Validation of Fractional Flow Reserve
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Sung Eun Kim and Jung-Won Suh
22.1 Introduction Fractional flow reserve (FFR) is now considered a gold standard for the invasive assessment of myocardial ischemia. Since the concept of FFR was developed and introduced by Pijls and De Bruyne in the early 1990s, not only the benefit of FFRguided revascularization strategy but also the issues of procedural feasibility have been thoroughly validated. In this chapter, evidences will be reviewed starting from the first validation study in animal and human to recent studies supporting the clinical benefit of FFR in daily practices.
22.2 F irst Animal and Human Validation Pijls introduced the term “fractional flow reserve” (FFR) in 1993. In his foundational article for FFR [1], three reasons why pressure measurements have not been useful until then were clarified:
S.E. Kim Division of Cardiology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea J.-W. Suh (*) Division of Cardiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, 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_22
unsuitable device to measure pressure, uncontrolled resistances in coronary circulation (i.e., lack of maximal vasodilation), and failure to account for collateral flow. They used thinner pressure monitoring wire (0.015 in.) and controlled myocardial resistance with maximal hyperemia using intracoronary administration of papaverine. The key component of their model was that it could distinguish between contributions from the epicardial conduit (fractional coronary artery flow reserve [FFRcor]) and collateral channel to myocardial blood flow (fractional myocardial flow reserve [FFRmyo]). In their experiment using five dogs, relative maximum blood flow through the stenotic artery (Qs) measured directly by Doppler flowmeter showed an excellent correlation with pressure-derived values (Qs) of the maximal myocardial blood flow and collateral blood flow (Fig. 22.1). The first validation study in human was performed by De Bruyne in 1994 [2]. In 22 patients, myocardial and coronary fractional flow reserve was calculated from mean aortic, distal coronary, and right atrial pressures which was recorded during maximal vasodilation. Additionally, relative myocardial flow reserve, defined as the ratio of absolute myocardial perfusion during maximal vasodilation in the stenotic area to the absolute myocardial perfusion during maximal vasodilation (adenosine 140 μg/kg/min intravenously during 4 min) in the contralateral normally perfused area, was assessed by 15O–labeled water and positron emission tomography (PET). Fractional flow 223
S.E. Kim and J.-W. Suh
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stenosis in the supplying epicardial coronary artery, RA right atrium. Pijls NH, van Son JA, Kirkeeide RL, De Bruyne B, Gould KL. Experimental basis of determining maximum coronary, myocar
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