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Pa Measured With Pressure Wire Strongly Correlates With Fractional Flow Reserve
http://www.aievolution.com/tct0901/
TUESDAY, SEPTEMBER 22, 2009, 10:00AM - 12:00PM
Carotid, Aorta, and Great Vessels
TCT-48
O R A L A B S T R AC T S
Resting Pd/Pa Measured With Pressure Wire Strongly Correlates With Fractional Flow Reserve Mamas Mamas, E Welch, A Ashworth, Bernard Clarke, Douglas Fraser, Raj Khattar, Vaikom Mahadevan, Farzin Fath-Ordoubadi, Ludwig Neyses, Magdi El-Omar Manchester Heart Centre, Manchester, United Kingdom Background: )UDFWLRQDO ÀRZ UHVHUYH ))5 LV DQ LQYDVLYH LQGH[ RI WKH functional severity of a coronary artery stenosis determined from coronary pressure measurement during cardiac catheterization. FFR expresses PD[LPXPDFKLHYDEOHEORRGÀRZWRWKHP\RFDUGLXPVXSSOLHGE\DVWHQRWLF DUWHU\ DV D IUDFWLRQ RI QRUPDO PD[LPXP ÀRZ ))5 SURYLGHV LPSRUWDQW prognostic information in PCI, the recent FAME study has demonstrated that FFR guided revascularization in multi-vessel PCI is associated with a reduction in adverse outcomes compared to angiography guided intervention. It is generally believed that there is poor correlation between the resting distal coronary pressure to aortic pressure ratio (Pd/Pa) and FFR obtained during maximal hyperemia with pharmacological stress. Methods: We have therefore retrospectively analyzed 528 consecutive pressure wire studies performed in 483 patients at a single UK centre over a 2 year period to determine whether resting Pd/Pa can be used to predict FFR obtained during maximal hyperemia. Results: A total of 102 out of 528 (19.3%) studies performed were positive if a FFR cut off value of 0.75 was used (as per DEFER study) and 169 studies (32.0%) were positive if a FFR cut off value of 0.80 (as per FAME study) was used. A linear correlation between resting Pd/Pa and FFR post pharmacological hyperaemia was observed (rho=0.73, p<0.0001). When FFR RI RU DVSHU)$0( ZDVGH¿QHGDVSRVLWLYHDUHVWLQJ3G3DRI < 0.85 (< 0.87) had a positive predictive value (PPV) of 95% (94.6%) whilst a resting Pd/Pa of > 0.93 (> 0.96) had a negative predictive value (NPV) of 95.7% (93%). Conclusions: In summary, we have demonstrated a strong correlation between resting Pd/Pa and FFR in a contemporary PCI cohort undergoing pressure wire measurements. We have shown that resting values of Pd/Pa can be used to predict a positive FFR result with relatively high positive and negative predictive values (in the region of 95%). This may obviate the need for adenosine infusion in a proportion of patients undergoing pressure wire assessments, such as those with a relative contraindication to adenosine, or ZLWK PXOWLYHVVHO FRURQDU\ DUWHU\ GLVHDVH 7KLV PD\ UHQGHU WKH ¿QGLQJV RI the FAME study more acceptable where all important lesions of at least 50% diameter stenosis on angiography were routinely assessed with FFR prior to stenting. Our observations should stimulate further research into the utility of WKHVH¿QGLQJVDQGLQSDUWLFXODUZKHWKHUWKHGH¿QHGFXWRIIVRI3G3DFRXOG be used to predict outcomes in the same way as FFR.
