1. Pros and cons of FFR in multivessel disease: from FAME to ACS Giuseppe Biondi Zoccai University of Modena and Reggio Emilia, Modena, Italy gbiondizoccai@gmail.com

2. Learning goals Scope of the problem What are the implications of FAME What about the culprit lesion in ACS What about non-culprit lesions in ACS

3. The first coronary angioplasty by Andreas Gruentzig

4. Extent of CAD in the VANWISH trial Kerensky et al, J Am Coll Cardiol 2002;39:1456-63

5. Single culprit, multiple culprits, or no culprit at all? Kerensky et al, J Am Coll Cardiol 2002;39:1456-63

6. What is most trustworthy? Melikian et al, J Am Coll Cardiol Intv 2010;3:307–14

7. Is SYNTAX no more such? Nam et al, ACC 2011 (J Am Coll Cardiol 2011;57:E1090)

8. Learning goals Scope of the problem What are the implications of FAME What about the culprit lesion in ACS What about non-culprit lesions in ACS

9. Visual angiographic assessment vs FFR in the FAME trial Tonino et al, J Am Coll Cardiol 2010;55:2816-21

10. FAME trial

11. FAME at 2 years Pijls et al, J Am Coll Cardiol 2010;55:2816-21

12. FAME: deferred group Pijls et al, J Am Coll Cardiol 2010;55:2816-21

13. Learning goals Scope of the problem What are the implications of FAME What about the culprit lesion in ACS What about non-culprit lesions in ACS

14. Acute microvascular damage in myocardial infarction STEMI Variable degree of reversible microvascular stunning Maximum achievable flow is less Smaller gradient and higher FFR across any given stenosis With time, the microvasculature may recover, maximum achievable flow may increase, and a larger gradient with a lower FFR may be measured across a given stenosis

15. Similar stenosis but different extent of perfusion area

16. 26 col-schema fcf (figuur) 26 col-schema fcf (figuur) Poor collaterals low FFR = 0.50 100 Pd 50 An identical stenosis, but... 0

17. 26 col-schema fcf (figuur) 26 col-schema fcf (figuur) Good collaterals higher FFR = 0.75 100 Pd 750 An identical stenosis, but...

18. Visible collaterals on the coronary angiogram (Rentrop) and fractional collateral blood flow Qc/Qn

19. What about serial lesions?

20. What about severe left ventricular hypertrophy? In severe left ventricular hypertrophy, there is an exaggerated increase of left ventricular mass in comparison to the vascular bed, resulting in the potential for ischemia even in normal or almost normal coronary arteries Thus, specificity may be reduced (cut-off >0.80?) However, sensitivity remains satisfactory

21. What about lesion length? Brosh et al, Am Heart J 2005;150:338-43

22. What about culprit lesion FFR?

23. De Bruyne et al, Circulation 2001;104;157-62. What about culprit lesion FFR?

25. Tamita et al, Catheter Cardiovasc Intervent 2002;57:452-9

26. What about culprit lesion FFR? Beleslin et al, Eur Heart J 2008;29:2617-2624

27. What about culprit lesion FFR?

28. Samady et al, J Am Coll Cardiol 2006;47:2187-93

29. Learning goals Scope of the problem What are the implications of FAME What about the culprit lesion in ACS What about non-culprit lesions in ACS

30. What about non-culprit lesions?

31. Ntalianis et al, Catheter Cardiovasc Intervent 2002;57:452-9

32. What about non-culprit lesions? Ntalianis et al, Catheter Cardiovasc Intervent 2002;57:452-9

33. Is it worthwhile?

34. Take home messages

35. FFR has been proved safe and effective in several settings, including 2 RCTs with clinically relevant end-point (DEFER and FAME) ACS do benefit from FFR as well as all others, with the notable exception of acute/subacute culprit lesions The upcoming FAME 2 trial will hopefully further support FFR, and provide us another argument against (or better on top of) medical therapy for CAD

36. Interested in more?

37. Thank you for your attention For any correspondence: gbiondizoccai@gmail.com For these and further slides on these topics feel free to visit the metcardio.org website: http://www.metcardio.org/slides.html gbiondizoccai@gmail.com http://www.metcardio.org/slides.html