“How Coronary Flow Reserve Changed My Management” Case Presentation Dr Barry Hennigan Professor Keith Oldroyd Interventional Cardiology Department West of Scotland Regional Heart and Lung Centre
Jan 05, 2016
“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