaker's name : Pim, Tonino, Eindhoven

☑ I do not have any potential conflict of interest

• 68 year old female• History:

• COPD Gold 2 (treated by GP)• Hypertension

• Acute chest pain since 60 minutes• Ambulance ECG: acute inferoposterior infarct• BP: 140/75 mmHg• Access: radial right

FFR OptoWire and bio active stent Optimax in a STEMI case with MVD

RCX occluded; concomitant disease LAD

RCX occluded; concomitant disease LAD

RCX occluded; concomitant disease LAD and RCA

Asahi Sion wire passage; reperfusion

• Sizing stent

• OPTIMAX vs DES

Stent strategy?

Inhibits Platelet AggregationMinimizes Fibrin GrowthMinimizes Thrombus FormationReduce InflammationPromotes Endothelial Healing

Titanium-Nitride-Oxide coated BASIdeal stent for ACS?

Hexacath, France

Biological EffectActive Coating

Windecker et al. Circualtion 2001Zhang et al. Journal of Biomedical Material 1998

Patients presenting withAcute Coronary Syndrome

12 International SitesRandomisation 2:1

Clinical Follow-up30d 6mo 4yr2yr 5yr

Primary Endpoint: MACE (Cardiac death, MI, and TLR) at 12

months

Co-Primary Endpoint: Cardiac death, MI, major bleeding at 18 months

12mo 18mo

TIDES-ACS

BASTitanium-Nitride-Oxide-coated

Bioactive Stent1200 Patients

3yr

EESEverolimus-Eluting Stent with

biodegradable polymer600 Patients

Clinical Primary endpoint

PI P Karjalainen (FIN)Co-PI K Kervinen (FIN), J van Der Heyden (NED), H Romppanen (FIN), P Tonino (NED)

CEC: J Marco (FRA), A de Belder (UK), R Wiseth (NOR), J Gomez-Hospital (SPA), D Formigli (ITA)ClinicalTrials.gov: NCT02049229Minerva Cardioangiol. 2015;63:21-9.

TIDES-ACS Baseline CharacteristicsBAS

(n=989)EES

(n=502)P

value

Age (years) 62.7 ± 11.0 62.6 ± 10.5 0.85

Male 75.3% 76.3% 0.70

Diabetes 14.2% 12.5% 0.43

- Insulin treated 2.3% 3.8% 0.14

Hyperlipidemia 41.5% 40.2% 0.66

Hypertension 46.8% 43.6% 0.25

Current smoker 31.2% 35.9% 0.08

Prior myocardial infarction 7.6% 9.0% 0.37

Prior PCI 7.0% 6.6% 0.83

Prior CABG 0.6% 1.2% 0.23

NSTEMI 46.3% 45.0% 0.66

STEMI 44.9% 47.6% 0.32

7.0%5.1%

6.3%4.5%

0

5

10

15

30 90 180 270 360

OPTIMAX-BAS (n=989)SYNERGY (n=502)

Days after Index PCI

%*

* Cumulative incidence of events (%)TIDES-ACSMACE at 12 months

Log-Rank P = 0.60

P = 0.66HR (95%CI) = 1.12 (0.73-1.72)

Number at riskBAS (n=989) 945

917EES (n=502) 467

454

- 0.7%

Direct stenting: OPTIMAX 2.75/16

Plaque shift? distal from stent

Second stent: OPTIMAX 2.5/10

After 2nd OPTIMAX stent

After 2nd OPTIMAX stent

Conclusion so far

• STEMI RCX

• Primary PCI RCX with OPTIMAX

• Residual coronary disease LAD and RCA

• What strategy next?

What strategy next?

• FFR both vessels in acute phase

• FFR both vessels after a couple of days

• No repeat procedure;

Outpatient clinic non-invasive assessment

FFR in non-culprit vessels in acute phase reliable

• FFR both vessels in acute phase

• FFR both vessels after a couple of days

• No FFR, PCI

• No repeat procedure;

Outpatient clinic non-invasive assessment

Ntalianis et al. JACC Interv. 2010

FFR guided PCI MVD improves outcome

• FFR both vessels in acute phase

• FFR both vessels after a couple of days

• No FFR, PCI

• No repeat procedure;

Outpatient clinic non-invasive assessment

Tonino et al. NEJM 2009

14-5 2nd procedure (PPCI was 9-5)

• FFR-guided PCI strategy

FFR Optowire - OPSENS

Equalisation pressuresEqualisation pressures

OCT

Distal spasm due to OCT catheter

Resting gradientt

FFRt

Measuring LAD

Resting gradientt

FFRt

Measuring LAD

Van ‘t Veer et al. JACC 2017

Vessel interrogation by FFR

Focal hyperemic pressure gradientt

FFRt

What strategy next?

• Stent complete diseased traject LAD

• Focal stenting LAD and repeat FFR

• Bypass surgery

• OPTIMAX or DES FFR 0.77

Direct stenting: OPTIMAX 2.5/13

Postdilatation: 3.0/8 C balloon

Angio after focal stenting

FFR after focal stenting

Why is FFR not always 1.0 after PCI?

Why is FFR not always 1.0 after PCI?

Tonino, Johnson. JACC Interv. 2016

Would FFR post in LAD have been beter with OCT?

Meneveau et al. Circulation 2016

FFR RCA

• In STEMI PCI OPTIMAX should be considered default stent based on TIDES-ACS results

• FFR with OPSENS Optowire is quick, safe and accurate

• Residual coronary artery disease should be assessed by FFR (in most cases) prior to revasc

• FFR and OCT are tools that can help improve functional outcome of stenting

• The optimal strategy for treatment of residual coronary disease in ACS is not (yet)

known

Conclusions for this case