1. BSCK II HUỲNH NGỌC LONG VIỆN TIM TP.HCM
Khi nào nong động mạch vành trên bệnh nhân đau ngực ổn định với tổn thương hẹp lớn hơn 70% ?
BSCK II HUỲNH NGỌC LONG
VIỆN TIM TP.HCM

2. NONG MẠCH VÀNH DỰA VÀO 1-Đau ngực 2-Test chức năng (+) không xâm lấn.
3-Số nhánh hẹp
4-Anatomy thích hợp nong ( Syntax score).

3. TRƯỜNG HỢP 1: ĐIỂN HÌNH 1-Đau ngực 2-Test không xâm lấn (+) 3
TRƯỜNG HỢP 1: ĐIỂN HÌNH 1-Đau ngực 2-Test không xâm lấn (+) 3.Hẹp ≥70% 4-Syntax ≤ 22 NONG
TEST KHÔNG XÂM LẤN
LÚC NGHĨ
GẮNG SỨC
1-ECG
2-Siêu âm
3-Scinti

4. COURAGE: Study design
AHA/ACC Class I/II indications for PCI, suitable coronary artery anatomy + ≥70% stenosis in ≥1 proximal epicardial vessel + objective evidence of ischemia (or ≥80% stenosis + CCS class III angina without provocation testing)
Optimal medical therapy* + PCI (n = 1149)
Optimal medical therapy* (n = 1138)
Randomized
Primary outcomes: All-cause mortality, nonfatal MI
COURAGE: Study design
Secondary outcomes: Death, MI, stroke; ACS hospitalization
COURAGE was a multicenter trial of patients with documented ischemia and angiographically confirmed single or multivessel CAD:
Stenosis of at least 70% in at least one proximal epicardial artery and objective evidence of myocardial ischemia
One coronary stenosis of at least 80% and classic angina without provocative testing
A total of 2287 patients were randomized to a strategy of PCI plus optimal medical therapy (ie, intensive pharmacologic therapy plus lifestyle intervention) (n = 1149) or optimal medical therapy alone (n = 1138).
The primary outcome was death from any cause and nonfatal MI.
The secondary outcome was a composite of death, nonfatal MI, and stroke.
The median follow-up period was 4.6 years.
Follow-up: Median 4.6 years
*Intensive pharmacologic therapy + lifestyle intervention CCS = Canadian Cardiovascular Society
Boden WE et al. Am Heart J. 2006;151: Boden WE et al. N Engl J Med. 2007;356:

5. Freedom from Angina in COURAGE
We based the assumption that the change in utility in the FFR-Guided PCI arm would last 3 years on data from COURAGE which showed that the improvement in angina with PCI ended at 3 years.
Weintraub, et al. New Engl J Med 2008;359: 5

6. TRƯỜNG HỢP 2: KHÔNG ĐAU NGỰC 2-Test chức năng (+) 3
TRƯỜNG HỢP 2: KHÔNG ĐAU NGỰC 2-Test chức năng (+) 3.Hẹp ≥70% 4-Syntax ≤ 22
CÓ NÊN NONG KHÔNG ?

7. DUKE TREADMILL SCORE
DTSDuke treadmill 1-score >=+5 Low 2-Score +4 to -10 Moderate 3-Score <= -11 High risk

8. DUKE TREAMILL SCORE TIÊN LƯỢNG TỬ VONG
DTS Risk Category
1-Yr Mortality
No Stenosis >=75%
1 VD >=75%
2 VD >=75%
3VD >=75% or LM >=75%
Men
   Low  
0.9%
52.6%
22.4%
13.6%
11.4%
   Mod  
2.9%
17.8%
15.6%
27.9%
38.7%
   High
8.3%
1.8%
9.1%
17.5%
71.5%
Women
0.5%
80.9%
9.4%
6.2%
3.5%
1.1%
65.1%
14.2%
12.4%
10.8%
18.9%
24.3%
46%
VD = Vessel Disease;  LM = Left Main    

