Beyond CAG- IVUS and FFR Dr Frijo Jose A. CAG – Extensively used – Entire cor anatomy, including small & distal vessels – Helpful in clinical decision.

Slides:



Advertisements
Similar presentations
TAVOLA ROTONDA Quale Ruolo Clinico e Quale Rimborso per la Franctional Flow Reserve? Correlazioni anatomo-funzionali FFR vs IVUS Luigi Vignali, Parma Bologna.
Advertisements

IVUS-VH & Vulnerable Plaque Jang-Ho Bae, MD., PhD. Heart Center Konyang University Hospital Daejeon City, S. Korea Jang-Ho Bae, MD., PhD. Heart Center.
FFR & IVUS PRIOR TO REVASCULARISATION Journal review Dr. Sony Manuel M Senior Resident MCH Kozhikode.
FFR & IVUS PRIOR TO REVASCULARISATION Journal review Dr.Sony Manuel M Senior Resident MCH Kozhikode.
 An angiographic tool grading the complexity of coronary artery disease  A semiquantitative visual score that will help us to be aware of the anatomical.
Stents Are Not Enough: Statins Keith Channon Department of Cardiovascular Medicine University of Oxford John Radcliffe Hospital, Oxford.
PBL CV 2 Pathophysiology of coronary artery disease.
Θεματική ενότητα: Stenting Μ. Ματσάγκας, MD, PhD, FEBVS Σάββατο 9 Φεβρουαρίου 2013.
FRACTIONAL FLOW RESERVE versus ANGIOGRAPHY
FFR vs Angiography for Multivessel Evaluation
Angiographic V/s Functional Severity of Cor A Stenoses in the FAME Study FFR v/s CAG in Multivessel Evaluation JAmCollCardiol2010;55:2816–21 Tonino, Fearon.
To stent or not to stent Clinical Utility of Fractional Flow Reserve.
Journal : Evidence Review PCI : Role of FFR Dr Binjo J Vazhappilly SR Cardiology MCH Calicut.
29th ANNUAL SCIENTIFIC SESSIONS – SCA&I
Diagnostic Stress Testing
CORONARY PRESSURE MEASURENT AND FRACTIONAL FLOW RESERVE
DEFER STUDY: 5-YEAR FOLLOW-UP A Multicenter Randomized Study
FFR Going Beyond Angiography
Case of the month Dr P Arumugam Consultant Nuclear Physician
Chaim Lotan MD, Yaron Almagor MD, Karel Kuiper MD, M.J. Suttorp MD, William Wijns MD The SICTO Study CYPHER TM Sirolimus-eluting stent in Chronic Total.
FFR in specific circumstances Zsolt Piróth MD Gottsegen György Hungarian Institute of Cardiology.
Tips and Pitfalls in Measurement of FFR during Bifurcation Stenting Nanjing first hospital Nanjing cardiovascular hospital Yefei Chenshaoliang Zhangjunjie.
Multi-vessel disease and intracoronay physiology Combat MI 2009 Kees-joost Botman MD, PhD Catharina hospital Eindhoven Heart Institute The Netherlands.
BASIC SCIENCE: ATHEROSCLEROSIS 2 February 2006 St Luke’s-Roosevelt Hospital Department of Surgery.
Copyright ©2013 American Heart Association INTRAVASCULAR ULTRASOUND Sripal Bangalore, M.D., M.H.A. and Deepak L. Bhatt, M.D., M.P.H., F.A.H.A.
Navigating the Coronary Circulation: Angiography vs IVUS Pearls and Pitfalls Philippe L. L’Allier, MD Montreal Heart Institute Tuesday, March 27, 2007.
Clinical Trial Results. org Evaluation by Optical Coherence Tomography (OCT) of Neointimal Coverage of Sirolimus-Eluting Stent Three Months After Implantation.
Jie Qian National Heart Center & FuWai Hospitall FFR in Diffuse Multivessel Disease.
When I Use IVUS Neal Uren MD FRCP Consultant Cardiologist Royal Infirmary Edinburgh.
Pressure Wire Evaluation of the Left Main Stem Dr Phil MacCarthy Consultant Cardiologist King’s Cardiac Centre Left Main 5+ at AA2007, Jan 24 th, 2007.
SIROLIMUS-ELUTING STENTS EFFECTIVELY INHIBIT NEOINTIMAL PROLIFERATION AS COMPARED TO BARE METAL STENTS IN DISEASED SAPHENOUS VEIN GRAFTS: 6-month IVUS.
