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The Interventional Cardiology Training Manual pp 211–227Cite as

Physiologic Lesion Assessment: Fractional Flow Reserve

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Abstract

Patient outcome following percutaneous coronary intervention (PCI) is predominantly determined by three factors: clinical presentation, comorbidities, and decision-making process before, during, and after the PCI procedure. In order to justify any intervention, there needs to be reason to think that this will result in either (a) an improvement of symptoms, or (b) an improvement in prognosis, or (c) both. For the interventionalist, the skillful application of modern diagnostic tools and reference to the appropriate evidence base can facilitate delivery of optimal patient care. Coronary angiography has been used as a diagnostic tool for more than half a century. However, it is now well established that coronary angiography alone has important flaws and, in particular, can correlate poorly with the functional importance of a stenosis within the epicardial arteries. Further, the evidence base increasingly points to lesion-level ischemia as our target for revascularization. The availability of invasive physiological lesion assessment has revolutionized our ability to define with precision the presence or absence of lesion-level ischemia. The aim of this chapter is to review the evidence for and the expanding role of physiological lesion assessment in our everyday interventional practice.

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References

  1. Blows LJ, Redwood SR. The pressure wire in practice. Heart. 2007;93(4):419–22.

    Article  Google Scholar 

  2. Redwood S, Curzen N, Banning A. Oxford textbook of interventional cardiology. Oxford: Oxford University Press; 2010.

    Book  Google Scholar 

  3. Kern MJ, Lerman A, Bech JW, De Bruyne B, Eeckhout E, Fearon WF, et al. Physiological assessment of coronary artery disease in the cardiac catheterization laboratory: a scientific statement from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology. Circulation. 2006;114(12):1321–41.

    Article  Google Scholar 

  4. Hoffman JI, Spaan JA. Pressure-flow relations in coronary circulation. Physiol Rev. 1990;70(2):331–90.

    Article  CAS  Google Scholar 

  5. Jones CJ, Kuo L, Davis MJ, Chilian WM. Distribution and control of coronary microvascular resistance. Adv Exp Med Biol. 1993;346:181–8.

    Article  CAS  Google Scholar 

  6. Spaan JA, Cornelissen AJ, Chan C, Dankelman J, Yin FC. Dynamics of flow, resistance, and intramural vascular volume in canine coronary circulation. Am J Physiol Heart Circ Physiol. 2000;278(2):H383–403.

    Article  CAS  Google Scholar 

  7. De Bruyne B, Hersbach F, Pijls NH, Bartunek J, Bech JW, Heyndrickx GR, et al. Abnormal epicardial coronary resistance in patients with diffuse atherosclerosis but “normal” coronary angiography. Circulation. 2001;104(20):2401–6.

    Article  Google Scholar 

  8. Kaplan JA. Essentials of cardiac anesthesia. Philadelphia, PA: Saunders/Elsevier; 2008. http://www.sciencedirect.com/science/book/9781416037866

    Google Scholar 

  9. Longman K, Curzen N. Should ischemia be the main target in selecting a percutaneous coronary intervention strategy? Expert Rev Cardiovasc Ther. 2013;11(8):1051–9.

    Article  CAS  Google Scholar 

  10. Fearon WF, Shah M, Ng M, Brinton T, Wilson A, Tremmel JA, et al. Predictive value of the index of microcirculatory resistance in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2008;51(5):560–5.

    Article  Google Scholar 

  11. Pijls NH, van Schaardenburgh P, Manoharan G, Boersma E, Bech JW, van't Veer M, et al. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER study. J Am Coll Cardiol. 2007;49(21):2105–11.

    Article  Google Scholar 

  12. Tonino PA, De Bruyne B, Pijls NH, Siebert U, Ikeno F, van’ t Veer M, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009;360(3):213-224.

    Google Scholar 

  13. De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012;367(11):991–1001.

    Article  Google Scholar 

  14. Curzen N, Rana O, Nicholas Z, Golledge P, Zaman A, Oldroyd K, et al. Does routine pressure wire assessment influence management strategy at coronary angiography for diagnosis of chest pain?: the RIPCORD study. Circ Cardiovasc Interv. 2014;7(2):248–55.

    Article  Google Scholar 

  15. Barbato E, Toth G, Johnson N, et al. A prospective natural history study of coronary atherosclerosis using fractional flow reserve. J Am Coll Cardiol. 2016;68:2247–55.

    Article  Google Scholar 

  16. Redwood S, Curzen N, Thomas MR, editors. Coronary physiology in clinical practice. Chapter 9. In: Oxford Textbook Of Interventional Cardiology. Oxford: Oxford University Press.

    Google Scholar 

  17. Jeremias A, Filardo SD, Whitbourn RJ, Kernoff RS, Yeung AC, Fitzgerald PJ, et al. Effects of intravenous and intracoronary adenosine 5′-triphosphate as compared with adenosine on coronary flow and pressure dynamics. Circulation. 2000;101(3):318–23.

