FFR et bifurcation

FFR et MB avant ATL

MBSB

?

1. Intermediate stenoses (Pijls et al. New Engl J Med 1996) (Pijls et al. JACC 2010)

2. Post-myocardial setting (De Bruyne et al Circulation 2001)(Ntalianis et al. JACCInterv 2010)

3. Multivessel Disease (Tonino et al. New Engl J Med 2009)

4. Left main stenosis (Hamilos, Muller et al. Circulation 2009)

5. Proximal LAD stenosis (Muller et al. JACCInterv 2011)

The Value of FFR in terms of Clinical Outcome

Has Been Validated in patients with

FFR et MB avant ATL

MBSB

Oui

FFR et SB avant ATL

MBSB

?

Mach band in bifurcation

http://en.wikipedia.org/wiki/Lateral_inhibition

"Mach bands are an optical illusion consisting of an image of two wide bands, one light and one dark, separated by a narrow strip with a light-to-dark gradient. The human eye perceives two narrow bands of different brightnesses either side of the gradient that are not present in the original image."

Lateral Inhibition (or Mach band visual effect)

Mach band in bifurcation

Mach band in bifurcation

FFR et SB avant ATL

FFR overestimates the severity1.

2. Jailing of a pressure wire between the stent and the vessel wall is not recommended

Anatomical changes after MB stenting: carina shift, stent struts3.

FFR et SB avant ATL

MBSB

Peu utile

FFR et MB après ATL

MBSB

?

FFR et MB après ATL

Pijls, Circulation 2002 Samady, JACCinterv 2009

Pas d’interet

FFR et SB après ATL

MBSB

?

FFR et SB après ATL

1. FFR-guided provisional SB intervention strategy is feasible and effective

2. Functional status of jailed SB lesions after DES implantation does not change significantly during follow-up

Koo, European Heart Journal (2008)

FFR Basics for bifurcation

Bifurcation

MB

Before PCI

YES

After PCI

(YES)

SB

Before PCI

(YES and NO)

After PCI

YES(subset of lesions)

FFR

Anatomically significant stenosis is frequently functionally insignificant

Among side branch lesions > 75% stenosis after main vessel stenting, only 27% were functionally significant.

(Pd/Pa)

FFR PdPa

=

Koo BK, J Am Coll Cardiol 2005

FFR can tell what you have really done……

Before PCI After MB stenting After kissing balloon

MMain prox. first

AMain Accross side first

DDistal first

SSide branch first

Extended V

Skirt

PM stenting

MB stenting across SB

MB stenting + kissing

MB stenting + SB balloon

ElectiveT

stentingInternalcrush

Culotte TAP

DM stenting

ProvisionalSKS

Vstenting

SKS

Trouser legsand seat

SB ostial stenting

SB minicrush

SB crush

Syst. T Stenting

Minicrush Crush

Afterballoon

2 stents

3 stents

1st stent

Skirt +

DMSkirt + SB

Y. Louvard, CCI 2008;71(2):175-83.

Provisional SB Stenting is

The Gold Standard !