9. ACIP: Study design
Angiographic CAD (≥50% stenosis in ≥1 major vessel or branch) suitable for revascularization + ischemia during exercise or pharmacologic stress testing and ≥1 asymptomatic episode during 48-hr AECG
Angina-guided strategy (n = 183)
Ischemia-guided strategy (n = 183)
Revascularization strategy (n = 192)
ACIP: Study design
Primary outcome: Absence of ischemia at 12 weeks Secondary outcomes: Death, MI, recurrent hospitalization for cardiac disease, nonprotocol revascularization at 1 and 2 years
The target population in the Asymptomatic Cardiac Ischemia Pilot (ACIP) study was clinically stable patients with angiographically documented CAD suitable for revascularization.
Eligible patients had ischemia during exercise or pharmacologic stress testing and at least 1 episode of silent ischemia during 48-hour ambulatory Holter monitoring.
Subjects were randomized to one of three strategies:
Angina-guided strategy: During the first 4 weeks of the study, subjects in this group received open-label medical therapy (combinations of atenolol and sustained release formulations of nifedipine, diltiazem, and isosorbide dinitrate) to control angina. During the subsequent 8 weeks, they also received placebo.
Ischemia-guided strategy: Treatment during the first 4 weeks was the same as for the angina-guided group. However, during the subsequent 8 weeks this group received intensified therapy if silent ischemia was detected on ambulatory monitoring.
Revascularization strategy: Subjects received percutaneous transluminal coronary angioplasty or CABG to achieve the most complete revascularization possible. Open-label medication was also permitted to control angina as necessary.
The primary endpoint was ischemia at 12 weeks, but subjects were followed for up to 2 years for secondary endpoints.
Pepine CJ et al. J Am Coll Cardiol. 1994:24:1-10. Davies RF et al. Circulation. 1997;95:
Asymptomatic Cardiac Ischemia Pilot

10. ACIP: Two-year cumulative all-cause mortality rates
558 patients , functionally significant stenosis without
symptoms: randomization in 3 treatments strategies
8 %
Cumulative Mortality
6.6%
4.1%
Medical treatment 6
No treatment 4
For instance the ACIP trial which studied over 500 patients with moderate angina but with additional documented signs of silent ischemia. They were randomly assigned either a immediate revascularization startegy, or to a strategy in which revascularization was performed only in case of persistend ischemia or of persistent anginal complaints; well we see that if in our patient we choose for this strategy or this one we impose the patient a 4 to 6-fold incraesed risk of mortality. This is not a soft end-point like recurrent angina of the need for revascularization, this is death.
P < 0.05 2
1.1%
Revascularization
mos
Davies et al, Circulation, 1997 40

11. SWISSI II: Study design
Recent first MI with asymptomatic myocardial ischemia on exercise testing and 1- or 2-vessel coronary disease suitable for PCI
PCI (n = 96)
Randomized, unblinded
Anti-ischemic therapy* (n = 105)
Primary outcomes: Cardiac death, nonfatal MI, symptom-driven revascularization
SWISSI II: Study design
The Swiss Interventional Study on Silent Ischemia Type II (SWISSI II) was similar to ACIP.
This study randomized patients to PCI (without stenting) or to anti-ischemic therapy (dosed to eliminate or maximally reduce silent ischemia during bicycle ergometry).
All patients also received aspirin 100 mg daily and a statin.
The primary endpoint was survival free of major adverse CV events (cardiac death, nonfatal MI, or symptom-driven coronary revascularization).
There was a mean follow-up of 10.2 years.
The trial was not blinded.
Follow-up: 10.2 years (mean)
*Nitrates, β-blockers, CCBs
All patients also received aspirin and statin
Swiss Interventional Study on Silent Ischemia Type II
Erne P et al. JAMA. 2007;297:

12. SWISSI II: Baseline characteristics
PCI
Anti-ischemic therapy
Age (years)
54.4
56.2
Female (%)
11.5
13.3
Diabetes (%)
9.4
Hypertension (%)
44.8
Dyslipidemia (%)
75.0
58.1
Family history of CAD (%)
40.0
Smoking (%)
72.9
74.3
SWISSI II: Baseline characteristics
The SWISSI II population was younger than the ACIP population (55 years vs 61 years, respectively).
There was a slightly higher proportion of hypertensive patients and a much higher proportion of smokers in the SWISSI trial.
Erne P et al. JAMA. 2007;297:

13. SWISSI II: Treatment effect on primary outcome
SWISSI II: THEO DÕI 15 NĂM
1.00
PCI
0.75
Event-free survival
0.50
Drug therapy
0.25
P < 0.001*
SWISSI II: Treatment effect on primary outcome 5 10 15
During the 10.2-year mean follow-up, the primary endpoint occurred in 28% and 64% of the PCI and anti-ischemic therapy groups, respectively (adjusted HR 0.33, 95% CI , P < 0.001).
Time from randomization (years)
*Log-rank
Erne P et al. JAMA. 2007;297:

14. ACIP, SWISSI II: Summary and implications
1-ACIP: In patients with documented CAD + symptomatic and asymptomatic ischemia, PCI compared with anti-ischemic or antianginal therapy reduced 2-year risk of major CV events
2-SWISSI II extended these finding to post-MI patients with asymptomatic ischemia and a longer 10-year follow-up
ACIP, SWISSI II: Summary and implications
ACIP demonstrated that in patients with documented CAD and both symptomatic and asymptomatic ischemia, coronary revascularization reduced the 2-year risk of major CV events compared with antianginal and anti-ischemic therapy.
SWISSI II extended these findings to post-MI patients with asymptomatic ischemia.
However, the risk factor management and interventions in both trials reflected strategies current in the 1990s. Based on current guidelines, risk factor management was not optimal.
Davies RF et al. Circulation. 1997;95:
Erne P et al. JAMA. 2007;297:

15. TRƯỜNG HỢP 2: KHÔNG ĐAU NGỰC 2-Test chức năng (+) 3
TRƯỜNG HỢP 2: KHÔNG ĐAU NGỰC 2-Test chức năng (+) 3.Hẹp ≥70% 4-Syntax ≤ 22
NÊN NONG

16. TRƯỜNG HỢP 3: 1-Có đau ngực 2-Có test chức năng (+)
3-Giải phẩu thích hợp, syntax score ≤22.
4-Nhưng tổn thương hẹp trung bình 50-70%
CÓ NÊN NONG KHÔNG ?

17. HẸP 50% LAD, NÊN NONG KHÔNG ? 1-Nam 56 Tuổi 2-Đau ngực điển hình
3-Duke score= -2
4-Nguy cơ trung bình, nguy cơ tử vong 1 năm=2,9%

18. TƯƠNG TỰ CÁCH ĐẶT VẤN ĐỀ CỦA DEPER STUDY
female, 58-y-old
underwent PCI of severe LCX lesion a minute before
50 % stenosis in mid RCA
Should this lesion be stented ??
158 vb38/interm.RCA/Buddem (1)

19. prospective randomized multicentric trial
The DEFER Study: Design
prospective randomized multicentric trial
(14 centers) in 325 patients with stable
chest pain and an intermediate stenosis
without objective evidence of ischemia
Aalst
Amsterdam
Eindhoven
Essen
Gothenborg Hamburg
Liège
Maastricht
Madrid
Osaka
Rotterdam
Seoul
Utrecht
Zwolle
data collection & analysis:
Jan Willem Bech, MD, PhD
Pepijn van Schaardenburgh, MD

21. THE DEFER STUDY: RANDOMIZATION
deferral of PCI
performance of PCI
1 : 1 randomization
If FFR < performance anyway
reference group
If FFR > randomization followed
defer PCI perform PCI

