Coronary Physiology for

Interventional Cardiology
Boards
Morton J. Kern, MD
Professor of Medicine
Chief of Cardiology LBVAH
Associate Chief Cardiology
University California Irvine
Orange, California
Braunwalds Heart Disease, 7
th
Edition
Control of Coronary Blood Flow
R1
R2
R3
1. CFR = max flow/basal flow and decreases with increasing
stenosis (R1) severity.
2. CFR may also be reduced with abnormal microvasculature
The limitation: Because there are 2 components, CFR cannot
distinguish between an epicardial stenosis and an impaired
microcirculation.
Aortic Pressure, PA
Coronary wire pressure, Pd
Aortic Pressure, PA
Coronary wire pressure, Pd
The rationale for using coronary physiology is the inability of
the angiogram to accurately depict lesion characteristics
limiting flow.
75% Dia
20% Dia
1
2
3
4,5,6
7
P
d
Morphologic factors producing Pressure Loss across a stenosis
Energy loss due to friction, separation,
turbulence.
Energy is taken out as heat and pressure loss
results.
The loss of distal pressure is related to the blood
flow rate
Pressure and flow move on a curvelinear line
1 2 3
Aortic, Pa
Coronary, Pd
FFR= Pd/Pa = 65/90 = 0.72
Adenosine
Resting pressures
Hyperemic pressures
Doses for Vasodilatory Agents
Adenosine Adenosine Papaverine NTP
Route IV IC IC IC
Dosage 140
mcg/kg/min
40-60 mcg LCA
20-30 mcg RCA
15 mg LCA
10 mg RCA
50-100 mcg
T 1/2 1 2 min 30-60 sec 2 min 1-2min
Time to max 1 2 min 5-10 sec 30 - 60 sec 10-20sec
Advantage Gold
Standard
Short action Short action Short action
Disadvantage BP by 10-
15%, Chest
burning
AV delay, BP Torsades,
severe BP
BP by 10-
15%
P
a
P
d
NHJ Pijls et al. Circulation 1993
2. Resistance=P/Q
3. Flow, Q=P/R
4. Qs/Qn = (Pd/Rs)
(Pa/Rn)
5. If Rs = Rn, then
Qs/Qn = Pd/Pa, hence
6. FFR= Pd/Pa, at max
hyperemia
1. First Principle:
Aortic pressure, Pa, is the same
along the length of the normal
vessel.
Myocardial flow (Qs) across
stenosis/myocardial flow (Qn)
without stenosis = FFR
Pressure
5
4
3
2
1
FFR=
Q
s
Q
N
max
max
Q
s
Q
N
Q
base
Q
s
Q
base
max
CFR=
Differences between FFR and CFR
Single anatomic parameters do
not predict FFR with confidence
IVUS v FFR
Comparison of Physiologic Indices
Hemo Microvasc Normal Ischemic Assess
Independ Independ Value Threshold Collaterals
CFR - - -- >2.0 +
IMR/HSR+ + 1.0 (>0.8) -
FFR + + 1.0 (>0.8) +
Application FFR
Ischemia detection, >15 studies Pos <0.75
Neg >0.80
Deferred angioplasty, >8 studies
(Key Study: Defer)
>0.75
Multivessel FFR guided PCI, LM
(Key Study: FAME)
(Key Study: Hamilos for LM)
>0.80
Endpoint of stenting
*(IVUS better post stent)
>0.94*
Coronary Physiologic (FFR) Criteria and
Clinical Outcome Studies
62 yo Man, RCA stent occl 2yr ago with return of CP
LAD FFR=0.86, 0.87
Now 1V CAD and
new approach
JACC 2007;49:2105
DEFER Study 5 year data
JACC
2007;49:2105
Q: What happens when you bypass normal FFR stenoses?
A: High Occlusion rate of SVG/LIMA of vessels with non-
ischemic FFR
Botman CJ et al Ann Thorac Surg 2007;83:20937
20% occluded SVGs ,FFR >0.80
RW. 59 yo man with Angina, inferior perf defect
3V CAD CABG vs PCI?
FFR=0.71
2 Questions
How Accurate is Stress Test?
If PCI needed, FFR directed?
