- Email: [email protected]
Coronary Fractional Flow Reserve (FFR) measurement: which method of adenosine administration is the safest?
13
Archives of Cardiovascular Diseases Supplements (2017) 9, 11-28
of 0.02. However a drift of more than 0.02 between the first equalization and the equalization checked after FFR measurements might be observed. We sought to investigate the prevalence, the impact and the potential causes of drift. Methods In our prospective monocentric study, we included all consecutive patients between February and December 2014 with FFR measurement indication. In all patients we measured FFR with a pressure wire (St Jude Medical, St Paul MN USA) under maximal hyperemia with intravenous adenosine administration. FFR equalization was performed in the same position with the sensor placed at 1 mm outside of the guiding to obtain an initial Pd/Pa=1. We systematically checked the Pd/Pa value after FFR measurement at the same position. We defined drift as a difference of Pd/Pa after FFR measurement of more than 0.02. We evaluated mean arterial pressure, baseline Pd/Pa, FFR, hyperemia time, procedure time and pressure wires type (wireless or not). Results During the study period we analyzed in 152 patients and 195 coronary lesions. No drift was observed in 130 patients (86%). A drift >0.02 was observed in 22 patients (14%). Revascularization indication changed in 3 patients (2%). No correlation was found between FFR drift and mean arterial pressure, baseline Pd/Pa, FFR, hyperemia time, procedure time and pressure wires type. After second equalization in 22 cases no second drift was observed. Conclusion In our study FFR measurement is accurate in 86% of the cases and 100% of the cases after a second equalization when a drift of more than 0.02 is observed without potential factor incriminated. Drift check changed the revascularization indication in 3 patients (2%). Drift should be systematically checked after FFR measurement. The authors hereby declare no conflict of interest
374 Fractional flow reserve (FFR) and angiographic estimation correlation of coronary stenoses: the impact of risk factors J. Adjedj (*) (1) (2), P. Xamplanteris (2), G. Toth (2), A. Ferrara (2), V. Flore (2), M. Pellicano (2), E. Barbato (2), B. De Bruyne (2) (1) APHP-Hôpital Cochin, Cardiologie, Paris, France – (2) Cardiovascular center OLV Aalst clinic, Aalst, Belgique *Corresponding author: [email protected] Introduction Poor correlation between angiographic assessment of coronary stenoses and fractional flow reserve (FFR) has been extensively described. FFR assesses the ischemia induced by the stenosis, whereas, angiographic estimation either by “eyeballing” or by quantitative coronary angiography (QCA) does not address the functional importance of a stenosis. To date, it is unknown if the accumulation of risk factors differentially impacts on the interplay of angiographic indices and FFR. We sought to retrospectively explore these relationships of visual estimation (VE), QCA, FFR and risk factors in a large cohort of patients that underwent catheterization. Methods We retrospectively collected VE, QCA and FFR values assessed by independent operators (April 1997-July 2013). Patients were divided according to the presence of risk factors. ROC curves for VE and QCA (FFR as the gold standard to detect significant stenosis with a cut-off value of <0.80) were calculated for each subgroup, and respective areas under the curves (AUCs) were compared. Results 1382 coronary stenoses (1104 patients) were analyzed. Stenosis location, VE and QCA indices did not differ across subgroups (P=NS for all). The AUCs of the ROC curves of VE and QCA diminished with the accumulation of risk factors. FFR was significantly higher in the diabetic group compared to the non-diabetic group respectively 0.81±0.12 and 0.79±0.13, p=0.007. ROC curves comparing VE and QCA to FFR showed significantly lower AUC for both VE and QCA in the diabetic group compared to the nondiabetic group. AUC for VE and QCA was respectively 0.53, 0.51 in the diabetic group and 0.73, 0.65 in the non-diabetic group (p<0.05). Conclusion Correlation between angiographic indices of coronary stenoses and FFR is weak and progressively weakens as risk factors accumulate. FFR should be measured across intermediate stenoses, especially in patients with several risk factors, as visual estimation and QCA become unreliable in such setting. The authors hereby declare no conflict of interest