LM strategy Interventional cardiology dpt Cardiovascular Hospital - Lyon - France Gilles Rioufol MD PhD INSERM U1060 High Tech Marseille, 26 Janvier 2012.
左主干分叉病变治疗策略的选择 Left main bifurcation: what is the best choice? Lei Ge, MD Department of Cardiology, Zhongshan Hospital, Fudan University.
Progression, Regression, and Remodeling of Atherosclerosis ( 동맥경화증의 진행, 퇴축, 그리고 재성형 ) Hyo-Soo Kim, MD, PhD Cardiovascular Center, Seoul National University.
New techniques for the “invasive diagnosis” of the vulnerable plaque Antwerp, 17 March 2006.
Effect of Intravascular Ultrasound- Guided vs. Angiography-Guided Everolimus-Eluting Stent Implantation: the IVUS-XPL Randomized Clinical Trial Myeong-Ki.
Saqib Chowdhary Wythenshawe Hospital STENT THROMBOSIS How Do IVUS & OCT Help.
CARDIAC CT IN SCREENING FOR CAD Hossein Nademi MD CARDIOLOGIST JAVADOL-A-EME HEART HOSPITAL OCT
Multivessel Coronary Artery Disease
Afsane mohammadi,MD Interventional cardiologist.  The presence of inducible ischemia is an important risk factor for adverse outcome.the more inducible.
R4 하 상 진. Introduction Circulation May 1;115(17):
Influence of a Pressure Gradient Distal to Implanted Bare-Metal Stent on In-Stent Restenosis After Percutaneous Coronary Intervention Lisette Okkels Jensen,
End points in PTCA trials. A successful angioplasty is defined as the reduction of a minimum stenosis diameter to
Date of download: 7/9/2016 Copyright © The American College of Cardiology. All rights reserved. From: Development and Validation of a New Adenosine-Independent.
J Am Coll Cardiol 2008;52:636–43 Comprehensive Assessment of Coronary Artery Stenoses Computed Tomography Coronary Angiography Versus Conventional Coronary.
Ischaemic heart disease. Coronary artery disease(CAD) is the leading cause of death worldwide. The rates of mortality and disability due to CAD are increasing.
Intravascular ultrasound (IVUS) in the treatment of long and diffuse lesions– summary of key articles Prepared by Radcliffe Cardiology 21 November2016.
Invasive Assessment of Coronary Artery Disease
Fractional Flow Reserve Evaluation in Patients Considered for Transfemoral Transcatheter Aortic Valve Implantation: A Case Series Cardiology 2012;123:234–239.
Nico H.J. Pijls, William F. Fearon, Peter Jüni, and Bernard De Bruyne
IVUS, FFR, OCT- Which Should I Use For PCI?
Multi Modality Approach to Diagnosis of Ischemia in Post CABG Cases
Clinical Usefulness of Post-Stenting FFR
(DES)+BVS +DCB for long diffuse LAD disease
The Winking Saphenous Vein Graft: Acute Aorto-Vein Graft Anastomotic Torsional Kink causing Dynamic Systolic Compression Complicating Vein Graft PCI Dr.
9:00 AM-9:05 AM, Tuesday, Oct. 31; Room 201/203
OCT-Guided PCI What needs to be done to establish criteria?
Fractional Flow Reserve Workshop
Circ Cardiovasc Interv
Using Coronary CTA to Guide Intervention for CTO
Section 5: Intervention and drug therapy
Christopher D. Owens, MD, MSc  Journal of Vascular Surgery 
Intravascular imaging and physiologic lesion assessment to define critical coronary stenoses  Luis Gruberg, MD, Gary S Mintz, MD, Lowell F Satler, MD,
Role of CT Coronary Angiogram in pre-renal transplant evaluation
Section 4: Plaque dynamics and stenosis
Christopher D. Owens, MD, MSc  Journal of Vascular Surgery 
Presented at TCT 2006.
DEScover: One-Year Clinical Results
Detection of Hemodynamically Significant Coronary Stenosis: CT Myocardial Perfusion versus Machine Learning CT Fractional Flow Reserve Myocardial blood.
Presentation transcript:

Beyond CAG- IVUS and FFR Dr Frijo Jose A

CAG – Extensively used – Entire cor anatomy, including small & distal vessels – Helpful in clinical decision making 1.Eccentricity 2.Vascular remodelling 3.Relative % stenosis 4.Reference segment assessment 5.Limited correlation with physiology 6.Post PTCA/dissec

1. Eccentricity of lesions

In coronaries with atherosclerosis, the lumen is often irregular and non-circular

Topol, E. J. et al. Circulation 1995;92: Schematic representation of an important limitation of projection imaging

Pitfall: lesion eccentricity

Topol, E. J. et al. Circulation 1995;92: Angiographically unrecognized left main coronary artery disease

2. Vascular Remodelling (Glagov’s phenomenon)

Topol, E. J. et al. Circulation 1995;92: Effect of coronary remodeling

These plaques are particularly prone to rupture. Missed by angiography.

3. Reference seg assessment & Relative % stenosis

Topol, E. J. et al. Circulation 1995;92: Concealment of severe coronary disease by diffuse concentric involvement

IVUS Imaging 2D Cross-Sectional Imaging

4.Limited correlation with physiology and pre-stenting

Chest pain with normal coronaries 50 % have plaques on IVUS, which might have ruptured to cause the chest pain

IVUS before PCI Baseline plaque composition Vessel size Confirm CAG severity

Lesions of uncertain severity- IVUS can solve- (changed original provisional decision in 20%) Intermediate severity (40-75%)- FFR can provide further information (>0.75- favorable outcome with medical Rx) LMCA obstruction- – Contrast in cusps can obscure the ostium – Streaming of contrast can falsely suggest narrowing – There may not be a normal reference segment – Branch vessels overlap distal part- stenosis is masked In ostial lesions, IVUS provides information about whether there is a lesion at all and whether the lesion is truly ostial or not

Quantitation of atheroma (slight overestimation)

Intimal thickness ≥0.5 mm - abnormal and indicative of atherosclerosis Total atheroma volume- motorized device pulls back transducer at 0.5 mm/sec. From the slices so obtained, TAV is found by the Simpson’s rule Most plaques are eccentric- max thickness is more than twice the minimum thickness

Fatty streaks are not clearly identified. Atheroma- fibrosis and calcification are clearly identified, but hypoechoic part may be lipid, thrombus or necrotic degeneration. Radiofrequency analysis superimposed on IVUS helps to clarify the situation. More sensitive than fluoroscopy to detect calcification. Positive remodeling- landmark study by Glagov- initially there is increase in plaque area without decrease in luminal area- due to increase in EEM (enclosed) area.

large, soft, lipid-laden atheroma with a thin fibrous cap is seen (arrows). It is eccentric, involving only approximately 50 percent of the vessel wall shows a circumferential atheroma with an area of focal calcification is evident (arrow).

ACS- – Less obstructive plaques are much more common – More lipid pool – Thin fibrous cap – Ruptured cap – Superimposed thrombus – Multiple sites of rupture

Potentially unstable coronary lesion Echolucent

5. post-stenting and dissection

Initial procedural results Quantifying late intimal hyperplasia

Topol, E. J. et al. Circulation 1995;92: Overestimation of lumen gain by angiography after balloon angioplasty

IVUS – mechanisms of lumen gain by balloon dilation- – Fracture of the plaque – Plaque is redistributed axially – Arterial wall stretching

