FFR in specific circumstances

Zsolt Piróth MDGottsegen György Hungarian Institute of Cardiology

Specific circumstances

• Ostial lesions

• Left main coronary artery disease

• Sequential lesions

• Diffusely diseased vessels

• Bifurcations

Technical note on ostial & LM lesions

i. Equilibrate guide and wire pressures in the aorta, not in the coronary

ii. Advance PW across the lesion

iii. Unseat the guiding catheter from the ostium

iv. Induce steady state hyperemia (iv ado, no ic ado!)

FFR in LM lesions

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Patient flow chart

Patient enrollment in the study. From 1999 to 2007, 274 patients with equivocal LMCA underwent pressure measurements in our center. Excluded were 26 patients with protected LMCA stenosis, 10 with concomitant valvular disease requiring surgery, and 25 with stenoses in arteries other than the LMCA that required surgery. Thus, 213 patients were included, 4 of whom (2 in each group) were lost during follow-up (FU). Finally, 136 patients in the nonsurgical and 73 in the surgical group were included in the analysis. For purposes of comparison, 2 other groups of patients also were studied (but are not shown): 70 patients with a left main stenosis of 70% by visual estimate (who underwent CABG).

Circulation 2009; 120: 1505-1512

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Circulation 2009; 120: 1505-1512

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Circulation 2009; 120: 1505-1512

Correlation of FFR & DS

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Circulation 2009; 120: 1505-1512

Do you think this LM is significant?

Circulation 2009; 120: 1505-1512

Do you think this LM is significant?

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Circulation 2009; 120: 1505-1512

Copyright © 2009 Wolters Kluwer. 10

Circulation 2009; 120: 1505-1512

FFR in serial stenoses (1)i. Place the wire distal to the most distal lesion

ii. Induce steady state hyperemia (iv ado, ic pap)

iii. Start pull-back under fluoroscopy establishing sudden increases in pressure

iv. If local increases of > 10 mmHg are present, stenting may be considered

v. Generally the most severe spot is stented first, pull-back should be repeated thereafter to check the remaining lesions

FFR in serial stenoses (2)i. Sometimes, for technical reasons the most distal

lesion is stented first

ii. Stenting a severe lesion may increase the gradient across another

iii. Make a final pull-back to check the stents and the remaining artery

iv. Stenting segments w/ a gradient < 10 mmHg does not make much sense – inability of PCI to „cure” diffuse disease

FFR in side branches

1. The angio cut-off value for (jailed) side branches is 75% DS

2. 70% of the SB are hemodynamically OK after stenting of the MB

3. No “FFR late loss” at 6 months whether or not kissing is performed...

Side Side bbranches: much ado about nothingranches: much ado about nothing

JACC 2005; 46: 633-637