Fractional Flow Reserve in Specific Lesion Subsets
Fractional Flow Reserve (FFR) has been also investigated in various conditions of coronary arteries and hearts. The objective of this chapter is to summarize all the relevant literature available about the use of FFR for various coronary lesions and heart
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Hyun-Hee Choi and Sang Yeub Lee
29.1 F ractional Flow Reserve (FFR) in Post-percutaneous Coronary Intervention (PCI) Pre-PCI FFR has been recommended and used to assess of ischemia in the angiographically intermediate lesion and use of percutaneous coronary intervention [1, 2]. In contrast, post-PCI FFR has been less frequently performed and rarely recommended. Nevertheless, post-PCI FFR can support useful information to perform functional optimization of PCI and be a strong predictor of clinical outcomes. Even though angiographic result seems optimal, post-PCI FFR could give an opportunity for identifying patient with a suboptimal interventional result and higher risk for poor clinical outcome who might advantage from further intervention [3, 4]. There are four mechanisms of low post-PCI FFR (Fig. 29.1). First, unmasked or unappreciated tandem lesions will occasionally increase
H.-H. Choi Department of internal Medicine, Chunchoen Sacred Heart Hospital, Hallym University, Chunchoen, South Korea S.Y. Lee (*) Division of Cardiology, Chungbuk National University Hospital, Chungbuk National University School of Medicine, Cheongju, South Korea e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2018 M.-K. Hong (ed.), Coronary Imaging and Physiology, https://doi.org/10.1007/978-981-10-2787-1_29
their gradients after PCI of the primary stenosis. Second, diffuse disease frequently coexists with focal lesions and remains untreated after PCI. Third, pressure drift can cause an artifactual FFR that does not reflect true condition. Fourth, stent implantation itself causes a gradient as demonstrated by longitudinal observations [5]. In previous studies included relatively simple lesions with an overall low coronary artery disease burden, post-PCI FFR > 0.90 has been considered an optimal functional endpoint of PCI and has been associated with favorable clinical outcomes [6]. Shiv et al. reported the post-PCI FFR identified 20% of angiographically satisfactory lesions, which required further intervention, thereby providing an opportunity for functional optimization of PCI results at the time of the index procedure, and further optimization intervention improved the post-PCI FFR by approximately 0.05; furthermore, final FFR ≤ 0.86 had incremental prognostic value over clinical and angiographic variables for major cardiovascular events (MACE) prediction [7].
29.2 FFR in Myocardial Bridge Myocardial bridging (MB) is a common incidental finding noted on coronary angiography and has been considered a benign condition. However, there are a number of reports that have related MB with myocardial ischemia, acute coronary syndrome, arrhythmia, and sudden cardiac death [8, 9]. So the 293
H.-H. Choi and S.Y. Lee
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Unmasked 2nd lesion A
Diffuse disease
B FFR pullback curve
C
D
• Tandem or serial lesions • Post-PCI FFR mandatory • Largest gains in FFR
Pressure drift
• Pre-PCI selection vital • High risk post-PCI • Untreatable with more PCI
Optimization necessary
Pressure sensor back at guiding catheter re
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