IVUS and stenting- – Pioneering report by Colombo – High chance of incomplete stent apposition with usual dilation- not seen by check CAG - contrast flows outside the porous stent - fills space provided by the vessel which has been passively dilated by the balloon dilation. Higher pressure dilation or larger balloon size solves problem – Even aft high pressure dilation, when IVUS was done, additional procedures done in %

– STARS study- decreased restenosis in IVUS guided stenting. TULIP study- decreased restenosis only in long and diffuse lesions. – Stent to reference area ratio does not predict TVR. Stent area of 9 mm2 or more predicts freedom from restenosis. – Very useful in suspected dissection after stenting- to know the full length of the dissection. – Useful to discern the cause of “persistent haziness” after stenting. – Restenosis mech- usually neo-intimal proliferation. Also, restenosis at the margins. No decrease in the stent area- stents can withstand remodeling.

Late stent malapposition

IVUS – Tomographic views – Vessel wall + lumen visualization – Validated quantitative software – Plaque characterization – Need to instrument vessels – Limited to proximal segments – Bifurcation lesions – Cost – Not as well validated for clinical decision making – Limited correlation with physiology – Not always perpendicular to vessel axis

IVUS Pitfall : Imaging plane not perpendicular to vessel axis

ACC/AHA Recommendations for Coronary IVUS Class II A 1. Evaluation of lesion severity at a location difficult to image by angiography in patients with a positive functional study and a suspected flow-limiting stenosis 2. Assessment of a suboptimal angiographic result after coronary intervention 3. Diagnostic and management of coronary disease after cardiac transplantation

Absolute flow reserve – Drugs- intracoronary papaverine, intracoronary adenosine, intravenous dipyridamole – Ratio of maximum to resting flow rate – Below 2- causes stress induced ischemia – Reduction may be due to ↑resting flow also – ↓ in severe stenosis and microcirculatory abn

Relative flow reserve – Maximum exercise/pharmacological dilation – Minimum threshold of 0.8 – Inaccurate in multivessel disease – Inaccurate in microcirculatory disease

Fractional flow reserve – During maximum vasodilation – Mean cor pressure/mean Ao pressure – Unaffected by alteration in resting flow – Can immediately assess importance of a lesion for guiding intervention – Considerable prognostic information – FFR more than excellent outcome with deferred rather than prophylactic intervention – Affected by microcirculatory disease – Most direct way to assess physiological significance of a lesion

Simultaneous measurement of pressure in aorta and distal LAD at rest

Simultaneous measurement of pressure in aorta and distal LAD following intracoronary adenosine

Clinical uses of FFR 1. Determining the hemodynamic significance of CAG intermediate lesions: Pijls et al - cutoff 0.75 detected ischemia – sensitivity- 88%, specificity- 100%, diagnostic accuracy- 93% DEFER - moderate CAD + FFR> PCI v/s medical – PCI event rate > medical event rate

Clinical uses of FFR 2. Determining success of PCI: Multicenter registry - FFR determined immediately after stenting – most signi independent variable related to future events

Clinical uses of FFR 3. Determining significance of LMCA lesions: Bech et al- 54pts (29/12)- equivocal LMCA Medical - 24 pts with FFRs >0.75 CABG - 30 pts with FFR <0.75 Survival – medical- 100%, CABG- 97%

Clinical uses of FFR 4. Determining the significance of multiple stenoses in the same coronary artery: FFR can be used to “map” the hemodynamic effects of multiple stenoses in the same vessel FAME (1005pts)- clinical outcomes after PCI on CAG v/s CAG+ FFR in multivessel disease FFR gp- 37% of PCI indented lesns- FFR > yr- composite event rate -18.3% CAG-guided gp V/S 13.2% CAG+FFR-guided group

Recommendations for Use of Fractional Flow Reserve Class IIa Can be useful to determine whether PCI of a specific cor lesion is warranted Can be useful as an alternative to performing noninvasive functional testing (eg, when the functional study is absent or ambiguous) to determine whether an intervention is warranted In the assessment of the effects of intermediate cor stenoses (30% to 70% luminal narrowing) in pts with anginal symptoms

Case study