Skip to main content

Advertisement

Log in

Fractional Flow Reserve: A Practical Update

  • Published:
Current Cardiovascular Imaging Reports Aims and scope Submit manuscript

Abstract

This article serves as a practical update on the performance and clinical application of fractional flow reserve (FFR) in the evaluation of intermediate coronary stenoses. We review several methods for the induction of hyperemia, viability after myocardial infarction, the impact of diabetes, and the use of FFR in myocardial bridging. New data on the correlation of FFR with noninvasive imaging in multivessel disease are presented. Additionally, we touch on the growing body of FFR-guided revascularization trials.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance•• Of major importance

  1. Detre KM, Wright E, Murphy ML, Takaro T: Observer agreement in evaluating coronary angiograms. Circulation 1975, 52:979–986.

    CAS  PubMed  Google Scholar 

  2. Fischer JJ, Samady H, McPherson JA, et al.: Comparison between visual assessment and quantitative angiography versus fractional flow reserve for native coronary narrowings of moderate severity. Am J Cardiol 2002, 90:210–215.

    Article  PubMed  Google Scholar 

  3. De Bruyne B, Baudhuin T, Melin JA, et al.: Coronary flow reserve calculated from pressure measurements in humans. Validation with positron emission tomography. Circulation 1994, 89:1013–1022.

    PubMed  Google Scholar 

  4. Pijls NH, van Son JA, Kirkeeide RL, et al.: Experimental basis of determining maximum coronary, myocardial, and collateral blood flow by pressure measurements for assessing functional stenosis severity before and after percutaneous transluminal coronary angioplasty. Circulation 1993, 87:1354–1367.

    CAS  PubMed  Google Scholar 

  5. Pijls NH, Van Gelder B, Van der Voort P, et al.: Fractional flow reserve. A useful index to evaluate the influence of an epicardial coronary stenosis on myocardial blood flow. Circulation 1995, 92:3183–3193.

    CAS  PubMed  Google Scholar 

  6. Pijls NH, De Bruyne B, Peels K, et al.: Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med 1996, 334:1703–1708.

    Article  CAS  PubMed  Google Scholar 

  7. Inoue T, Asahi S, Takayanagi K, et al.: Qt prolongation and possibility of ventricular arrhythmias after intracoronary papaverine. Cardiology 1994, 84:9–13.

    Article  CAS  PubMed  Google Scholar 

  8. van der Voort PH, van Hagen E, Hendrix G, et al.: Comparison of intravenous adenosine to intracoronary papaverine for calculation of pressure-derived fractional flow reserve. Cathet Cardiovasc Diagn 1996, 39:120–125.

    Article  PubMed  Google Scholar 

  9. •Lindstaedt M, Bojara W, Holland-Letz T, et al.: Adenosine-induced maximal coronary hyperemia for myocardial fractional flow reserve measurements: Comparison of administration by femoral venous versus antecubital venous access. Clin Res Cardiol 2009, 98:717–723. This is a comparison of femoral versus antecubital adenosine for the induction of hyperemia. It highlights an alternative and potentially more convenient route of administration.

    Article  CAS  PubMed  Google Scholar 

  10. Jeremias A, Whitbourn RJ, Filardo SD, et al.: Adequacy of intracoronary versus intravenous adenosine-induced maximal coronary hyperemia for fractional flow reserve measurements. Am Heart J 2000, 140:651–657.

    Article  CAS  PubMed  Google Scholar 

  11. Casella G, Leibig M, Schiele TM, et al.: Are high doses of intracoronary adenosine an alternative to standard intravenous adenosine for the assessment of fractional flow reserve? Am Heart J 2004, 148:590–595.

    Article  CAS  PubMed  Google Scholar 

  12. Yoon MH, Tahk SJ, Yang HM, et al.: Comparison of the intracoronary continuous infusion method using a microcatheter and the intravenous continuous adenosine infusion method for inducing maximal hyperemia for fractional flow reserve measurement. Am Heart J 2009, 157:1050–1056.

