Fractional Flow Reserve Workshop Daniel M Kolansky MD Associate Professor of Medicine University of Pennsylvania Medical Center Director, Cardiac Care Unit Hospital of the University of Pennsylvania Philadelphia, Pennsylvania USA August 2011

Disclosure Information No relevant disclosures or conflict of interest

FFR Formula At maximal hyperemia: FFR = Mean Pd / Mean Pa Usually performed using pressure wire and intravenous Adenosine at 140 – 180 ug/kg/min

=1 P = FFR Normal FFR = 1.0 Pd Pd = Pa Pa 100 100 In a vessel without any stenosis the FFR is one (1.0). Nothing in the vessel disturbs the pressure. =1 P = FFR a d myo

FFR in the presence of a stenosis 100 70 Pd Pa Pd < Pa In the presence of a stenosis the pressure drops distal to the stenosis (compare to a kinked garden hose – the pressure after the kink isn't as high as before the kink). The FFR is < 1; in this case 0.70 (Pd=70/Pa=100) <1 P = FFR a d myo

Why Use FFR FFR is a lesion specific index FFR is independent of other hemodynamic parameters FFR takes into account collateral flow Has been validated for intermediate lesions Useful for decision making on intervention in intermediate (50-75% ) stenoses

Kern, M. J. et al. J Am Coll Cardiol 2010;55:173-185 Intermediate Left Anterior Descending Coronary Artery Stenosis Kern, M. J. et al. J Am Coll Cardiol 2010;55:173-185

Kern, M. J. et al. J Am Coll Cardiol 2010;55:173-185 FAME Study: Kaplan-Meier Survival Curves for 1-Year Follow-Up of the FAME Patients Kern, M. J. et al. J Am Coll Cardiol 2010;55:173-185

FFR CASE EXAMPLES

FFR Case 1 Clinical Summary STEMI and Multivessel Disease 84 yo woman presents after acute coronary syndrome, with transient inferior ST elevation Also had a stroke on presentation Cath on day 2 showed 100% RCA, 75% Circumflex, and 60 - 70% LAD RCA stented Returns for staged left coronary PCI

FFR Case 1: Angiogram RCA RCA occlusion RCA after stenting

FFR Case 1: Angiogram Left Circ Before stent After stent

FFR Case 1: Angiogram LAD Intermediate Stenosis

FFR Case 1 – Recording in LAD

FFR Case 2 Clinical Summary RCA stenosis 67 yo man with atrial fibrillation and shortness of breath with exertion New LV dysfunction with LVEF 35% Coronary angiogram with 50% RCA stenosis

FFR Case 2: Angiogram RCA RCA Ostial Stenosis

FFR Case 2 Recording in RCA

FFR Case 3 Clinical Summary Multivessel Disease, prior negative FFR 76 yo woman with history of CAD 2007 cath with 60% LAD stenosis with non-significant FFR assessment at that time Presents with increasing angina in 2011 Cath: 80% LAD 60 % RCA 50 - 60% circumflex OM

FFR Case 3: Angiogram Circumflex and RCA Moderate Circumflex OM-1 and RCA disease

FFR Case 3: Angiogram LAD LAD Lesion 2007 LAD Lesion 2011

FFR Case 3 – LAD Recording (2011)

FFR Case 3 – RCA Recording (2011)

FFR Case 4 Clinical Summary stent edge stenosis 67 yo man with prior mid LAD stent in 2007 Presented with chest pain and positive enzymes (NSTEMI) Cath showed patent stent with edge stenosis FFR performed

FFR Case 4: LAD Angiograms 2007 pre stent 2007 post stent 2011 angiogram

FFR Case 4 – LAD Recording Resting gradient .87 FFR 0.73

FFR Case 4: LAD Angiogram 2011 LAD Edge Restenosis LAD Stent Deployment LAD post stent

FFR Case 5 Clinical Summary Ostial LAD disease 54 yo woman with 2-3 months exertional chest pain Cath: Ostial LAD stenosis

FFR Case 5: Angiogram LAD

FFR Case 5 – LAD Recording FFR 0.66 across ostial LAD

FFR Case 5 – Pullback Recording to Left Main FFR = 0.91 across Left Main