ffr en bifurcaciones.pdf
TRANSCRIPT
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8/10/2019 FFR en bifurcaciones.pdf
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
Fractional Flow Reserve, when and why ?
Evaluation of the provisional side-branch strategy
for bifurcation lesion using FFR
Ch. Martinez, MD
University Hospital of Lige
Belgium
I do not have any potential conflict of interest
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
Evaluation of the provisional side-branch intervention
strategy for bifurcation lesion using FFR: Introduction
I. Even and specially with DES, bifurcation lesionsremains one of the most challenging lesion subset
in coronary intervention
II. No previous study as shown benefit for the 2
stents strategy, even with DES
III. The provisional side-branch strategy is actuallyconsidered as the best for bifurcation lesions
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
Evaluation of the provisional side-branch intervention
strategy for bifurcation lesion using FFR: Introduction
I. The decision making for SB interventions remains
problematic
II. The visual estimation of severity for such lesions
is very difficult
III. QCA systems are frequently inaccurate and does
not reflect the functional severity of such complex
and ostial lesions
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Koo BK and al, Eur Heart J. 2008 Mar;29(6):726-32.
Stenting of the main branch with DES
IC Nitroglycerin
Visual estimation
Residual stenosis > 50 % Residual stenosis < 50 %
FFR measurement
0.014 pressure wireIC adenosine bolus
+
IC adenosine infusion
Stop intervention
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Koo BK and al, Eur Heart J. 2008 Mar;29(6):726-32.
FFR measurement
FFR < 0.75
Functionally significant
residual stenosis
FFR > 0.75No functionally significant
Residual lesion
Kissing balloon PTCA
+
FFR again
Stop interventionIf FFR < 0.75
Kissing stenting
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Clinical case: 60 years old man with unstable angina
Direct stenting
with a BMS 3.5 x 23
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Clinical case: 60 years old man with unstable angina
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
3 month later, recurrent angina at rest
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
3 month later, in-stent diffuse restenosis with side-
branch involved
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
two conventional wires
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Pre-PTCA of side-branch because TIMI 2 flow
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Control after stenting => pressure wire
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
FFR measurement: 0.71
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Kissing balloon PTCA
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
FFR measurement after kissing balloon: 0.9
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Angiographic result after kissing balloon
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
Percentage of SB lesions requiring further intervention at each
step of the FFR guided strategy: comparison of angiographic
and functional criteria.
0
10
20
30
40
5060
70
Post-stent Post-kissing Follow-up
> 75 % Stenosis FFR < 0.75
68%
31% 32%
8%
48%
8%
Koo BK and al, Eur Heart J. 2008 Mar;29(6):726-32.
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Dr Ch. Martinez, CHU Sart Tilman, Belgium
Conclusion
Measurement of FFR can be helpful in determining
functional significance of lesions at each step of the
provisional side branch intervention strategy