20D
Room 114 Tuesday, September 22, 2009, 10:00 am – 12:00 pm (Abstract Nos 49-56) TCT-49 Transcranial Doppler Monitoring During Carotid Artery Stenting: Comparison between Flow Reversal and Filter for Cerebral Protection Claudio Schönholz1, Kasirajan Karthikeshwar2, Charles Welzig1, Naren GUPTA25HQDQ8ÀDFNHU1 1 Medical University of South Carolina, Charleston, SC;2Emory University, Atlanta, GA Background: Embolic events are common during carotid artery stenting (CAS). Most of them remain clinically silent. Embolic protection devices are used to prevent emboli from reaching the brain and cause infarction. Transcranial Doppler (TCD) is the only non-invasive technique available to detect and quantify the occurrence of microembolism in the cerebral arteries during the procedure. Methods: Bilateral temporal monitoring TCD insonating the M1 segment of the middle cerebral artery (MCA) was performed in patients undergoing carotid artery stenting.Seven patients were protected using various FDA DSSURYHGGLVWDO¿OWHUVDQGXVLQJUHYHUVDORIÀRZWHFKQLTXHZLWKWKH*RUH Flow Reversal System (GFRS, W.L Gore & Associates, Inc., Flagstaff, AZ). Doppler spectral and M-mode signals from ultrasound probes mounted to a head frame were continuously recorded. The use of software detecting high intensity transient signals (HITS) allowed for real-time intraoperative IHHGEDFNDERXWWKHHI¿FDF\RIWKHHPEROLFSURWHFWLRQPHWKRGXVHGDVZHOO DVDERXWWKHFHUHEUDOEORRGÀRZG\QDPLFV7KHUHFRUGHGGDWDZHUHGLJLWDOO\ VWRUHGIRUSRVWSURFHGXUDOFRPSDULVRQEHWZHHQWKH¿QGLQJVREWDLQHGZLWKWKH GLIIHUHQWSURWHFWLRQWHFKQLTXHVDQGSKDVHVRIWKHSURFHGXUHV4XDQWL¿FDWLRQ of microembolic signals (MES) for statistical analysis was performed by manual review to allow for differentiation from injection and other artifacts. Results: TCD signal recordings were evaluated for three stages of the procedure: protection device deployment (PD), stent delivery including preand post dilatation (SD), and protection device removal (PR). MES were counted when detected in the MCA of the side of the treated carotid artery and are presented as Filter vs. GFRS treatment group means ± SEM. Patients XQGHUJRLQJ &$6 XQGHU FHUHEUDO SURWHFWLRQ GHPRQVWUDWHG VLJQL¿FDQWO\ OHVV DYHUDJH WRWDO 0(6 FRXQWV FRPSDUHG WR SURFHGXUHV XVLQJ ¿OWHU GHYLFHV 431.3±65.4 vs. 116.3±20.8, N=14, p<0.001. While the PD and PR phases ZHUHQRWVLJQL¿FDQWO\GLIIHUHQW 3'YV ns, and PR 34.3.4±24.4 vs. 36.7±8.9, ns), the SD phase, i.e. with the respective protection GHYLFHLQSODFHWKHDYHUDJH0(6FRXQWVZHUHVLJQL¿FDQWO\KLJKHULQSDWLHQWV WUHDWHGZLWK¿OWHUSURWHFWLRQ YVp<0.001. Conclusion: Preliminary analysis of the study data suggests that patients XQGHUJRLQJ &$6 XQGHU UHYHUVDO RI ÀRZ ZLWK WKH *)56 GHYLFH KDYH VLJQL¿FDQWO\OHVV0(6WKDQSDWLHQWVSURWHFWHGZLWK¿OWHUGHYLFHV
The American Journal of Cardiology®
|
September 21-25, 2009
|
TCT Abstracts/ORAL
TUESDAY, SEPTEMBER 22, 2009, 10:00AM - 12:00PM
Carotid, Aorta, and Great Vessels
TCT-48
O R A L A B S T R AC T S
Resting Pd/Pa Measured With Pressure Wire Strongly Correlates With Fractional Flow Reserve Mamas Mamas, E Welch, A Ashworth, Bernard Clarke, Douglas Fraser, Raj Khattar, Vaikom Mahadevan, Farzin Fath-Ordoubadi, Ludwig Neyses, Magdi El-Omar Manchester Heart Centre, Manchester, United Kingdom Background: )UDFWLRQDO ÀRZ UHVHUYH ))5 LV DQ LQYDVLYH LQGH[ RI WKH functional severity of a coronary artery stenosis determined from coronary pressure measurement during cardiac catheterization. FFR expresses PD[LPXPDFKLHYDEOHEORRGÀRZWRWKHP\RFDUGLXPVXSSOLHGE\DVWHQRWLF DUWHU\ DV D IUDFWLRQ RI QRUPDO PD[LPXP ÀRZ ))5 SURYLGHV LPSRUWDQW prognostic information in PCI, the recent FAME study has demonstrated that FFR guided revascularization in multi-vessel PCI is associated with a reduction in adverse outcomes compared to angiography guided intervention. It is generally believed that there is poor correlation between the resting distal coronary pressure to aortic pressure ratio (Pd/Pa) and FFR obtained during maximal hyperemia with pharmacological stress. Methods: We have therefore retrospectively analyzed 528 consecutive pressure wire studies performed in 483 patients at a single UK centre over a 2 year period to determine whether resting Pd/Pa can be used to predict FFR obtained during maximal hyperemia. Results: A total of 102 out of 528 (19.3%) studies performed were positive if a FFR cut off value of 0.75 was used (as per DEFER study) and 169 studies (32.0%) were positive if a FFR cut off value of 0.80 (as per FAME study) was used. A linear correlation between resting Pd/Pa and FFR post pharmacological hyperaemia was observed (rho=0.73, p<0.0001). When FFR RI RU DVSHU)$0( ZDVGH¿QHGDVSRVLWLYHDUHVWLQJ3G3DRI < 0.85 (< 0.87) had a positive predictive value (PPV) of 95% (94.6%) whilst a resting Pd/Pa of > 0.93 (> 0.96) had a negative predictive value (NPV) of 95.7% (93%). Conclusions: In summary, we have demonstrated a strong correlation between resting Pd/Pa and FFR in a contemporary PCI cohort undergoing pressure wire measurements. We have shown that resting values of Pd/Pa can be used to predict a positive FFR result with relatively high positive and negative predictive values (in the region of 95%). This may obviate the need for adenosine infusion in a proportion of patients undergoing pressure wire assessments, such as those with a relative contraindication to adenosine, or ZLWK PXOWLYHVVHO FRURQDU\ DUWHU\ GLVHDVH 7KLV PD\ UHQGHU WKH ¿QGLQJV RI the FAME study more acceptable where all important lesions of at least 50% diameter stenosis on angiography were routinely assessed with FFR prior to stenting. Our observations should stimulate further research into the utility of WKHVH¿QGLQJVDQGLQSDUWLFXODUZKHWKHUWKHGH¿QHGFXWRIIVRI3G3DFRXOG be used to predict outcomes in the same way as FFR.
