Fractional Flow Reserve

Interventional Conference
 Fundamentals
• Supply and Demand Equation of normal
coronary physiology:

– Myocardial Flow will increase to meet demand

and is influenced by:
• Heart Rate
• LV wall stress
• Contractility
 Fundamentals
• Sources of perfusion of a vessel:
– Epicardial
– Myocardial
– Collaterals
As per equation
stenosis physiology
is very flow
dependent
 Coronary Flow Reserve
• Doppler guidewire
sends out 12-15MHz
signal reflecting off
moving Red Cells
• Measures velocities
rather than actual flow –
changes in vessel
diameter therefore
become important

Adenosine given
 CFR Definition:
Coronary Flow
Reserve
=
Ratio of maximal
Flow / resting Flow

Hyperemic to Resting flow ratio and

normally greater > 2
 CFR
• Normal CFR implies that resistances
across epicardial vessels and
microcirculation are low (normal)

• An abnormal CFR is therefore unable to

distinguish microvascular impedance to
epicardial impedance due to
atherosclerotic disease
Relative Coronary Flow Reserve
Ratio of 2 CFR = One in a target vessel/One in a normal vessel
Assumes basal flow is similar and therefore eliminates effect of the
microcirculation
Also derived by separate doppler measurements
Assumes normal vessel is truly “normal”, therefore clinically not very useful
 Intra-Coronary FFR
• Lesions produce energy loss by friction,
separation and turbulance
• Energy is taken out as heat and pressure
loss occurs
FFR=
Maximal Flow in Target artery / Flow in the same artery before the stenosis

Derived by pressure distal to the stenosis and aorta at the time of maximal
hyperemia induced by adenosine
FFR differs from FFR is unaffected by hemodynamics
CFR in 3 ways
Increased contractility increases
CFR

FFR is
unaffected by
systemic
pressure
FFR is unaffected by changing
Hypertension the basal flow parameters
decreases
CFR
Tachycardia will increase
CFR
 Drugs used to induce hyperemia
Drug Dose Onset ½ Life Side E.
Papaverine 15mg LCA 30 – 60 s 2 min QT prolong
IC 10mg RCA TdP

Adenosine 140mcg/kg/ 60 - 120 s 1 – 2 min Hypotension Avoid in

IV min CP asthma

Adenosine >30µ LCA 5 – 10s 0.5 – 1 min AV Block in Repeated in

IC 24-36µ RCA dominant escalating
artery doses
Dobutamine 20 - 40 µ 60 -120 s 3 – 5 min Tachycardia
IV g/kg/min Elev. BP

Nitroprussid 0.3-0.9 µg/kg 20 s 1 min Dec. BP

e IC
FFR vs. IVUS vs. Spect
 Conclusion
• FFR is comparable to IVUS and SPECT
imaging
• FFR < 0.75:
– Specificity 100%
– Sensitivity 88%
– PPV 100%
– Accuracy 93%
Radi Wire
Handling characteristic almost similar
to standard guidewires

Compatible with monorail balloon

catheter systems
Intermediate lesions with
Normal FFR
Importance of lesion assessment
Mild Angiographic disease
with positive FFR
 Angiographically unremarkable
LAD in patient with angina

Area with significant

FFR reduction identified
with pressure wire
assessment
Serial Stenosis and Diffuse
Disease
 FFR in Distal Vessels with Diffuse
FFR can help
Disease
identify the patient
with diffuse
disease, that
cannot be treated
with intervention but
may have
significant diffuse
disease.

This may explain

some positive
stress findings in
the absence of
obvious epicardial
disease.
Multiple sequential lesions:
Can be assessed by a gradual pull back
and guide intervention
Illustrated are a significant step up at the
distal and proximal stenosis
Mibi Spect is usually unable to differentiate
between severe stenosis in a single vessel
 Multivessel Disease
• Number of small studies examined tailored
approach selective PCI for
hemodynamically significant stenosis +
medical therapy vs. CABG
• After 2 years follow up no difference in
event free survival with decreased repeat
revascularization compared to standard
trials
Considerations
FFR = 0.94
 FFR with ostial lesions
• No indication for stenting for ostial lesions
with normal FFR
• Many case reports on FFR measurements
in jailed sidebranches after bifurcation
stenting
• No studies on the validity of FFR in this
lesion subset
FFR for Stent Deployment
-FFR does not help with stent implantation is because the stent implantation relies
on the anatomic structures surrounding the stent.

-However, FFR does provide prognosis and can identify gross under deployment in
many patients.