    Article  CAS  PubMed  Google Scholar 

  13. De Bruyne B, Pijls NH, Bartunek J, et al.: Fractional flow reserve in patients with prior myocardial infarction. Circulation 2001, 104:157–162.

    PubMed  Google Scholar 

  14. Samady H, Lepper W, Powers ER, et al.: Fractional flow reserve of infarct-related arteries identifies reversible defects on noninvasive myocardial perfusion imaging early after myocardial infarction. J Am Coll Cardiol 2006, 47:2187–2193.

    Article  PubMed  Google Scholar 

  15. Marques KM, Knaapen P, Boellaard R, et al.: Hyperaemic microvascular resistance is not increased in viable myocardium after chronic myocardial infarction. Eur Heart J 2007, 28:2320–2325.

    Article  PubMed  Google Scholar 

  16. • Beleslin B, Ostojic M, Djordjevic-Dikic A, et al.: The value of fractional and coronary flow reserve in predicting myocardial recovery in patients with previous myocardial infarction. Eur Heart J 2008, 29:2617–2624, This article evaluates the ability of FFR to assess the presence of hibernating myocardium after myocardial infarction, compared with traditional measures of viability.

    Article  PubMed  Google Scholar 

  17. Sahinarslan A, Kocaman SA, Olgun H, et al.: The reliability of fractional flow reserve measurement in patients with diabetes mellitus. Coron Artery Dis 2009, 20:317–321.

    Article  PubMed  Google Scholar 

  18. Verna E, Ceriani L, Giovanella L, et al.: “False-positive” myocardial perfusion scintigraphy findings in patients with angiographically normal coronary arteries: Insights from intravascular sonography studies. J Nucl Med 2000, 41:1935–1940.

    CAS  PubMed  Google Scholar 

  19. Yanagisawa H, Chikamori T, Tanaka N, et al.: Application of pressure-derived myocardial fractional flow reserve in assessing the functional severity of coronary artery stenosis in patients with diabetes mellitus. Circ J 2004, 68:993–998.

    Article  PubMed  Google Scholar 

  20. Kini AS, Kim MC, Moreno PR, et al.: Comparison of coronary flow reserve and fractional flow reserve in patients with versus without diabetes mellitus and having elective percutaneous coronary intervention and abciximab therapy (from the predict trial). Am J Cardiol 2008, 101:796–800.

    Article  PubMed  Google Scholar 

  21. Fearon WF, Balsam LB, Farouque HMO, et al.: Novel index for invasively assessing the coronary microcirculation. Circulation 2003, 107:3129–3132.

    Article  PubMed  Google Scholar 

  22. Fearon WF, Aarnoudse W, Pijls NHJ, et al.: Microvascular resistance is not influenced by epicardial coronary artery stenosis severity: Experimental validation. Circulation 2004, 109:2269–2272.

    Article  PubMed  Google Scholar 

  23. Ng MKC, Yeung AC, Fearon WF: Invasive assessment of the coronary microcirculation: Superior reproducibility and less hemodynamic dependence of index of microcirculatory resistance compared with coronary flow reserve. Circulation 2006, 113:2054–2061.

    Article  PubMed  Google Scholar 

  24. Christian TF, Miller TD, Bailey KR, Gibbons RJ: Noninvasive identification of severe coronary artery disease using exercise tomographic thallium-201 imaging. Am J Cardiol 1992, 70:14–20.

    Article  CAS  PubMed  Google Scholar 

  25. Ragosta M, Bishop AH, Lipson LC, et al.: Comparison between angiography and fractional flow reserve versus single-photon emission computed tomographic myocardial perfusion imaging for determining lesion significance in patients with multivessel coronary disease. Am J Cardiol 2007, 99:896–902.

    Article  PubMed  Google Scholar 

  26. •Förster S, Rieber J, Ubleis C, et al.: Tc-99m sestamibi single photon emission computed tomography for guiding percutaneous coronary intervention in patients with multivessel disease: A comparison with quantitative coronary angiography and fractional flow reserve. Int J Cardiovasc Imaging 2010, 26:203–213, This article compares the predictive power of sestamibi nuclear perfusion and FFR/QCA in guiding multivessel revascularization with complex coronary disease.