Abstract 374 – Figure
350 Comparison of the instantaneous wave-free ratio and resting Pd/Pa with fractional flow reserve to assess coronary artery stenosis of intermediate severity J. Clerc, P. Meimoun*, A. Luycx-Bore, U. Djou, S. Martis, T. Botoro, F. Elmkies, H. Zemir CH Compiegne, Compiegne, France *Corresponding author: [email protected] Introduction Assessment of the functional significance of coronary artery stenosis of intermediate severity (IS) is challenging and often based on fractional flow reserve (FFR). The instantaneous wave-free ratio (IFR), a new vasodilator-free index of coronary stenosis severity, is also potentially useful, as well as resting distal coronary artery pressure to aortic pressure (Pd/Pa). Our objective was to test the diagnostic accuracy of IFR and Pd/Pa with respect to FFR, in patients with IS and stable coronary artery disease. Methods 152 stable consecutive patients (mean age, 68±10 years; 30 women) (162 lesions with angiographic IS, 50-70% diameter stenosis), were prospectively studied. All lesions were evaluated by 1/ IFR, which was calculated as a trans-lesion pressure ratio during the wave-free period in baseline diastole, 2/resting Pd/Pa, which was time average over the entire cardiac cycle, and 3/ FFR defined as the lowest stable value of Pd/Pa during maximal hyperemia (using 180-µgg intracoronary bolus of adenosine). Results The mean values of IFR, Pd/Pa and FFR, were 0.89±0.08, 0.92±0.05, and 0.82±0.09 respectively. A significant linear correlation was found between Pd/Pa and FFR (r=0. 76), FFR and IFR (r=0.69), and between Pd/Pa and IFR (r=0.87) (all, p<0.001). Using a ROC curve analysis, the best cut-off to detect a significant lesion based on FFR assessment (FFR ≤0.8, n=52) was IFR ≤0.88, with a sensitivity (Se) of 77%, specificity (Sp) of 79%, diagnostic accuracy of 81%, AUC 0.85±0.03; and Pd/Pa ≤0.92 with a Se=92%, Sp=65%, diagnostic accuracy of 82%, AUC 0.86±0.03 (all, p<0.001). Furthermore, IFR and Pd/Pa had a diagnostic accuracy of 93% to predict a positive or negative FFR in 61% and 66% of lesions respectively. Conclusion In stable patients with coronary stenosis of IS, IFR and Pd/Pa demonstrated a similar diagnostic accuracy to detect an FFR ≤0.8. Furthermore, both indices had a diagnostic accuracy of 93% in ~ 2/3 of lesions. The authors hereby declare no conflict of interest
473 Coronary Fractional Flow Reserve (FFR) measurement: which method of adenosine administration is the safest? M. Calcaianu*, D. Bresson, Y. Doghmi, C. Vilbois, T. El Nazer, A. Felder, L. Lachmet-Teebaud, J. Wiedemann, O. Roth, L. Jacquemin, J. Levy CH Mulhouse, Cardiologie, Mulhouse, France *Corresponding author: [email protected] Introduction Recent results suggest that intracoronary (IC) bolus injection of adenosine provides better patient comfort and lower cost than standard intravenous (IV) injection. The extremely close correlation between FFR measurements with IV and IC adenosine is well established, however there is only
© Elsevier Masson SAS. All rights reserved.
14
Archives of Cardiovascular Diseases Supplements (2017) 9, 11-28
limited data which assesses the safety of IC administration compared with standard method. Purpose To compare the occurrence of side effects (SE) according to the adenosine injection method (IC or IV) during the evaluation of intermediate coronary stenosis by FFR. Methods From August 2015 to January 2016, we prospectively included all adult patients with at least 1 angiographically intermediate stenosis which underwent FFR assessment. The adenosine injection method and severe SE were recorded. Results During the study period, a total of 104 patients with 131 lesions were included (Table 1). Occurrences of SE between the IC group and the IV group were not significantly different, respectively 4 (7.1%) versus 6 (13.3%) SE, p=0.75. Multivariate analysis did not identified the IC injection as independently associated with the occurrence of an SE (OR 1.5; 95% CI 0.34-6.9; p=0.58). Conclusion These results suggest that IC adenosine is as safe as IV infusion. These data need to be verified on a larger sample. Data are expressed as mean±SD or number (%); BMI, body mass index; LM, left main; LAD, left anterior descending artery; LCX, circumflex artery; DG, diagonal branch; RCA, right coronary artery; IC, intracoronary; IV, intravenous.
