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Cardiology
Application of Intracoronary Physiology Use of Pressure and Flow Measurements
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
18 sections · 167 slides
Overview
- Scope of this presentation
Limits of Coronary Angiography
- Revascularisation and its limits
- The angiogram as a two-dimensional lumenogram
- Eccentric stenosis seen in different radiographic projections
- Angiographic artefacts that degrade interpretation
Development of Coronary Physiology
- Origins of the pressure-flow model
- Quantitative angiography and early stent haemodynamics
- Doppler wire and coronary flow reserve
- Pressure wire, FFR and iFR
- Trial development of iFR and angiography-derived indices
- Origin and development of coronary physiology
Determinants of Coronary Blood Flow
- Layers of the epicardial coronary artery
- Endothelial regulation of vascular tone
- Autoregulation at the tissue level
- Mechanisms of endothelial autoregulation
- Factors that adversely affect coronary blood flow
- Atherosclerosis and resistance to myocardial flow
- Epicardial artery size and myocardial mass
- Flow, pressure and resistance relationships
- Distal coronary pressure as an unequivocal reference
- Phasic coronary flow during the cardiac cycle
- Multifactorial control of myocardial blood flow
- Two-compartment model of the coronary circulation
- Compensation and exhaustion of coronary flow reserve
- Schematic of coronary blood flow pathways
- Comparison of Fractional Flow Reserve ( Ffr ) and Coronary Flow Reserve ( Cfr )
Physiological Indices of the Coronary Circulation
- Which indices are in everyday use
- Comparison of Coronary Physiological Indices
- Coronary Physiologic Measurements in the Catheterization Lab
- Coronary Physiologic Measurements in the Catheterization Lab (continued)
- Coronary Physiologic Measurements in the Catheterization Lab: Measurement Principle
- Coronary Physiologic Measurements in the Catheterization Lab: Measurement Principle (continued)
- Coronary Physiologic Measurements in the Catheterization Lab: Clinical Application
- Coronary Physiologic Measurements in the Catheterization Lab: Clinical Application (continued)
- Definition of coronary flow reserve
- Reproducibility and haemodynamic dependence of CFR
- Normal values and confounders of CFR
- Conceptual limitations of coronary flow reserve
- Definition of fractional flow reserve
- Validation basis of fractional flow reserve
- Myocardial, coronary and collateral FFR
- Simplification to the Pd/Pa ratio
- Properties that make FFR lesion-specific
- Experimental proof of haemodynamic independence
- Interpreting the numerical value of FFR
Technique of Intracoronary Sensor Wire Use
- Sensor wires and guiding catheters
- Zeroing and sensor position
- Pressure output connector ports and power indicator
- Console controls for equalising and zeroing distal and aortic pressure
- Doppler flow velocity signal acquisition
- Steps in fractional flow reserve measurement
- Pressure pullback to localise disease
- Step-by-step diastolic hyperaemia-free ratio and fractional flow reserve study
Pharmacologic Hyperaemia
- Requirement for maximal hyperaemia
- Submaximal hyperaemia and its use
- Adenosine pharmacology and dosing
- Intravenous versus intracoronary adenosine
- Regadenoson
- Intracoronary sodium nitroprusside
- Coronary Physiologic Indexes: Hyperaemic Agents Used for Coronary Physiology Assessment
- Coronary Physiologic Indexes: Hyperaemic Agents Used for Coronary Physiology Assessment: Mechanism of Action
- Coronary Physiologic Indexes: Hyperaemic Agents Used for Coronary Physiology Assessment: Dose
- Coronary Physiologic Indexes: Hyperaemic Agents Used for Coronary Physiology Assessment: Side Effects
Assessment of Microvascular Disease
- Definition of the index of microcirculatory resistance
- Clinical value of IMR
- Measurement of IMR
FFR, Ischaemia and PCI Outcomes
- Ischaemic threshold of fractional flow reserve
- The DEFER trial
- The FAME trial
- Deferred lesions within FAME
- Outcomes in the FFR grey zone
- The FAME 2 trial
