1. Bifurcation FFR - Helpful or Wasteful?
Allen Jeremias, MD, MSc
Director, Interventional Cardiology Research
Assoc. Director, Cardiac Catheterization
St. Francis Hospital, Roslyn, NY
Director, Physiology Core Laboratory
Cardiovascular Research Foundation, NY, NY

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Company
Consulting Fees/Honoraria
Astra Zeneca
Volcano/Philips
Abbott Vascular
Medtronic
St. Jude Medical

3. Why “Physiologic Evaluation” in Bifurcation Lesion?
Uniqueness of side branch lesions
Various size, various amount of supplying myocardium
Side branch ostial lesion is unique
Underlying plaque  Eccentric plaque
Remodeling  Negative remodeling
Mechanisms of ostial narrowing after main branch stenting
Carina shift, plaque shift, stent struts, thrombus…..
Koo and De Bruyne. Eurointervention 2010;6:J94-J98.

4. Anatomical and Functional Mismatch
Diagonal branch:
Minimal lumen diameter: 1.7mm
Lumen area: 2.7mm2
Vessel area: 5.0mm2
LAD FFR
LAD:
Minimal lumen diameter: 1.8mm
Lumen area: 2.8mm2
Vessel area: 9.0mm2
Diagonal FFR
Courtesy Bon-Kwon Koo, MD, PhD 5

5. Poor Correlation btw Diameter Stenosis and FFR in Jailed Side Branches
Fractional Flow Reserve
SNUH SB-FFR registry
Park SH & Koo BK, J Ger Cardiol 2012
Ahn JM, et al. JACC intv 2012
Fractional Flow Reserve
Kumsars I, et al. Eurointervention 2011
Bellenger, et al. Heart 2007

6. Physiologic Assessment of Jailed Side Branch Lesions
97 lesions in 92 patients
All had >50% angio stenosis and TIMI 3 flow after being jailed by stent
All > 2mm in diameter
FFR successful in all but 3 lesions
No TVR (f/u 10 months) for FFR > 0.75
BK Koo, et al. JACC 2005; 46:633

7. Reason for Mismatch: Carina Shift
Carina shift accentuates lumen eccentricity and results in more angiographic diameter loss than lumen area loss
Koo BK, et al. Circ Cardiovasc Interv 2010;3:113

8. Which side branch is clinically important?
Focus more on “myocardial mass at risk” than angiographic parameters
~10%
How much % of myocardium is at risk?
Hachamovitch, Circulation 2003

9. What is the ischemic burden of the myocardium?

10. Shiono Y et al., Catheter Cardiovasc Interv 2014;1;84(3):406-13.
Impact of myocardial supply area on transstenotic hemodynamics as determined by FFR
Representative cases with mismatch between QCA and FFR. A: Intermediate stenosis (percent diameter stenosis = 53%) was seen in a proximal LAD which had a large‐sized diagonal branch. Because the myocardial area supplied by the coronary artery distal to the stenosis was large (modified APPROACH score = 47.75%), the FFR value was below the ischemic threshold (FFR = 0.58). B: Severe stenosis (percent diameter stenosis = 80%) was found in mid RCA with small myocardial supply area (modified APPROACH score = 9.25%). Then, the FFR value was above the ischemic threshold (FFR = 0.91). APPROACH score, Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease score; FFR, fractional flow reserve; LAD, left anterior descending artery; QCA, quantitative coronary angiography; RCA, right coronary artery. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
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Shiono Y et al., Catheter Cardiovasc Interv 2014;1;84(3):

11. Shiono Y et al., Catheter Cardiovasc Interv 2014;1;84(3):406-13.
Impact of Myocardial Supply Area on Transstenotic Hemodyamics as Determined by FFR
Percent Diameter Stenosis
Myocardial Supply Area
Shiono Y et al., Catheter Cardiovasc Interv 2014;1;84(3):

12. Clinical Significance: Main vs. Side Branch
- Responses to 1-minute balloon occlusion -
LAD
Diagonal
P value
Chest pain (VAS score) 5 2
<0.0001
ST elevation ≥ 1mm
92.3%
35.4%
0.001
QTc interval, msec
454.0±45.4
440.4±35.7
0.07
QTc dispersion, msec
83.8±39.2
70.7±28.5
Side branches have much less clinical relevance in terms of symptoms, ischemia and arrhythmic potential
Koo BK, et al., JACC Cardiovasc Intervent 2012