Purpose study the incidence of contrast media induced nephropathy, major adverses events in patients with chronic kidney disease undergoing coronarography with our nephroprotection protocol. Methods all patients with chronic kidney disease undergoing coronarogrpahy between january 2014 and february 2016 were included. They all received a sodium bicarbonate solution (1mL/kg/h) and diuresis with matched hydratation with saline solution 12 or 24 hours before coronarography and 24 or 48 hours after, furosemide was added to allow a urine output over 150mL/hour. Contrast media induced nephropathy and major events incidence were analysed. Results Over 575 patients, 51 (8.8%) suffered from contrast media induced nephropathy, The latters had a creatinine clearance lower (45±11mL/min/1.73m² vs 48.4±8.7 11mL/min/1.73m²; p=0.034), recieved more contrast media (232±146mL vs 184±106 mL vs; p=0.036), suffered more from pulmonary congestion (9.8% vs 2.7%; p=0.02), died more (11.8% vs 1.15%; p<0.0001) than patients not affected. Our results compare favorably with those of the literature. Conclusion Contrast media induced nephropathy concerns 8.8% of the patients with chronic kidney disease and seems to led to high morbi mortality. Our protocol could give a better protection against this nephropathy comparatively with a standard hydratation with saline solution. Randomised studies must be led to confirm this hypothesis. The authors hereby declare no conflict of interest
The authors hereby declare no conflict of interest
746 718
Percutaneous coronary interventions with drug eluting stents in the elderly: the experience of a tertiary Tunisian cardiac center
Contrast media induced nephropathy prevention for patients at risk: matched diuresis evaluation
S. Charfeddine*, L. Abid, R. Hammami, I. Chamtouri, M. Baccouche, S. Mallek, A. Maalej, D. Abid, S. Kammoun Hôpital universitaire Hedi Chaker, Cardiologie, Sfax, Tunisie *Corresponding author: [email protected]
J. Dally GHICL, Cardiologie, Lomme, France *Corresponding author: [email protected] Background incidence of contrast media induced nephropathy is more frequent and potentially serious in case of chronic kidney disease.
Aims The prognostic impact of percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation in the elderly population with prolonged dual antiplatelet therapy is unclear. The aim of this study was to evaluate the safety and efficacy of DES implantation in the elderly.
Abstract 473 – Table: Clinical, angiographic and FFR characteristics
Age (years)
Study cohort N=104
With side effects N=10
Without side effects N=94
p value
68.1±10.4
64.8±13.2
68.4±10.1
0.40
Male sexe
74 (71)
7 (10)
67 (90)
0.59
BMI (kg/m2)
27.4±4.5
26.8±3.7
27.5±4.6
0.25
Hyperlipidemia
52 (50)
4 (8)
48 (92)
0.37
Hypertension
59 (57)
6 (10)
53 (90)
0.55
Diabetes mellitus
21 (20)
2 (10)
19 (90)
0.67
Smoking
35 (33)
1 (3)
34 (97)
0.21
Family history
10 (10)
1 (10)
9 (90)
0.65
Acute Coronary Syndrome
22 (21)
2 (9)
20 (91)
0.56
Positive stress test
58 (56)
5 (9)
53 (91)
Diagnostic coronarography
24 (23)
3 (13)
21 (87)
Risk factors
Indication
Target vessel
Adenosine administration
LM
6 (4)
0
6 (100)
0.41
LAD
70 (53)
10 (14)
60 (86)
0.03
LCX
27 (21)
3 (12)
24 (88)
0.72
DG
5 (4)
1 (20)
4 (80)
0.40
RCA
23 (18)
2 (9)
21 (91)
0.87
IC
70 (70)
5 (7)
65 (93)
0.32
IV Syntax Score
30 (30)
4 (13)
26 (87)
7.8±7.5
7.3±7.1
7.9±7.6
© Elsevier Masson SAS. All rights reserved.