22. The DEFER Study: Catheterization
6 or 7 F guiding catheter for measurement of
aortic pressure ( Pa)
QCA from 2 orthogonal views
Coronary pressure measurement (Pd ) by
0.014” pressure wire (Radi Medical Systems)
Maximum hyperemia by i.v. adenosine (140 ug/kg/min)
Calculation of Fractional Flow Reserve by:
FFR = Pd / Pa

23. The DEFER Study: Base line data
Randomized to Randomized to
Deferral of PTCA Performance of PTCA
N= N=158
Age, (yr) 62 10
Female sex (%)
Ejection Fraction (%) 67 9
Diabetes (%)
Hypertension (%)
Hyperlipidemia (%)
Current Smoker (%)
Family History CAD (%)

24. The DEFER Study: Baseline QCA and FFR
Ref. diam. (mm) ± ± 0.57
MLD (mm) ± 0.40
DS (%) ± 10
1.42 ± 0.38
52 ± 11
Randomized to Randomized to
Deferral of PTCA Performance of PTCA
N= N=158
FFR 0.19
0.730.19
All baseline characteristics were identical between both groups

25. DEFER: Clinical Outcome at 5 Years
FFR ≥0.75
FFR<0.75
Defer
Perform
Reference
Number of patients 91 90
144
Lost to follow-up
Cardiac Death(%)
3 (3.3)
2 (2.3)
8 (6.0)
Non Cardiac Death(%)
3 (3.3)
3 (3.4)
4 (3.0)
Q wave MI (%)
4 (4.5)
6 (4.5)
Non-Q wave MI(%)
1 (1.1)
7 (5.2)
CABG(%)
1 (1.1)
4 (4.5)
14 (10.4)
TLR(%)
8 (8.9)
8 (9.1)
18 (13.4)
11 (8.2)
6 (6.8)
6 (6.7)
Non-TLR(%)
Other (%)
1 (1.1)
2 (1.5)
Total events 21 29 70
52 (39 %)
24 (27 %)
19 (21 %)
Patients ≥1 event (%)
Pts free of angina(%)
68 %
58 %
72 %

27. Cardiac Death And Acute MI After 5 Years
P< 0.03 % 20
P< 0.005
15.7 15
P=0.20 10
7.9 5
3.3
DEFER PERFORM REFERENCE
FFR > FFR < 0.75

29. The risk for death or acute myocardial infarction in the next five years is 20 times higher for an ischemic lesion compared to a non-ischemic lesion !!! 8
12000 Patients
( 2 x 6000)
similar stenosis
severity by
coronary angio 7
7.4 6 5
% death or Acute MI 4 3 2 1
0.6
no ischemia ischemia
Iskander S, Iskandrian A E JACC 1998

30. FFR LÀ TEST CHỨC NĂNG XÂM LẤN QUAN TRONG
1-Một nhánh, hẹp trung bình 50-70%
2-Có đau ngực
3-Không có test không xâm lấn
Nhưng bù lại, có FFR ≤ 0.75
NÊN NONG

31. HẸP 50% LAD 1-Nam 56 Tuổi 2-Đau ngực điển hình 3-Duke score= -2
4-Nguy cơ tử vong 1 năm=2,9%.
Làm thêm FFR ≤ 0.75 Nong
FFR >0.75Nguy cơ tử vong < 1%/năm

32. TRƯỜNG HỢP 3: 1-Có đau ngực 2-Hẹp trung bình 50-70%.
3-FFR ≤ 0.75 test chức năng xâm lấn
NÊN NONG

33. FFR LÀ GÌ ? Fractional Flow Reserve
THIẾU MÁU CƠ TIM ?
1- ECG gắng sức, Siêu âm
dobutamin, Scintigraphi
 “mất cân bằng cung/cầu”
2-FFR Giảm lưu lượng trong mạch vành thủ phạm

34. LƯU LƯỢNG MÁU TRONG MẠCH VÀNH
1-Tương tự định luật Ohm trong dòng điện:
U=R.I I= U/R
2-Lưu lượng mạch máu Q= Pressure/Resistance
TỈ LỆ LƯU LƯỢNG MÁU SAU
VÀ TRƯỚC CHỖ HẸP
3-Q sau/Q trước= Psau/P trước=FFR

35. CÁCH THỰC HIỆN FFR 1-Đo trạng thái bình thường
2-Đo sau khi chích adenosin (140 ug/kg/min) vào mạch vành.
3-FFR ≤ 0.80  Lưu lượng máu sau chỗ hẹp đã giảm 20%.
4-FFR ≤ 0.75 Lưu lượng máu sau chỗ hẹp đã giảm 25%.

