case-based presentation: ffr optowire and bio active stent
TRANSCRIPT
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