“How Coronary Flow Reserve Changed My Management”Case PresentationDr Barry Hennigan
Professor Keith OldroydInterventional Cardiology Department
West of Scotland Regional Heart and Lung Centre
Speaker's name: Barry Hennigan
☑ Speaker for Volcano Corp today
Potential conflicts of interest
Patient MW• 65 year old man
• Presented July 2013
• CCS2 angina
• CABG Feb 1st 2011
• LIMA to LAD Heavily calcified proximal lesion (failed PCI)
• SVG to OM- (poor surgical target noted intra-op)
Hx continued
• T2DM
• Obesity BMI 39
• HTN
• Hyperlipidemia
• Echo - mild Ant HK with good LV fx
July 2013
• RAO RCALAO RCA
July 2013
• LAO Cranial LIMA to LAD RCA Caudal LIMA to LAD
Angiogram July 2013• LAO Caudal LCX LAO Cranial LCX
Angiogram July 2013 Summary
• Heavily calcified proximal LCX • Occluded SVG to OM
• Patent LIMA to LAD
• Patent native RCA
• Medical therapy advised
Clinical Course Nov 13-March 14
• Ongoing exertional chest pain
• Interfering with ability to run business
• On oral nitrate, ca++ channel blocker and BB
• Keen for intervention
? Evidence of Ischemia
• DSE-suboptimal image quality due to BMI
• Daycase FFR +/- PCI to LCX
March 2014
• PA Caudal RAO Caudal
Combowire Assessment
Combowire Design
Case: Resting Perfusion
Case: Hyperemic Perfusion
Dilemma
• Normal FFR• Abnormal CFR• Ongoing symptoms• Single probable ischemic territory
• ? Optimal treatment
PCI
•Predilated with a 3.0 sprinter to 18 atm
•Stented with a 4.0 by 18mm biomatrix to 14 atm•Post dilated 4.0 NC
Hyperemic Perfusion Post PCI
Clinical Progress
• Painfree• Back running business• Walking 1 mile without
symptoms• Exertional SOB on hills only• Actively losing weight• Completed further cardiac
rehab course
Case Summary
• Discordant FFR/CFR results• ?causes – increased microvascular resistance• Convincing clinical scenario for ischemia• Single identifiable culprit territory• Excellent improvement in flow post
intervention
Relationship between FFR CFR
Johnson et al. J Am Coll Cardiol Img. 2012;5(2):193-202
Reasons for Discordant FFRwhere FFR>0.75 but CFR<2
• Diffuse microvascular disease • Previous infarcted territory• Distal stenosis
Influencing Factors on CFR
- Preload- Afterload- Contractility- Hypertension- Diabetes mellitus- Cardiomyopathy- Age- LVH- Recent MI
Thermodilution Versus Doppler
• Tmnhyperaemic/Tmnrest ratio
• Thermodilution may overestimate CFR
• Mean values• IMR calculation
rather than HMR• Good correlation
with doppler
• Uses APVH/APVB• In good hands
>90% success in achieving good doppler signal
• Learning curve
European Heart Journal (2004) 25, 219–223
Thermodilution vs Doppler ctd
European Heart Journal (2004) 25, 219–223
TIPS
• Anterograde vs retrograde• Positioning- use audio cues• Use sidebranches• Know your console• Wire handling- avoid trauma to tip• Experienced Operator• Don’t give up
Conclusion• Would we recommend this approach routinely?• No• Flow does add useful information • New wire technologies enable easier + rapid
complementary dataset acquisition that improve decision making
• Supplements pressure data• Should be interpreted carefully with attention to
clinical scenario• Further validation in RCTs awaited
Thank You Thank You
Defer if CFR>2