37. FFR =TRƯỚC + BÀNG HỆ + VI TUẦN HOÀN

40. FFR ESC GUIDELLINE 2008
Class I A

41. TRƯỜNG HỢP 4: Hẹp nhiều nhánh và lan tỏa

42. ECG GẮNG SỨC, SIÊU ÂM DOBUTAMIN, SCINTIGRAPHI
KHÓ XÁC ĐỊNH:
1-Mạch nào thủ phạm
2-Đoạn nào cần nong
NÊN DÙNG FFR

43. FAME 2 STUDY Fractional Flow Reserve (FFR) vs
FAME 2 STUDY Fractional Flow Reserve (FFR) vs. Angiography in Multivessel Evaluation

44. FAME 2: FFR-Guided PCI versus Medical Therapy in Stable CAD
Available on-line on Aug 28, 2012 on

45. Background
1-The FAME 2 trial, multicenter, international, randomized study comparing fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) to best medical therapy (MT) in patients with stable coronary disease.
2-The study was stopped early because of a significantly higher rate of the composite endpoint of death, MI and urgent revascularization in patients assigned to MT.
Read 45

46. Stable patients with 1, 2, or 3 vessel CAD evaluated for PCI with DES
Trial Design
Stable patients with 1, 2, or 3 vessel CAD evaluated for PCI with DES
n=1220
FFR in all target lesions
At least 1 stenosis with FFR ≤ 0.80 (n=888)
Randomization 1:1
PCI + MT MT
Randomized Trial
All FFR > 0.80
(n=322) MT
Registry
50% randomly assigned to follow-up
The FAME 2 trial included stable patients with single, double or triple vessel coronary disease being evaluated for PCI with DES. This study was different from previous trials evaluating PCI in patients with stable CAD in that FFR was first measured across all lesions. By doing this, patients with angiographically significant CAD, but not hemodynamically significant (and therefore unlikely to be responsible for symptoms or to cause a future event) were not included in the randomized study. On the other hand, patients who did have at least one lesion in a major epicardial vessel with an FFR ≤0.80 were included, ensuring a significant ischemic burden in those randomized to FFR-Guided PCI or to MT. The primary endpoint was D, MI, or urgent revasc at 2 years.
Primary Endpoint: Death, MI, Urgent Revascularization at 2 years 46

47. Baseline Characteristics
Angio-Guided n = 496
FFR- Guided n = 509
P Value
Age, mean ±SD
64±10
65±10
0.47
Male, % 73 75
0.30
Diabetes, % 25 24
0.65
Hypertension, % 66 61
0.10
Current smoker, % 32 27
0.12
Hyperlipidemia, % 72
0.62
Previous MI, % 36 37
0.84
NSTE ACS, % 29
0.11
Previous PCI , % 26
0.34
LVEF, mean ±SD
57±12
57±11
0.92
LVEF < 50% , %

48. FAME study: Procedural Results (1)
ANGIO-group
N=496
FFR-group
N=509
P-value
# indicated lesions per patient
2.7 ± 0.9
2.8 ± 1.0
0.34
FFR results
Lesions succesfully measured, No (%) -
1329 (98%)
Lesions with FFR ≤ 0.80 ,No (%)
874 (63%)
Lesions with FFR > 0.80 ,No (%)
513 (37%)
FFR in ischemic lesions
0.60 ± 0.14
FFR in non-ischemic lesions
0.88 ± 0.05

