Pressure-Derived Fractional Flow Reserve to Assess Serial Epicardial Stenoses

Bruyne, Bernard De; Pijls, Nhj Nico; Heyndrickx, Gr.; Hodeige, D; Kirkeeide, R. L.; Gould, K. Lance

doi:10.1161/01.cir.101.15.1840

Cited by 253 publications

(162 citation statements)

References 25 publications

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“…Therefore even trivial stenoses or diffuse disease have the capacity to confound hyperemic assessments pressure assessments. [73][74][75][76] In the resting state, resting coronary flow is preserved despite the presence of even severe stenoses; 39 this suggests a transtenotic pressure drop distal to a stenosis will be resultant only from stenoses proximal to the pressure sensor with less confounding from distal disease. If iFR-Pullback is performed, all the gradients in the vessel can be determined to quantify the severity of each lesion in the vessel.…”

Section: Discussionmentioning

confidence: 99%

Advances in Coronary Physiology

Nijjer

Sen

Petraco

et al. 2015

Circ J

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Pressure-wire technology, most typically fractional flow reserve (FFR), has provided interventional cardiologists with a means of determining the physiological importance of a stenosis during angiography. There has been renewed interest in coronary physiology in the light of guideline recognition, ongoing clinical research and new technologies changing the paradigm of how assessment is performed in the catheter laboratory. We reflect on FFR, with regards the potential effects of changing hemodynamics on FFR and the latest evidence with regards to outcomes. We also review the instantaneous wave-free ratio (iFR), a new pressure-only index, measured at rest, that is under active evaluation in several international randomized controlled trials. We review the accumulated evidence and discuss the important physiological concepts between pressure and flow that underlie the approach to using resting indices. Finally we investigate future developments, including physiological mapping with iFR-Pullback and the potential to predict the hemodynamic effect of stenting. (Circ J 2015; 79: 1172 -1184

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Section: Discussionmentioning

confidence: 99%

Advances in Coronary Physiology

Nijjer

Sen

Petraco

et al. 2015

Circ J

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“…However, the flow through the LMCA stenosis in the presence of a 2nd (and in-series) stenosis in the LAD would be submaximal because of tandem-lesion physiology. 6 After our intervention on the LAD stenosis in series, the FFR of the LMCA stenosis dropped again to the ischemic range-a phenomenon explained by the fact that the recruitment of more myocardium leads to greater volume of blood flow through the stenosis. Finally, the uneventful LMCA stenting was accomplished with the help of Impella support, after adequate peripheral access conduits had been established.…”

Section: Discussionmentioning

confidence: 93%

Effect of Revascularization of Chronic Total Occlusion on Tandem Stenoses in a “Donor” Artery

Sachdeva¹

2014

Texas Heart Institute Journal

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I n multivessel coronary artery disease (CAD), noninvasive testing usually underestimates the extent of ischemia-more so when one of the lesions is a chronic total occlusion (CTO). Ischemia, regardless of the method by which it is diagnosed, is a major determinant of outcomes in CAD. We present a case of multivessel CAD wherein the determination of fractional flow reserve (FFR) was useful in revealing the evidence of ischemia, thereby resolving the ambiguity of a stenosis. Case ReportAn 82-year-old man presented with acute onset of dyspnea and chest pain. His history included chronic obstructive pulmonary disease (emphysema and bronchitis), chronic kidney disease, depression, chronic atrial fibrillation, hypertension, congestive heart failure, and intermittent claudication after walking about 10 yards. A year before the current presentation, he had undergone implantation of a biventricular automatic implantable cardioverter-defibrillator (AICD) for symptomatic congestive heart failure, after medical therapy had failed. A dipyridimole nuclear stress test performed before AICD insertion showed an inferior infarction without ischemia (Fig. 1), and the patient's echocardiogram showed severe diffuse global hypokinesis, with a left ventricular ejection fraction (LVEF) of 0.15.He was hospitalized and diagnosed with myocardial infarction (peak troponin I level, 5.04 ng/mL). After his medical management was optimized, the patient underwent coronary angiography. This showed 40% stenosis of the distal left main coronary artery (LMCA) and 80% stenosis (in tandem) of the left anterior descending coronary artery (LAD), with septal collateral vessels (Fig. 2) from the "donor" LAD to an occluded right coronary artery (RCA) (Fig. 3). He also had occlusion of the right external iliac artery and 70% stenosis of the left external iliac artery, with ankle-brachial indices of 0.45 and 0.8, respectively.Before making a decision to perform coronary revascularization, we performed a fractional flow reserve (FFR) procedure on the intermediate stenosis in the LMCA. The FFR was 0.58 with the transducer distal to the LAD stenosis, and 0.73 with the transducer between the LMCA and LAD stenoses. Case ReportsRajesh Sachdeva, MD

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“…For serial stenoses a more complex equation, which takes into account the pressure between the two stenoses and the wedge pressure, can be used to determine the true FFR of each lesion separately. 14,15 Normally the diameter of coronary arteries gradually declines in proportion to the myocardial mass to be perfused. Therefore, mean coronary flow velocity is the same throughout the epicardial coronary system and thus the site where flow velocity is measured has no impact on the v-dp relation.…”

Section: Discussionmentioning

confidence: 99%

Characteristics of the flow velocity-pressure gradient relation in the assessment of stenoses: an in vitro study

Marques¹,

Westerhof²

2008

NHJL

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Objectives. The flow velocity-pressure gradient (v-dp) relation is clinically used to assess coronary stenoses. This in vitro study aimed to investigate the ability to determine the impact of each individual stenosis in the setting of two consecutive stenoses, the effect of variable stenosis reference diameters and the impact of one or two wires in a stenosis, on the v-dp relation. Methods. The model consisted of a reservoir and different sized tubes and stenoses. Pressure gradient and flow velocity were assessed with a pressure and a Doppler wire. By plotting flow velocity and pressure gradient on an X-Y plot, the v-dp relation was determined. Results. The v-dp relation of a proximal stenosis was not influenced by a distal stenosis. The diameter of the segment where flow velocity was measured influenced the v-dp relation. This could be corrected by substituting flow velocity with volume flow. The presence of one or two wires in a stenosis made the v-dp relation substantially steeper. Conclusions. The v-dp relation can be used to determine the significance of each individual stenosis in arteries with consecutive stenoses, provided that the distance between the stenoses is large enough. The diameter of the segment where flow velocity is measured and the presence of one or two wires substantially affect the v-dp relation. (Neth Heart J 2008;16:156-62.)

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Pressure-Derived Fractional Flow Reserve to Assess Serial Epicardial Stenoses

Cited by 253 publications

References 25 publications

Advances in Coronary Physiology

Advances in Coronary Physiology

Effect of Revascularization of Chronic Total Occlusion on Tandem Stenoses in a “Donor” Artery

Characteristics of the flow velocity-pressure gradient relation in the assessment of stenoses: an in vitro study

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