pressure wire evaluation of the left main stem dr phil maccarthy consultant cardiologist king’s...
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Pressure Wire Evaluation of Pressure Wire Evaluation of the Left Main Stemthe Left Main Stem
Dr Phil MacCarthyDr Phil MacCarthy
Consultant CardiologistConsultant Cardiologist
King’s Cardiac CentreKing’s Cardiac Centre
Left Main 5+ at AA2007, Jan 24th, 2007.
No conflicts of interestNo conflicts of interest
Assessment of critical LMS Assessment of critical LMS disease is sometimes easy…disease is sometimes easy…
A more common clinical A more common clinical scenarioscenario
How do you currently establish the
haemodynamic importance of a LMS
lesion?Surgery!
The stakes are high…The stakes are high…
The angiogram is a 2D The angiogram is a 2D representation of a complex 3D representation of a complex 3D
structurestructure
Topol and Nissen, Circulation 1995
Correlation between LMS Correlation between LMS anatomy and physiologyanatomy and physiology
Jasti et al, Circulation 2004
Studies of LMS FFR vs Studies of LMS FFR vs OutcomeOutcome
ReferenceReference nn FFR<0.FFR<0.7575
FFR>0.FFR>0.7575
(Deferr(Deferred)ed)
F/UF/U(mont(mont
hs)hs)
MortalitMortality in y in
deferredeferred groupd group
Bech et alBech et al Heart 2001Heart 2001 5454 3030 2424 2929 00
Jimenez-Jimenez-Navarro et Navarro et
alal
J Inv CardiolJ Inv Cardiol20042004
2727 77 2020 2626 00
Jasti et alJasti et al CirculationCirculation20042004
5555 1414 4141 3838 3 (all 3 (all non-non-
cardiac)cardiac)
Suemaru Suemaru et alet al
Heart Heart VesselsVessels20052005
1515 77 88 32.532.5 00
Legutko et Legutko et alal
Kardiol PolKardiol Pol20052005
3838 1818 2020 2424 00
Lindstaedt Lindstaedt et alet al
Am Heart JAm Heart J20062006
5151 2727 2424 2929 00
54 patients with equivocal LMS stenosis – FFR>0.75 in 24 (medical), FFR<0.75in 30 (CABG)
Bech et al Heart 2001; 86: 547
Jasti et al, Circulation 2004
51 patients – 24 FFR>0.75 treated medically, 27 FFR<0.75 treated surgically
Lindstaedt et al, Am Heart J 2006; 152: 156
Left main disease in the Left main disease in the stable patientstable patient
Case 1 - StableCase 1 - Stable
Case 1 - StableCase 1 - Stable
Case 2 - StableCase 2 - Stable
Case 2 - StableCase 2 - Stable
Pressure-wire study LMSPressure-wire study LMS FFR 0.88 – No significant step-up on FFR 0.88 – No significant step-up on
hyperaemic pull-backhyperaemic pull-back
Proceed to PCI of RCA CTO….Proceed to PCI of RCA CTO….
Case 2 - StableCase 2 - Stable
Left main disease in acute Left main disease in acute coronary syndromescoronary syndromes
Case 1 - UnstableCase 1 - Unstable
Case 1 - UnstableCase 1 - Unstable
Case 2 - UnstableCase 2 - Unstable
Case 2 - UnstableCase 2 - Unstable
5.5mm2
Case 2 - UnstableCase 2 - Unstable
Practical TipsPractical Tips
Intravenous, centrally administered Intravenous, centrally administered adenosineadenosine
Guide catheter Guide catheter engagement/dampingengagement/damping
Beware distal diseaseBeware distal disease
Differing FFRs in the LAD and CxDiffering FFRs in the LAD and Cx
Intravenous Infusion of Adenosine 140 µg/kg/minIntravenous Infusion of Adenosine 140 µg/kg/min
Adenosine IV Femoral
Pull-back under maximal Pull-back under maximal hyperaemiahyperaemia
Practical TipsPractical Tips
Intravenous, centrally administered Intravenous, centrally administered adenosineadenosine
Guide catheter Guide catheter engagement/dampingengagement/damping
Beware distal diseaseBeware distal disease
Differing FFRs in the LAD and CxDiffering FFRs in the LAD and Cx
3 mm3 mm
3 mm3 mm
3 mm3 mm 1.8 mm1.8 mm
2.1 mm2.1 mm
2.4 mm2.4 mm64%64%
49 %49 %
36 %36 %
AreaAreaStenosisStenosis
8F8F
7F7F
6F6F
Guiding Catheter in Ostium = StenosisGuiding Catheter in Ostium = Stenosis
Practical TipsPractical Tips
Intravenous, centrally administered Intravenous, centrally administered adenosineadenosine
Guide catheter Guide catheter engagement/dampingengagement/damping
Beware distal diseaseBeware distal disease
Differing FFRs in the LAD and CxDiffering FFRs in the LAD and Cx
PPaa
BB
AA
PPmm
PPdd
FFR(A)FFR(A)predpred = =PPdd - (P - (Pmm/P/Paa) P) Pww
PPaa - P - Pmm + P + Pdd -P -Pww
FFR(B)FFR(B)predpred = = (P(Paa - P - Pww) (P) (Pm m - P- Pdd))
PPaa (P (Pmm - P - Pww))
PPww == Coronary occlusive pressureCoronary occlusive pressure De Bruyne et al, Circulation 2000
Practical TipsPractical Tips
Intravenous, centrally administered Intravenous, centrally administered adenosineadenosine
Guide catheter Guide catheter engagement/dampingengagement/damping
Beware distal diseaseBeware distal disease
Differing FFRs in the LAD and CxDiffering FFRs in the LAD and Cx
FFR = 0.90
FFR = 0.63
ConclusionsConclusions
Pressure wire assessment of the LMS Pressure wire assessment of the LMS is technically easyis technically easy
Medical treatment when the Medical treatment when the FFR>0.75 seems safeFFR>0.75 seems safe
Use central, iv adenosine and Use central, iv adenosine and disengage the guide catheter before disengage the guide catheter before measuringmeasuring
Beware underestimating FFR with Beware underestimating FFR with downstream diseasedownstream disease