“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