20D
Room 114 Tuesday, September 22, 2009, 10:00 am – 12:00 pm (Abstract Nos 49-56) TCT-49 Transcranial Doppler Monitoring During Carotid Artery Stenting: Comparison between Flow Reversal and Filter for Cerebral Protection Claudio Schönholz1, Kasirajan Karthikeshwar2, Charles Welzig1, Naren GUPTA25HQDQ8ÀDFNHU1 1 Medical University of South Carolina, Charleston, SC;2Emory University, Atlanta, GA Background: Embolic events are common during carotid artery stenting (CAS). Most of them remain clinically silent. Embolic protection devices are used to prevent emboli from reaching the brain and cause infarction. Transcranial Doppler (TCD) is the only non-invasive technique available to detect and quantify the occurrence of microembolism in the cerebral arteries during the procedure. Methods: Bilateral temporal monitoring TCD insonating the M1 segment of the middle cerebral artery (MCA) was performed in patients undergoing carotid artery stenting.Seven patients were protected using various FDA DSSURYHGGLVWDO¿OWHUVDQGXVLQJUHYHUVDORIÀRZWHFKQLTXHZLWKWKH*RUH Flow Reversal System (GFRS, W.L Gore & Associates, Inc., Flagstaff, AZ). Doppler spectral and M-mode signals from ultrasound probes mounted to a head frame were continuously recorded. The use of software detecting high intensity transient signals (HITS) allowed for real-time intraoperative IHHGEDFNDERXWWKHHI¿FDF\RIWKHHPEROLFSURWHFWLRQPHWKRGXVHGDVZHOO DVDERXWWKHFHUHEUDOEORRGÀRZG\QDPLFV7KHUHFRUGHGGDWDZHUHGLJLWDOO\ VWRUHGIRUSRVWSURFHGXUDOFRPSDULVRQEHWZHHQWKH¿QGLQJVREWDLQHGZLWKWKH GLIIHUHQWSURWHFWLRQWHFKQLTXHVDQGSKDVHVRIWKHSURFHGXUHV4XDQWL¿FDWLRQ of microembolic signals (MES) for statistical analysis was performed by manual review to allow for differentiation from injection and other artifacts. Results: TCD signal recordings were evaluated for three stages of the procedure: protection device deployment (PD), stent delivery including preand post dilatation (SD), and protection device removal (PR). MES were counted when detected in the MCA of the side of the treated carotid artery and are presented as Filter vs. GFRS treatment group means ± SEM. Patients XQGHUJRLQJ &$6 XQGHU FHUHEUDO SURWHFWLRQ GHPRQVWUDWHG VLJQL¿FDQWO\ OHVV DYHUDJH WRWDO 0(6 FRXQWV FRPSDUHG WR SURFHGXUHV XVLQJ ¿OWHU GHYLFHV 431.3±65.4 vs. 116.3±20.8, N=14, p<0.001. While the PD and PR phases ZHUHQRWVLJQL¿FDQWO\GLIIHUHQW 3'YV ns, and PR 34.3.4±24.4 vs. 36.7±8.9, ns), the SD phase, i.e. with the respective protection GHYLFHLQSODFHWKHDYHUDJH0(6FRXQWVZHUHVLJQL¿FDQWO\KLJKHULQSDWLHQWV WUHDWHGZLWK¿OWHUSURWHFWLRQ YVp<0.001. Conclusion: Preliminary analysis of the study data suggests that patients XQGHUJRLQJ &$6 XQGHU UHYHUVDO RI ÀRZ ZLWK WKH *)56 GHYLFH KDYH VLJQL¿FDQWO\OHVV0(6WKDQSDWLHQWVSURWHFWHGZLWK¿OWHUGHYLFHV
The American Journal of Cardiology®
|
September 21-25, 2009
|
TCT Abstracts/ORAL