0.82
Archives of Cardiovascular Diseases Supplements (2017) 9, 11-28
of 0.02. However a drift of more than 0.02 between the first equalization and the equalization checked after FFR measurements might be observed. We sought to investigate the prevalence, the impact and the potential causes of drift. Methods In our prospective monocentric study, we included all consecutive patients between February and December 2014 with FFR measurement indication. In all patients we measured FFR with a pressure wire (St Jude Medical, St Paul MN USA) under maximal hyperemia with intravenous adenosine administration. FFR equalization was performed in the same position with the sensor placed at 1 mm outside of the guiding to obtain an initial Pd/Pa=1. We systematically checked the Pd/Pa value after FFR measurement at the same position. We defined drift as a difference of Pd/Pa after FFR measurement of more than 0.02. We evaluated mean arterial pressure, baseline Pd/Pa, FFR, hyperemia time, procedure time and pressure wires type (wireless or not). Results During the study period we analyzed in 152 patients and 195 coronary lesions. No drift was observed in 130 patients (86%). A drift >0.02 was observed in 22 patients (14%). Revascularization indication changed in 3 patients (2%). No correlation was found between FFR drift and mean arterial pressure, baseline Pd/Pa, FFR, hyperemia time, procedure time and pressure wires type. After second equalization in 22 cases no second drift was observed. Conclusion In our study FFR measurement is accurate in 86% of the cases and 100% of the cases after a second equalization when a drift of more than 0.02 is observed without potential factor incriminated. Drift check changed the revascularization indication in 3 patients (2%). Drift should be systematically checked after FFR measurement. The authors hereby declare no conflict of interest
374 Fractional flow reserve (FFR) and angiographic estimation correlation of coronary stenoses: the impact of risk factors J. Adjedj (*) (1) (2), P. Xamplanteris (2), G. Toth (2), A. Ferrara (2), V. Flore (2), M. Pellicano (2), E. Barbato (2), B. De Bruyne (2) (1) APHP-Hôpital Cochin, Cardiologie, Paris, France – (2) Cardiovascular center OLV Aalst clinic, Aalst, Belgique *Corresponding author: [email protected] Introduction Poor correlation between angiographic assessment of coronary stenoses and fractional flow reserve (FFR) has been extensively described. FFR assesses the ischemia induced by the stenosis, whereas, angiographic estimation either by “eyeballing” or by quantitative coronary angiography (QCA) does not address the functional importance of a stenosis. To date, it is unknown if the accumulation of risk factors differentially impacts on the interplay of angiographic indices and FFR. We sought to retrospectively explore these relationships of visual estimation (VE), QCA, FFR and risk factors in a large cohort of patients that underwent catheterization. Methods We retrospectively collected VE, QCA and FFR values assessed by independent operators (April 1997-July 2013). Patients were divided according to the presence of risk factors. ROC curves for VE and QCA (FFR as the gold standard to detect significant stenosis with a cut-off value of <0.80) were calculated for each subgroup, and respective areas under the curves (AUCs) were compared. Results 1382 coronary stenoses (1104 patients) were analyzed. Stenosis location, VE and QCA indices did not differ across subgroups (P=NS for all). The AUCs of the ROC curves of VE and QCA diminished with the accumulation of risk factors. FFR was significantly higher in the diabetic group compared to the non-diabetic group respectively 0.81±0.12 and 0.79±0.13, p=0.007. ROC curves comparing VE and QCA to FFR showed significantly lower AUC for both VE and QCA in the diabetic group compared to the nondiabetic group. AUC for VE and QCA was respectively 0.53, 0.51 in the diabetic group and 0.73, 0.65 in the non-diabetic group (p<0.05). Conclusion Correlation between angiographic indices of coronary stenoses and FFR is weak and progressively weakens as risk factors accumulate. FFR should be measured across intermediate stenoses, especially in patients with several risk factors, as visual estimation and QCA become unreliable in such setting. The authors hereby declare no conflict of interest