49. FAME study: Procedural Results (2)
ANGIO-group
N=496
FFR-group
N=509
P-value
Procedure time (min)
70 ± 44
71 ± 43
0.51
Contrast agent used (ml)
302 ± 127
272 ± 133
<0.001
Materials used at procedure
(US $)
6007
5332

50. Procedural Characteristics
Angio-Guided n = 496
FFR- Guided n = 509
P Value
Indicated lesions / patient
2.7±0.9
2.8±1.0
0.34
Stents / patient
2.7 ± 1.2
1.9 ± 1.3
<0.001

51. Trial Results % FFR-Guided PCI (n=447) MT (n=441) P-Value
Primary Endpoint
4.3
12.7
<0.001
Death
0.2
0.7
0.31
Myocardial Infarction
3.4
3.2
0.89
Urgent Revascularization
1.6
11.1
Free from Angina (1 month) 71 48 %
The study was stopped early after 888 patients were included and after a mean follow-up of 7 months. There was a highly significant difference in the primary endpoint with 12.7% of the MT patients reaching it and 4.3% of the FFR-Guided PCI patients reaching it. There was no difference in death or MI, but a highly significant difference in urgent revascularization and freedom from angina favoring the FFR-guided PCI group. This raises the question of whether this benefit is worth the cost of up front FFR-guided PCI in all patients with stable coronary disease.
De Bruyne, et al. New Engl J Med 2012;367: 51

52. FAME study: Adverse Events at 1 year
ANGIO-group
N=496
FFR-group
N=509
P-value
Events at 1 year, No (%)
Death, MI, CABG, or repeat-PCI
91 (18.4)
67 (13.2)
0.02
Death
15 (3.0)
9 (1.8)
0.19
Death or myocardial infarction
55 (11.1)
37 (7.3)
0.04
CABG or repeat PCI
47 (9.5)
33 (6.5)
0.08
Total no. of MACE
113 76
Myocardial infarction, specified
All myocardial infarctions
43 (8.7)
29 (5.7)
0.07
Small periprocedural CK-MB 3-5 x N 16 12
Other infarctions (“late or large”) 27 17
In the patients whose care was guided by FFR, fewer stents were used (2.7±1.2 and 1.9±1.3, respectively). After one year, the primary endpoint of death, nonfatal myocardial infarction, and repeat revascularization were lower in the FFR group (13.2% versus 18.3%). There also was a non-significant higher number of patients of residual angina sufferers (81% versus 78%). In the FFR group, hospital stay was slightly shorter (3.4 vs 3.7 days) and procedural costs were less ($5,332 vs $6,007). FFR did not prolong procedure (around 70 minutes in both groups).

53. 1 Year Event-Free Survival
Absolute Difference in MACE-Free Survival
FFR-guided
Angio-guided
30 days
2.9%
90 days
3.8%
180 days
4.9%
360 days
5.1%

54. 1 Year Economic Evaluation
Bootstrap Simulation
Angio
Less
Costly
Angio Better FFR Better
QALY
FFR
Less
Costly
USD

55. Adverse Events at 2 Years
Angio-Guided n = 496
FFR- Guided n = 509
P Value
Total no. of MACE
139
105
Individual Endpoints
Death
19 (3.8)
13 (2.6)
0.25
Myocardial Infarction
48 (9.7)
31 (6.1)
0.03
CABG or repeat PCI
61 (12.3)
53 (10.4)
0.35
Composite Endpoints
Death or Myocardial Infarction
63 (12.7)
43 (8.4)
Death, MI, CABG, or re-PCI
110 (22.2)
90 (17.7)
0.07

56. 2 Year Survival Free of MACE
FFR-Guided
Angio-Guided
730 days
4.5%

57. 2 Year Survival Free of Repeat Revascularization
FFR-Guided
Angio-Guided
730 days
1.9%

