Upload
others
View
5
Download
0
Embed Size (px)
Citation preview
FFR/iFR/PdPa/RFR Caveats:What are the Traps, Common Physician Errors
Morton J. Kern, MDChief of Medicine, VA Long Beach HCS
Professor of MedicineUniversity California Irvine
Orange, California103019 Scripps
Disclosure: Morton J. Kern, MD
Within the past 12 months, the presenter or their spouse/partner havehad a financial interest/arrangement or affiliation with the organizationlisted below.
Company Name RelationshipCompany Name RelationshipAbbott / St Jude SpeakerBSC SpeakerPhilips / Volcano SpeakerAcist Speaker/ConsultantOpsens Speaker/Consultant
• 74 y/o man with HBP, HDL, DM, ESRD on HD, LBBB, andCAD mid LAD stent 6mo. ago (NSTEMI) now with ACS,CP w exertion.
• Same symptoms in 12/2018 which resolved after• Same symptoms in 12/2018 which resolved afterrotablator atherectomy followed by 3.0x38 mm SynergyDES post-dilated to 3.5mm.
FFR=0.86
Diagonal branch narrowing assessed
FFR=0.86
• Successful PCI mid LAD 3.0x23mmXience Sierra DES overlapping theprior LAD stent.
• Provisional bifurcation LAD stentingpinched D1 branch.pinched D1 branch.
• D1 iFR = 0.90; Pd/Pa 0.91; FFR = 0.86,
• Further D1 intervention deferred.
FFR
FFR =Pdistal (hyper)
Paortic (hyper)
Invasive Translesional Pressure Measurements
Non-hyperemic Pressure ratios, NHPRFFR
iFR
iFR =Pdistal (rest, wfp)
Paortic (rest, wfp)
Pd/Pa =Pdistal (rest)
Paortic (rest)
Non-hyperemic Pressure ratios, NHPR
Definitions – Physiologic Indices
Pd
Ahn JM, TCT 2018.
Comparison Physiologic Indices – IRIS FFR Registry
Pd
Ahn JM, TCT 2018.
HyperemicNon-HyperemicPressure Ratios
(NHPR)
Diastolic/Sub-CycleWhole-Cycle
Translesional Coronary Pressure Measurements 2019
Sub maxHyperemic
FFRAll
Systems
≤0.80
Diastolic/Sub-CycleWhole-Cycle
DFR™Boston
Scientific
iFR®Philips
RFR™Abbott
Pd/PaAll
Systems
≤0.91 ≤0.89
dPROpsens
cFFRAll
Systems
≤0.83
Traps and Errors in the use of FFR and NHPR
1. Equipment factors (FFR/NHPR):
– Erroneous zero,(tubing/connector leaks)
– Faulty electric wire connection
– Pressure signal drift,miscalibration, ECG
NHPRRmiscalibration, ECG
2. Procedural factors
– Guide catheter damping
– Incorrect sensor position
– Inadequate hyperemia
– Changing basal flow
FFR
NHPRR
NHPRR
Trap #2: Watch the Pressure Waveformfor Damping?
Courtesy of Nico Pijls.
Traps and Errors in the use of FFR and NHPR
2. Procedural factors
– Guide catheter damping
– Incorrect sensor position
– Inadequate hyperemia– Inadequate hyperemia
– Changing basal flow
– Pick the SMART Minimum FFR
According to Matt Price MD
Why We don’t do FFR…We hate… Solution
Set up, zero, driftAutomatic zero, plug/play, signalstability
Adenosine Pd/Pa, cFFR, NHPRs
Mediocre pressure wire handling,multiple exchanges, etc.
Improved wire construction and micro-monorail catheters
Pull back accuracy Angiographic co-registrationPull back accuracy Angiographic co-registration
Not knowing if microvascular diseaseis really a problem…
It depends…
PW can’t last through complexanatomy, multi lesion, bifurcations
2nd Gen sensors/wires--One-wire startto finish
That I don’t get paid to FFR, but I dofor stenting…
We should do the right thing for thepatient anyway…
Traps and Errorsin the use of FFR and NHPR
Physiological, clinical factors, conceptual barriers
– Serial lesions
– LM
– STE/ACS
– LVH?
– LVEDP?
– RA?
– AS/TAVR
Common Conceptual Barrier: Accepting the angiogram for what it can and cannot tell you
Trap: Are you done? Use of Post-PCI-FFR
574 patients SA/ACS
Improvementin func class
Johnson N, et al. JACC 2014 64(16):1641-54.
Agarwal S, et al. JACC Cardiov. Interv. 2016;9(10):1022-31.
Fournier S, et al.JAMA Cardiol 2019.
Vessel orientedclin outccome
When Can We Use FFR in ACS?
Fearon WF, JACC. 2016 Sep 13;68(11):1192-4. (Table 1).
Is FFR Useful in Culprit Vessel During AcuteMI?
Pijls and Sels, JACC 2012;59:1045.
Baseline Pd/Pa = 0.94 FFR = 0.80
How to Understand Discordancebetween NHPR and FFRbetween NHPR and FFR
Discordance between NHPR and FFR:2 ways to get FFR
De Waard G et al,Eurointervention, Jan 2017.
Predictors of Discordance Between iFR/FFR:Stenosis Location, Severity, HR, Age, and BB’s
(FFR+/iFR-)=69/587(FFR-/iFR+)=52/587
Derimay F, et al. Cath and CV Interven 2019:1-8.
(FFR-/iFR+)=52/587
Physiological Pattern of Diseasehas an Influence on FFR/iFR Discordance
Warisawa T, et al. Circ Cardiovasc Interv.2019;12(5):e007494.
FFR-/iFR+In Diffuse Disease
Intermediate lesion with Pd/Paassessment
Pd/Pa > 0.93Defer
Pd/Pa = 0.87-0.93
Contrast FFR (cFFR) assessment
Pd/Pa < 0.87Intervene
Algorithm for FFR/iFR Discordance
cFFR > 0.83Defer
cFFR = 0.76-0.82
FFR assessment
FFR > 0.80Defer
cFFR < 0.75Intervene
FFR < 0.80Intervene
Clinical Challenges– Patient Outcome Studies in Specific Subgroups