Abstract 374 – Figure
350 Comparison of the instantaneous wave-free ratio and resting Pd/Pa with fractional flow reserve to assess coronary artery stenosis of intermediate severity J. Clerc, P. Meimoun*, A. Luycx-Bore, U. Djou, S. Martis, T. Botoro, F. Elmkies, H. Zemir CH Compiegne, Compiegne, France *Corresponding author: [email protected] Introduction Assessment of the functional significance of coronary artery stenosis of intermediate severity (IS) is challenging and often based on fractional flow reserve (FFR). The instantaneous wave-free ratio (IFR), a new vasodilator-free index of coronary stenosis severity, is also potentially useful, as well as resting distal coronary artery pressure to aortic pressure (Pd/Pa). Our objective was to test the diagnostic accuracy of IFR and Pd/Pa with respect to FFR, in patients with IS and stable coronary artery disease. Methods 152 stable consecutive patients (mean age, 68±10 years; 30 women) (162 lesions with angiographic IS, 50-70% diameter stenosis), were prospectively studied. All lesions were evaluated by 1/ IFR, which was calculated as a trans-lesion pressure ratio during the wave-free period in baseline diastole, 2/resting Pd/Pa, which was time average over the entire cardiac cycle, and 3/ FFR defined as the lowest stable value of Pd/Pa during maximal hyperemia (using 180-µgg intracoronary bolus of adenosine). Results The mean values of IFR, Pd/Pa and FFR, were 0.89±0.08, 0.92±0.05, and 0.82±0.09 respectively. A significant linear correlation was found between Pd/Pa and FFR (r=0. 76), FFR and IFR (r=0.69), and between Pd/Pa and IFR (r=0.87) (all, p<0.001). Using a ROC curve analysis, the best cut-off to detect a significant lesion based on FFR assessment (FFR ≤0.8, n=52) was IFR ≤0.88, with a sensitivity (Se) of 77%, specificity (Sp) of 79%, diagnostic accuracy of 81%, AUC 0.85±0.03; and Pd/Pa ≤0.92 with a Se=92%, Sp=65%, diagnostic accuracy of 82%, AUC 0.86±0.03 (all, p<0.001). Furthermore, IFR and Pd/Pa had a diagnostic accuracy of 93% to predict a positive or negative FFR in 61% and 66% of lesions respectively. Conclusion In stable patients with coronary stenosis of IS, IFR and Pd/Pa demonstrated a similar diagnostic accuracy to detect an FFR ≤0.8. Furthermore, both indices had a diagnostic accuracy of 93% in ~ 2/3 of lesions. The authors hereby declare no conflict of interest
473 Coronary Fractional Flow Reserve (FFR) measurement: which method of adenosine administration is the safest? M. Calcaianu*, D. Bresson, Y. Doghmi, C. Vilbois, T. El Nazer, A. Felder, L. Lachmet-Teebaud, J. Wiedemann, O. Roth, L. Jacquemin, J. Levy CH Mulhouse, Cardiologie, Mulhouse, France *Corresponding author: [email protected] Introduction Recent results suggest that intracoronary (IC) bolus injection of adenosine provides better patient comfort and lower cost than standard intravenous (IV) injection. The extremely close correlation between FFR measurements with IV and IC adenosine is well established, however there is only
© Elsevier Masson SAS. All rights reserved.
14
Archives of Cardiovascular Diseases Supplements (2017) 9, 11-28
limited data which assesses the safety of IC administration compared with standard method. Purpose To compare the occurrence of side effects (SE) according to the adenosine injection method (IC or IV) during the evaluation of intermediate coronary stenosis by FFR. Methods From August 2015 to January 2016, we prospectively included all adult patients with at least 1 angiographically intermediate stenosis which underwent FFR assessment. The adenosine injection method and severe SE were recorded. Results During the study period, a total of 104 patients with 131 lesions were included (Table 1). Occurrences of SE between the IC group and the IV group were not significantly different, respectively 4 (7.1%) versus 6 (13.3%) SE, p=0.75. Multivariate analysis did not identified the IC injection as independently associated with the occurrence of an SE (OR 1.5; 95% CI 0.34-6.9; p=0.58). Conclusion These results suggest that IC adenosine is as safe as IV infusion. These data need to be verified on a larger sample. Data are expressed as mean±SD or number (%); BMI, body mass index; LM, left main; LAD, left anterior descending artery; LCX, circumflex artery; DG, diagonal branch; RCA, right coronary artery; IC, intracoronary; IV, intravenous.