58. 2 Year Survival Free of MI
FFR-Guided
Angio-Guided
730 days
3.6%

59. 2 Year Survival Free of Death/MI
FFR-Guided
Angio-Guided
730 days
4.3%

60. Other 2 Year Outcomes Follow-up (%) 92.7 94.5 0.31
Angio-Guided n = 496
FFR- Guided n = 509
P Value
Follow-up (%)
92.7
94.5
0.31
Anti-anginal Medications, No.
1.2 ±0.8
1.2 ±0.7
0.66
Dual Antiplatelet Therapy (%)
33.6
31.4
0.49
Freedom from Angina, (%)
75.8
79.9
0.14

61. FAME study: CONCLUSIONS (1)
Routine measurement of FFR during PCI with DES
in patients with multivessel disease, when
compared to current angiography guided strategy,
furthermore:
is cost-saving and does not prolong the procedure
reduces the number of stents used
decreases the amount of contrast agent used

62. FAME study: CONCLUSIONS (2)
Routine measurement of FFR during PCI with DES
in patients with multivessel disease, when
compared to current angiography guided strategy
reduces the rate of the composite endpoint of
death, myocardial infarction, re-PCI and CABG
at 1 year by ~ 30% và kêt quả được duy trì đến 2 năm
reduces mortality and myocardial infarction at
1 year by ~ 35 %

63. Outcome of Deferred Lesions
513 Deferred Lesions in
509 FFR-Guided Patients
2 Years 22
Peri-procedural
31 Myocardial Infarctions 8
Due to a New Lesion
or Stent-Related 9
Late Myocardial Infarctions
Only 1/513 or 0.2% of deferred
lesions resulted in a late
myocardial infarction 1
Myocardial Infarction due to
an Originally Deferred Lesion

64. Outcome of Deferred Lesions
513 Deferred Lesions in
509 FFR-Guided Patients
2 Years 37
in a New Lesion or
in a Restenotic One
53 Repeat Revascularizations 6
Without FFR or
Despite an FFR > 0.80 16
Originally Deferred Lesions
Only 10/513 or 1.9% of deferred
lesions clearly progressed
requiring repeat revascularization 10
Originally Deferred Lesions
with Clear Progression

65. TRƯỜNG HỢP 4: Hẹp nhiều nhánh và lan tỏa nên dùng FFR xác định chỗ cần nong

66. CHIẾN LƯỢC CHỌN MỔ BẮC CẦU HAY NONG ?

67. 3 Year MACE in Patients With 3 VD AND LM in the SYNTAX trial

68. Results For Each SYNTAX Tercile
Cumulative 3-Year Incidence of MACE in Patients With 3-Vessel CAD in the SYNTAX trial
Results For Each SYNTAX Tercile
GNL 2011

70. CHỌN MỔ BẮC CẦU HAY NONG ?
1-Tiểu đường 2-Bệnh thận mạn 3-Tái lưu thông hoàn toàn hay không ? 4-Chức năng thất trái 5-Tiền sử mổ bắc cầu trước 6-Khả năng uống 2 thuốc chống kết tập tiểu cầu 7-Bệnh phổi tắc nghẽn-Tai biến mạch não
GNL 2011

71. Heart Team Approach to UPLM or Complex CAD
Anatomic Setting
COR
LOE
UPLM or Complex CAD
I – Heart Team Approach C
IIa – Calculation of the STS and SYNTAX scores B
GNL 2011

73. IVUS TƯƠNG ĐƯƠNG VỚI FFR

77. TÓM TẮT 1-Đau ngực + Test (+) + Hẹp ≥ 70%Nong
2-Không đau ngực + Test (+) Nong.
3-Hẹp trung bình 50-70%FFR ≤0.75 (+)
4- 3 nhánh, lan tỏa, thân chung FFR ≤0.80 (+) Syntax score, Euro scoreBàn luận phẩu thuật viên và bệnh nhân để quyết định
5-FFR, IVUS, VOLCANAL, OTC là test chức năng xâm lấn, giúp trong trường hợp phức tạp.