    Article  PubMed  Google Scholar 

  27. Melikian N, De Bondt P, Tonino P, et al.: Fractional flow reserve and myocardial perfusion imaging in patients with angiographic multivessel coronary artery disease. JACC Cardiovasc Interv 2010, 3:307–314.

    Article  PubMed  Google Scholar 

  28. Beller GA, Ragosta M: Decision making in multivessel coronary disease: The need for physiological lesion assessment. JACC Cardiovasc Interv 2010, 3:315–317.

    Article  PubMed  Google Scholar 

  29. De Rosa R, Sacco M, Tedeschi C, et al.: Prevalence of coronary artery intramyocardial course in a large population of clinical patients detected by multislice computed tomography coronary angiography. Acta Radiol 2008, 49:895–901.

    Article  PubMed  Google Scholar 

  30. Ge J, Erbel R, Rupprecht HJ, et al.: Comparison of intravascular ultrasound and angiography in the assessment of myocardial bridging. Circulation 1994, 89:1725–1732.

    CAS  PubMed  Google Scholar 

  31. Bourassa MG, Butnaru A, Lespérance J, Tardif JC: Symptomatic myocardial bridges: Overview of ischemic mechanisms and current diagnostic and treatment strategies. J Am Coll Cardiol 2003, 41:351–359.

    Article  PubMed  Google Scholar 

  32. Hazenberg AJC, Jessurun GAJ, Tio RA: Mechanisms involved in symptomatic myocardial bridging: Value of sequential testing for endothelial function, flow reserve measurements and dobutamine stress angiography. Neth Heart J 2008, 16:10–15.

    CAS  PubMed  Google Scholar 

  33. Escaned J, Cortés J, Flores A, et al.: Importance of diastolic fractional flow reserve and dobutamine challenge in physiologic assessment of myocardial bridging. J Am Coll Cardiol 2003, 42:226–233.

    Article  PubMed  Google Scholar 

  34. Hakeem A, Cilingiroglu M, Leesar MA: Hemodynamic and intravascular ultrasound assessment of myocardial bridging: Fractional flow reserve paradox with dobutamine versus adenosine. Catheter Cardiovasc Interv 2010, 75:229–236.

    Article  PubMed  Google Scholar 

  35. Pijls NHJ, van Schaardenburgh P, Manoharan G, et al.: Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the defer study. J Am Coll Cardiol 2007, 49:2105–2111.

    Article  PubMed  Google Scholar 

  36. Legalery P, Schiele F, Seronde MF, et al.: One-year outcome of patients submitted to routine fractional flow reserve assessment to determine the need for angioplasty. Eur Heart J 2005, 26:2623–2629.

    Article  PubMed  Google Scholar 

  37. Meuwissen M, Chamuleau SAJ, Siebes M, et al.: The prognostic value of combined intracoronary pressure and blood flow velocity measurements after deferral of percutaneous coronary intervention. Catheter Cardiovasc Interv 2008, 71:291–297.

    Article  PubMed  Google Scholar 

  38. ••Tonino PAL, De Bruyne B, Pijls NHJ, et al.: Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009, 360:213–224, This is the first randomized trial to address FFR versus angiography for guiding PCI in multivessel disease.

    Article  CAS  PubMed  Google Scholar 

  39. Alderman EL, Bourassa MG, Cohen LS, et al.: Ten-year follow-up of survival and myocardial infarction in the randomized coronary artery surgery study. Circulation 1990, 82:1629–1646.

    CAS  PubMed  Google Scholar 

  40. Boden WE, O’Rourke RA, Teo KK, et al.: Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007, 356:1503–1516.

    Article  CAS  PubMed  Google Scholar 

Download references

Disclosure

No potential conflicts of interest relevant to this article were reported.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to William F. Fearon.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Daniels, D.V., Fearon, W.F. Fractional Flow Reserve: A Practical Update. curr cardiovasc imaging rep 3, 215–221 (2010). https://doi.org/10.1007/s12410-010-9030-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12410-010-9030-z

Keywords

Navigation