JACC 2010;56:177
FAME study: Death and MI after 2 Years
10
0
5
2 year
12.7
8.4
%
FFR-guided
Angio-guided
P= 0.03
9.5
6.1
P= 0.03
2 year(exclusion of small
periprocedural infarction)
Tonino et al, NEJM 2009, Pijls et al, JACC 2010
Death or MI
MI
-5000
-4000
-3000
-2000
-1000
0
1000
2000
3000
4000
5000
-0.075 -0.050 -0.025 0.000 0.025 0.050 0.075
Increm. QALY
I
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.

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FFR Guidance Improves outcomes
FFR Guidance
Saves Resources
ICER of 50,000 $ / QALY
Incremental
QALY
FFR Guidance
Improves Outcomes
FFR Guidance
Saves
Resources
I
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DES
CABG
ROTO
BMS
Balloon
Economic Evaluation of
FFR-guided PCI in pts with
MVD.
Fearon WF et al. Circ
2010;122:25450-2550
FAME: Angiography vs FFR
Tonino, P. A. L. et al. J Am Coll Cardiol 2010;55:2816-2821
Angiographic 3- or 2-Vessel Disease does NOT equal Physiologic 3- or 2V CAD
3V CAD Angio = 14% physiol 2V CAD Angio= 43% physiol
Nam, C.-W. et al. J Am Coll Cardiol 2011;58:1211-1218
FFR in Multivessel PCI reduces the ischemic Burden:
Functional (FFR+) Syntax Score
SYNTAX Score FSS Score
Angiogram
Angiogram
Distal LAD Guide catheter
Distal LAD Guide catheter
Focal Stenosis
Diffuse disease
Differentiating Focal from Diffuse Disease
DeBruyne et al, Circulation 2001 104: 2401 - 2406.
Diffused CAD can produce abnormal FFR in the
absence of epicardial stenoses
1
2
3
4
Serial Lesions and FFR
Pressure pull back to assess lesion significance
FFRb=Pd/Pm FFRa=Pm/Pa
FFR(a+b)=Pd/Pa
Distal to Proximal Pull back
Gradient across Lesion #3
Final FFR=0.88
Stent in lesion #3
FFR and Acute MI
Culprit vessel not for >5 days [De Bruyne et al,
Circulation 2001]
Pijls and Sels, JACC 2012;59:1045
FFR and Acute MI
Non-Culprit vessel
FFR probably valid at
any stage
Ntalianis et al, JACC Int 2010;3:1274
Myocardial Mass and Flow affect FFR
explaining a visual-functional mismatch
56 yo M exertional angina mid LAD stenosis (red arrow)
Iqbal, M. B. et al. Circ Cardiovasc Interv 2010;3:89-90
IMR=Pa*Tmn [(PdPw)/(PaPw)]
HSRv=Pa-Pv/APVhyper
Characterizing the microcirculation
Physiologic explanations
Small perfusion territory, MI, abundant collaterals, severe
microvascular disease (rarely affecting FFR)
Technical explanations
Insufficient hyperemia
Guiding catheter (deep engagement, small ostium,sideholes)
Electrical drift
Actual false negative FFR
Acute phase of ST elevation myocardial infarction
Severe left ventricular hypertrophy
Exercise-induced spasm
From Koolen JJ and Pijls NHJ, Coronary Pressure Never Lies CCI;72:248;2008
Reasons of False Negative FFR
Artifact causing false negative FFR:
Guide Catheter Damping
FFR and CFR for the Interventional
Cardiologist
Key Points
1. Anatomy (also IVUS) does NOT equal physiology,
especially for Intermediate lesions.
2. Adenosine, IV (140mcg/kg/min) or IC (RCA 20-30mcg;
LCA 40-100mcg), stimulates maximal hyperemia, i.e.
minimal resistance required to measure FFR.
3. CFR measures both R1 conduit (stenosis) and R2
microvascular flow. Non-ischemic value >2.0. Use for
microvascular disease assessment only.
FFR and CFR for the Interventional Cardiologist
Key Points
4. FFR (Pd/Pa at hyperemia) is independent of
microvascular and hemodynamic status. FFR is
specific for stenosis resistance. Non-ischemic value
>0.80.
5. FFR does not address adequacy of stent implantation
(use IVUS).
6. Compared to angiography alone, FFR identifies best
treatment approach (DEFER and FAME).
7. FFR not used in ACS due to dynamic conditions but
can be used after several days.
Class IIa Guidelines - ACC/ AHA/ SCAI
Class IA Guidelines - ESC
Use of FFR
ESC Guidelines = 1A
ACC/AHA/SCAI guidelines = 2A