- Combined message of the FFR outcome trials
Left Main Coronary Artery Disease
- FFR-guided decisions in left main stenosis
- Left main revascularisation outcomes with FFR guidance
- Left main revascularisation outcomes with FFR guidance: Enrollment Criteria
- Left main revascularisation outcomes with FFR guidance: Mace Definition
- Left main revascularisation outcomes with FFR guidance: Main Findings
- Instantaneous wave-free ratio outcomes in left main disease
- Instantaneous wave-free ratio outcomes in left main disease: Mace Definition
- Instantaneous wave-free ratio outcomes in left main disease: Main Findings
- Instantaneous wave-free ratio compared with FFR in left main disease
- Instantaneous wave-free ratio compared with FFR in left main disease: Mace Definition
- Instantaneous wave-free ratio compared with FFR in left main disease: Main Findings
- Assessment of simple and distal left main lesions
- Effect of downstream stenosis on left main FFR
- Human validation of apparent versus true left main FFR
- Serial left main and LAD lesions
- When downstream disease genuinely invalidates left main FFR
Serial Lesions and Diffuse Disease
- Physiology of tandem or serial lesions
- Practical approach to serial lesions
- Diffuse coronary atherosclerotic disease
- Focal versus diffuse pressure loss on pullback
Non-hyperaemic Indices
- Rationale for adenosine-free indices
- The ADVISE study
- Hybrid iFR strategy of Petraco
- The RESOLVE core laboratory study
- Comparison of iFR and FFR in stable coronary disease
- Comparative assessment of iFR and FFR in stable coronary artery disease
- Comparative assessment of iFR and FFR in stable coronary artery disease: Mace Definition
- Comparative assessment of iFR and FFR in stable coronary artery disease: Main Findings
Acute Coronary Syndromes
- Microvascular dysfunction after acute injury
- Timing of FFR after non-ST-elevation events
- Non-culprit lesions in ST-elevation myocardial infarction
- FFR of the culprit vessel after infarction
- Fractional flow reserve in acute coronary syndrome trials
- Fractional flow reserve in acute coronary syndrome trials (continued)
- Fractional flow reserve in acute coronary syndrome trials: Enrollment Criteria
- Fractional flow reserve in acute coronary syndrome trials: Enrollment Criteria (continued)
- Fractional flow reserve in acute coronary syndrome trials: Mace Definition
- Fractional flow reserve in acute coronary syndrome trials: Mace Definition (continued)
- Fractional flow reserve in acute coronary syndrome trials: Main Findings
- Fractional flow reserve in acute coronary syndrome trials: Main Findings (continued)
Bypass Grafts and Graft Patency
- FFR in coronary artery bypass graft lesions
- Native vessel physiology and graft patency
Quantitative Flow Ratio
- Principle of quantitative flow ratio
- FAVOR III China
- FAVOR III Europe
- Post-PCI QFR and vessel outcomes
- QFR-DECISION-PCI pilot study
- Claimed advantages of QFR over FFR and iFR
- Assessment of quantitative flow ratio in patients undergoing PCI
- Assessment of quantitative flow ratio in patients undergoing PCI: Enrollment
- Assessment of quantitative flow ratio in patients undergoing PCI: Outcomes
- Assessment of quantitative flow ratio in patients undergoing PCI: Findings
Special Clinical Situations
- Myocardial bridging
- Dobutamine challenge in myocardial bridging
- Coronary physiology in women
- Coronary physiology in pregnancy
- Vasospastic angina
- Takotsubo cardiomyopathy
- Comparison of dFR, iFR and RFR
- Limits of agreement between resting indices
Pitfalls and Complications
- Thresholds and cycle phase of iFR and FFR
- Pitfalls of iFR and FFR
- Pitfalls of iFR and FFR (continued)
- Complications of FFR compared with iFR
Summary
- Current place of invasive coronary physiology
- Threshold values worth memorising
- References
- References (continued)
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- References (continued)
- References (continued)
- References (continued)
- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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