    Article  CAS  Google Scholar 

  18. Niccoli G, Banning AP. Heparin dose during percutaneous coronary intervention: how low dare we go? Heart. 2002;88(4):331–4.

    Article  CAS  Google Scholar 

  19. Pijls NH, De Bruyne B, Peels K, Van Der Voort PH, Bonnier HJ, Bartunek JKJJ, et al. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med. 1996;334(26):1703–8.

    Article  CAS  Google Scholar 

  20. Wolfrum M, Fahrni G, de Maria GL, Knapp G, Curzen N, Kharbanda RK, et al. Impact of impaired fractional flow reserve after coronary interventions on outcomes: a systematic review and meta-analysis. BMC Cardiovasc Disord. 2016;16(1):177.

    Article  Google Scholar 

  21. Daniels DV, van't Veer M, Pijls NH, van der Horst A, Yong AS, De Bruyne B, et al. The impact of downstream coronary stenoses on fractional flow reserve assessment of intermediate left main disease. JACC Cardiovasc Interv. 2012;5(10):1021–5.

    Article  Google Scholar 

  22. Ntalianis A, Sels J, Davidavicius G, et al. Fractional flow reserve for the assessment of nonculprit coronary artery Stenoses in patients with acute myocardial infarction. J Am Coll Cardiol Interv. 2010;3:1274–81.

    Article  Google Scholar 

  23. Engstrom T, Kelbaek H, Helqvist S, Hofsten DE, Klovgaard L, Holmvang L, et al. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3-PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015;386(9994):665–71.

    Article  Google Scholar 

  24. Ahmed N, Layland J, Carrick D, Petrie MC, McEntegart M, Eteiba H, et al. Safety of guidewire-based measurement of fractional flow reserve and the index of microvascular resistance using intravenous adenosine in patients with acute or recent myocardial infarction. Int J Cardiol. 2016;202:305–10.

    Article  Google Scholar 

  25. Layland J, Oldroyd KG, Curzen N, Sood A, Balachandran K, Das R, et al. Fractional flow reserve vs. angiography in guiding management to optimize outcomes in non-ST-segment elevation myocardial infarction: the British Heart Foundation FAMOUS-NSTEMI randomized trial. Eur Heart J. 2015;36(2):100–11.

    Article  Google Scholar 

  26. Sant’Anna FM, Silva EE, Batista LA, Ventura FM, Barrozo CA, Pijls NH. Influence of routine assessment of fractional flow reserve on decision making during coronary interventions. Am J Cardiol. 2007;99(4):504–8.

    Article  Google Scholar 

  27. Baptista SB, Raposo L, Santos L, et al. Impact of routine fractional flow reserve evaluation during coronary angiography on management strategy and clinical outcome: one-year results of the POST-IT. Circ Cardiovasc Interv. 2016;9(7):e003288.

    Article  Google Scholar 

  28. Nakamura M, Yamagishi M, Ueno T, et al. Modification of treatment strategy after FFR measurement: CVIT-DEFER registry. Cardiovasc Interv Ther. 2015;30(1):12–21.

    Article  Google Scholar 

  29. Van Belle E, Rioufol G, Pouillot C, et al. Outcome impact of coronary revascularization strategy reclassification with fractional flow reserve at time of diagnostic angiography: insights from a large French multicenter fractional flow reserve registry. Circulation. 2014;129(2):173–85.

    Article  Google Scholar 

  30. Tonino PA, Fearon WF, De Bruyne B, et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J Am Coll Cardiol. 2010;55(25):2816–21.

    Article  Google Scholar 

  31. Toth G, Hamilos M, Pyxaras S, et al. Evolving concepts of angiogram: fractional flow reserve discordances in 4000 coronary stenoses. Eur Heart J. 2014;35(40):2831–8.

    Article  Google Scholar 

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Authors and Affiliations

  1. Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK

    Mohammad Sahebjalal & Nicholas Curzen

  2. Faculty of Medicine, University of Southampton, Southampton, UK

    Nicholas Curzen

Authors
  1. Mohammad Sahebjalal
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  2. Nicholas Curzen
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Correspondence to Nicholas Curzen .

Editor information

Editors and Affiliations

  1. Brighton and Sussex Medical School and the Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK

    Aung Myat

  2. Royal Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK

    Sarah Clarke

  3. Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK

    Nick Curzen

  4. Department of Cardiology, Bern University Hospital, Bern, Switzerland

    Stephan Windecker

  5. Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA

    Paul A. Gurbel

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Sahebjalal, M., Curzen, N. (2018). Physiologic Lesion Assessment: Fractional Flow Reserve. In: Myat, A., Clarke, S., Curzen, N., Windecker, S., Gurbel, P.A. (eds) The Interventional Cardiology Training Manual. Springer, Cham. https://doi.org/10.1007/978-3-319-71635-0_15

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  • DOI: https://doi.org/10.1007/978-3-319-71635-0_15

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-71633-6

  • Online ISBN: 978-3-319-71635-0

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