Purpose study the incidence of contrast media induced nephropathy, major adverses events in patients with chronic kidney disease undergoing coronarography with our nephroprotection protocol. Methods all patients with chronic kidney disease undergoing coronarogrpahy between january 2014 and february 2016 were included. They all received a sodium bicarbonate solution (1mL/kg/h) and diuresis with matched hydratation with saline solution 12 or 24 hours before coronarography and 24 or 48 hours after, furosemide was added to allow a urine output over 150mL/hour. Contrast media induced nephropathy and major events incidence were analysed. Results Over 575 patients, 51 (8.8%) suffered from contrast media induced nephropathy, The latters had a creatinine clearance lower (45±11mL/min/1.73m² vs 48.4±8.7 11mL/min/1.73m²; p=0.034), recieved more contrast media (232±146mL vs 184±106 mL vs; p=0.036), suffered more from pulmonary congestion (9.8% vs 2.7%; p=0.02), died more (11.8% vs 1.15%; p<0.0001) than patients not affected. Our results compare favorably with those of the literature. Conclusion Contrast media induced nephropathy concerns 8.8% of the patients with chronic kidney disease and seems to led to high morbi mortality. Our protocol could give a better protection against this nephropathy comparatively with a standard hydratation with saline solution. Randomised studies must be led to confirm this hypothesis. The authors hereby declare no conflict of interest
The authors hereby declare no conflict of interest
746 718
Percutaneous coronary interventions with drug eluting stents in the elderly: the experience of a tertiary Tunisian cardiac center
Contrast media induced nephropathy prevention for patients at risk: matched diuresis evaluation
S. Charfeddine*, L. Abid, R. Hammami, I. Chamtouri, M. Baccouche, S. Mallek, A. Maalej, D. Abid, S. Kammoun Hôpital universitaire Hedi Chaker, Cardiologie, Sfax, Tunisie *Corresponding author: [email protected]
J. Dally GHICL, Cardiologie, Lomme, France *Corresponding author: [email protected] Background incidence of contrast media induced nephropathy is more frequent and potentially serious in case of chronic kidney disease.
Aims The prognostic impact of percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation in the elderly population with prolonged dual antiplatelet therapy is unclear. The aim of this study was to evaluate the safety and efficacy of DES implantation in the elderly.
Abstract 473 – Table: Clinical, angiographic and FFR characteristics
Age (years)
Study cohort N=104
With side effects N=10
Without side effects N=94
p value
68.1±10.4
64.8±13.2
68.4±10.1
0.40
Male sexe
74 (71)
7 (10)
67 (90)
0.59
BMI (kg/m2)
27.4±4.5
26.8±3.7
27.5±4.6
0.25
Hyperlipidemia
52 (50)
4 (8)
48 (92)
0.37
Hypertension
59 (57)
6 (10)
53 (90)
0.55
Diabetes mellitus
21 (20)
2 (10)
19 (90)
0.67
Smoking
35 (33)
1 (3)
34 (97)
0.21
Family history
10 (10)
1 (10)
9 (90)
0.65
Acute Coronary Syndrome
22 (21)
2 (9)
20 (91)
0.56
Positive stress test
58 (56)
5 (9)
53 (91)
Diagnostic coronarography
24 (23)
3 (13)
21 (87)
Risk factors
Indication
Target vessel
Adenosine administration
LM
6 (4)
0
6 (100)
0.41
LAD
70 (53)
10 (14)
60 (86)
0.03
LCX
27 (21)
3 (12)
24 (88)
0.72
DG
5 (4)
1 (20)
4 (80)
0.40
RCA
23 (18)
2 (9)
21 (91)
0.87
IC
70 (70)
5 (7)
65 (93)
0.32
IV Syntax Score
30 (30)
4 (13)
26 (87)
7.8±7.5
7.3±7.1
7.9±7.6
© Elsevier Masson SAS. All rights reserved.
0.82