Imaging vs functional assessment ofImaging vs functional assessment ofleft main intermediate lesion.

A time for the final statement ?A time for the final statement ?

Tomasz Pawłowski, MD, PhD, FESCKlinika Kardiologii Inwazyjnej CSK MSWiA

Warsaw, Poland

□□ I have no conflict of interest related to this presentation□□ I have no conflict of interest related to this presentation□□ I have no conflict of interest related to this presentation□□ I have no conflict of interest related to this presentation

Left main stenosis

-LM disease5-7 % of all angios

- Mortality within 3 years – 50 % with medical treatment

How to assess intermediate left main ?

The question……

Limitations of angiography:

- Overlap of the catheter and LAD/Cx- Overlap of the catheter and LAD/Cx

- Spillover of contrast medium

- Mixing of blood & contrast media

- No reference segment- No reference segment

- Small LM – diffuse disease

- Bifurcation

- Calcification

- Continuity of the plaque into LAD/Cx

Contrast imaging of intermediate & ambigous lesion

Contrast imaging of intermediate & ambigous lesion

IVUS vs FFR – a selection bias ???

IVUSFFR FFR

IVUS IVUSFFR

Contrast imaging of intermediate & ambigous lesion

Misclasiffication by angio:

62/213pts = 29 %18/72 pts = 25 % (isolated LM)

Hamilos et al. Circulation 2009

The dots represent patients with isolated LMCA stenosis.

Hamilos et al. Circulation 2009

Non-invasive assessment of left main significance

Chest painIVUS ???IVUS ???

Ischemic cascade

ECG changeStress ECG

Diastolic & Systolicdysfunction

Stress Echo / MRI

Perfusionabnormalities

Nuclear imagingFFR

Case presentationCase presentation

• 78 years old man

• Hypertension history

• Dyslipidemia history

• Reffered for invasive

assessement of LM lesionassessement of LM lesion

How to assess intermediate left main ?

Intravascular ultrasound (IVUS)

• Tomographic view of left main as well as proximal parts

of LAD & Cxof LAD & Cx

• Plaque burden & composition, vessel size & remodelling

• Proved clinical value for LM PCI optimalisation

• Variability in sizes & lengths & plaque distribution

• Variability in amount of supplied myocardium

• Two separate pullbacks are needed

Visual estimation of LM stenosis by different reviewers

• 26 % of cases, Reviewers disagreed that LMwas significant, non-significant or unsure

• In 74 % they agreed,

• In 23 % cases were misclassified that meansIn 23 cases DS.>50 % - FFR was >0.80 andIn 23 cases DS.>50 % - FFR was >0.80 andIn 25 cases DS.<50 % - FFR was <0.80

• General – in 49 % of cases there was eitherdisagreement or misclassification

Hamilos et al. Circulation 2009

Plaque distribution in LM & proximal LAD & Cx

Oviedo et al. Circ Cardiovasc Interv 2010

Fractional flow reserve (FFR)

• Easy and accurate procedure protocol

• Proved clinical cut-off value for lesion deferral

• Proximal LAD & Cx disease affects FFR results in LM

• Adenosine infusion needed

Disadvantages in FFR

Side effects of Adenosine infusion (53 pts):Side effects of Adenosine infusion (53 pts):26 % shortness of breath

19 % flushing19 % headache

6 % AV block II degree6 % AV block II degree

Safety of LM revascularisation defferal (IVUS & FFR) (01)

0.75>FFR<0.750.75>FFR<0.750.75>FFR<0.750.75>FFR<0.75

Bech et al. Heart 2001 Hamilos et al. Circulation 2009

Safety of LM revascularisation defferal (IVUS & FFR) (02)

> 6 186 pts – 96,2 % LM revasc not done> 6mm2

< 6

186 pts – 96,2 % LM revasc not done

168 pts – 90,5 % LM revasc done< 6

mm2

168 pts – 90,5 % LM revasc done55,2 % - CABG

17,2 % - PCI LM27,6 % - PCI LM+other PCI

120p=0,04

97.7

87.386

62.5

80

100

120p=0,04

p=0,02

62.5

20

40

60

0

20

Death free MACE freeDeffered Revasc

IVUS in LM revascularisation

7.4 7.7

13

10

12

14

IVUS No IVUS

*7.4

3.3 3.5

7.7

6

4.5

6.3

2.22

4

6

8

*

11.9

13.6

16

12

14

16

18IVUS

*

0.6

0

2

Death Cardiac death MI TLR ST

*

64.7

7.1

8.89.6

4

6

8

10

12

*

0

2

4

Death TVR Death TVR

Overall Drug eluting stents 14.4

22.2

16

19

15

20

25Pts – distal LM lesion

** *

Park et al. Circ Cardiovasc Interv 2009

Overall Drug eluting stents 14.411.7 11

0

5

10

15 * *

*p<0.050

Death-MI-TLR Cardiac death-MI-TLR

Cardiac death-MI-TLR

IVUS No IVUSHernandez et al. JACC Interv 2014

IVUS & FFR in LM – substitute or surrogate ?

55 pts withambiguous LM

Jasti et al.Jasti et al.Circulation 2004

55 pts with 30-80% DS. of LM

Kang et al.Kang et al.JACC Interv 2011

Variability of IVUS LM cut-off values

8

9

Legutko et al. 2004 (8.0 mm2)

6

7

8

Jasti et al. 2004 (5.9 mm2)

Legutko et al. 2004 (8.0 mm2)

3

4

5Jasti et al. 2004 (5.9 mm2)

Kang et al. 2011 (4.8 mm2)

Kang et al. 2011 (4.1 mm2)

1

2

3

0

0.7 0.75 0.8 0.85 0.9 0.95 1

General recommendation is to use 6 mm2 to defer revascularisation

Variability of IVUS LM cut-off values

6 mm2 is enough ?FFR=0.85

6 mm2 is too small ?FFR=0.72

Kang et al.Fassa et al.