13. Collateral Supply Higher in Branch Vessels
assessed by coronary wedge pressure (Pw)
Diagonal
Pw 39mmHg, Pw/Pa 0.36
LAD
Pw 23mmHg, Pw/Pa 0.26
Koo BK, et al., JACC Cardiovasc Intervent 2012

14. Difference in Collateral Recruitability
- LAD vs. Diagonals -
LAD
Diagonal
P value
Pre-intervention FFR
0.67±0.10
0.71±0.11
0.02
Pw, mmHg
21.0±6.5
26.7±9.4
<0.0001
Pw/Pa
0.22±0.07
0.27±0.08
0.001
Pw: coronary wedge pressure, Pa: aortic pressure
Diagonal branch has higher Pw and Pw/Pa than LAD and may have higher collateral recruitability and more protection from ischemia
Koo BK, et al., JACC Cardiovasc Intervent 2012

15. Collateral Supply Independent Predictor of Mortality
739 pts with chronic stable angina
followed over 10 years
Coronary pressure derived ‘collateral
flow index’ (CFI) determined during a
1-minute coronary balloon occlusion
Independent predictors of
10-year mortality:
Age
Low CFI
Smoking
Meier P, et al., Circulation 2007

16. 61 year old woman atypical Chest pain, no ischemia testing
How would you treat this bifurcation?
Zaiee A, et al. AJC, 2004;93:

17. 61 year old woman atypical Chest pain, no ischemia testing
How would you treat this bifurcation?
FFR=0.94
Zaiee A, et al. AJC, 2004;93:

18. FFR of “jailed” Circumflex
Pre Stent
Post Stent
8 mo
Nam CW, et al. Korean Circ J 2011;41:304-7.

19. FFR of “jailed” Circumflex
FFR of “jailed” circumflex in 43 patients after LM cross-over PCI
During median 12.5 month follow-up only one adverse event (non-cardiac death) in 37 patients with deferred ostial LCx treatment
Kang SJ, et al. Catheter Cardiovasc Intervent 2014;83:

20. Kumsars, et al. Eurointervention 2012;7:1155-61.
Kissing Balloon Inflation for Jailed Side Branches
FFR in 75 “Jailed” side branches from Nordic-Baltic Bifurcation III study (42 with final kissing, 32 without)
Final
Kissing No
Immediately Post PCI
8 Month Follow-Up
FFR
No difference in clinical outcomes
Kumsars, et al. Eurointervention 2012;7:

21. Percent Diameter Stenosis vs. Functional Significance
Before PCI
After MB stenting
After kissing balloon

22. DKCRUSH-VI Randomized Bifurcation Trial
• Chinese Multi-Center
Study
• 320 Patients
• SB at least 2.5mm
• Medina 1,1,1/0,1,1
• 9% distal LMCA
Chen SL, et al, JACC Cardiovasc Interv 2015

23. One-year clinical outcomes
DKCRUSH-VI Study Design
One-year clinical outcomes
Angio group (n=160)
FFR group (n=160) p
Cardiac death, n(%)
1 (0.6)
2 (1.3)
0.56
MI, n(%)
22 (13.8)
19 (11.9)
0.74
TLR, n(%)
8 (5.0)
5 (3.1)
0.57
CABG, n(%)
-----
TVR, n(%)
11 (6.9)
9 (5.6)
0.82
MACE, n(%)
29 (18.1)
1.00
ST-def/prob, n(%)
• Less SB intervention with FFR (56% vs 63%, p=0.07)
• Fewer stents with FFR (26% vs 38%, p=0.01)
Chen SL, et al, JACC Cardiovasc Interv 2015

24. Consensus: FFR in Bifurcations
Lassen JF, et al. EuroIntervention 2016;12(1):38‐46

25. Consensus: FFR in Bifurcations
Sawaya FJ, et al. JACC Cardiovasc Interv. 2016;9(18):1861‐78