Variability of IVUS LM cut-off values

Murray law for LM = 5-6 mm2

4.2

4.0Briguori (4.0)

Murray law for LM = 5-6 mm

are

a(m

m2) 3.8

3.6

3.4

Min

imu

mlu

me

na

rea

3.2

3.0

2.8

Dor (3.2)

Takagi (3.0)

Koo(prox LAD) (3.0)

Koo(mid LAD) (2.75)

Waksman (3.07)

Historic IVUS/FFR data

Min

imu

mlu

me

n

2.8

2.6

2.4

Kang (2.4)

(mid LAD) (2.75)

Historic IVUS/FFR data

Current IVUS/FFR data

Current OCT/FFR data

Reference lumen area (mm2)

2.2

2.0

1.8

5 6 7 8 9 10 11

Pawłowski (2.05)

Gonzalo (1.95)

FFR vs IVUS in intermediate LM

Cardiac deaths & survival

Mallidi et al. Cather Cardiovasc Interv 2015 De la Torre Hernandez et al. JACC 2011

Invasive assessment of intermediate left main stenosisby intravascular ultrasound & fractional flow reserveby intravascular ultrasound & fractional flow reserve

Long term clinical outcome of defferal & revascularisation

T. Pawłowski, S. Gołębiewski, J. Bil, P. Modzelewski, R.J. Gil

Central Clinical Hospital of the Ministry of the Interior and AdministrationCentral Clinical Hospital of the Ministry of the Interior and AdministrationWarsaw, Poland

Direct comparison- IVUS vs FFR

Total 120 pts with angiointermediate LM lesion assesed

invasively in 2009-2014invasively in 2009-2014

Matched pairs according to demographics, risk factors, isolated LM stenosis

60 pts with assesed by FFR 60 pts with assesed by IVUS60 pts with assesed by FFR(140 ug/kg/min, Adenosine

infution, FFR<0,80 for defferal)

60 pts with assesed by IVUS(cut-off value >6 mm2 forrevascularisation defferal)

2 year follow-up with MACE(Death, infarction, TVR)(Death, infarction, TVR)

Direct comparison- IVUS vs FFR

Demographics

Group 1 (FFR) Group 2 (IVUS) p

Demographics

Age (years) 68.5±9.2 69.8±7.8 NS

Hypertension (%) 46.6 46.6 NS

Diabetes (%) 15.0 15.0 NS

Smoking (%) 35.0 35.0 NS

Distal LM lesion (%) 36.6 38.3 NS

Previuos MI (%) 16.6 18.3 NS

Direct comparison- IVUS vs FFR

Results of LM assessment

80 70

71.3

50

60

70

80 70

28.3

IVUS10

20

30

40

30

FFR0

10

OMT

Revasc

FFR IVUS

Direct comparison- IVUS vs FFR

Operator & heart team decisionsRevascularisationRevascularisation

83.3

93.7

90

100

83.3

60

70

80

16.4

30

40

50

16.4

6.3

0

10

20

PCI CABGPCI CABG

FFR IVUS

Direct comparison- IVUS vs FFR

2 year follow-up – all patients

25

25

*

15

20

15

8.3 10

*

5

10

1.65

8.36.6

* *

FFR

IVUS0

MACEDeath

InfarctionTVRTVR

FFR IVUS

Direct comparison- IVUS vs FFR

2 year follow-up – deffered pts

15.8

14

16

18

9.110

12

14

*

7.1

4.7

9.1

4.56

8

0

2.4

4.7

2.2

4.5

0

2

4 *

00

MACE Death Infarction TVR

FFR IVUS

Direct comparison- IVUS vs FFR

2 year follow-up – revascularized pts

5050

60

33.331.2

40

*

16.620

30

*

5.5

11.1

6.2

12.5

0

10

*

0

MACE Death Infarction TVR

FFR IVUS

Direct comparison- IVUS vs FFR

2 year follow-up – mortality in subgroups

8.3

9.1

8

9

10

5.5

6.2

6

7

8

3

4

5

**

1.6

00

1

2

3 *

00

All Deffered Revasc

FFR IVUS

Conclusions (01)

• FFR in comparison to IVUS provides a better log term clinical outcome,

especially in terms of mortality in deffered from revascularisation ptsespecially in terms of mortality in deffered from revascularisation pts

• There is a trend to higher number of infarction in IVUS revascularized

subgroup

• The number of target vessel failure is lower in this subgroup that is probably

related with IVUS optimasition technique

• Using IVUS when assessing intermediate LM lesion, provides a larger number

of LM coronary angioplasty

Conclusions (02)

• The general recommendation (cardiologist’s feeling) was to use

FFR or IVUS to defer revascularisation but with tendency for IVUS forFFR or IVUS to defer revascularisation but with tendency for IVUS for

subsequent optimalisation of LM stenting

• Many data, similarly to native arteries, have showed that there is no single

cut-off value for intermediate LM lesion deffering.

Of note, huge variability in sizes & lengths of LM may play a role

• Fractional flow reserve provides a simple protocol, clear cut-off value &

good clinical outcomes and very important – is not related to variability of

LM sizes and myocardial area supplied