FFR/NHPR (eg, iFR) Caveats:

Real World Challenges –

Left Main, Diffuse Disease, CTOs

Morton J. Kern, MD
Chief of Medicine, VA Long Beach HCS
Professor of Medicine
University California Irvine
Orange, California

102418 @1300
Disclosure: Morton J. Kern, MD

Within the past 12 months, the presenter or their

spouse/partner have had a financial interest/arrangement or
affiliation with the organization listed below.

Company Name Relationship

Abbott Medical Inc. Speakers’ Bureau
Philips Volcano Inc. Speakers’ Bureau
Merit Medical Inc. Consultant
Acist Medical Inc. Consultant
Opsens, Inc. Consultant
Heartflow Consultant
Cathworks Speaker
Complex anatomy complicates decision making. FFR can be critical.

Serial lesions bifurcation ostial LAD

Left main jailed side branch

Pa

iFR
Mean Pd/Pa
WFP

RFR DPR dPR

Pd
Translesional coronary pressure measurements 2018

Non-Hyperemic
Hyperemic Pressure Ratios
(NHPR)

Diastolic/Sub-
Whole-Cycle
Cycle

FFR Pd/Pa
DFR™ iFR® RFR™ DPR™ dPR
All All
BSC Volcano ABT OPS tbd
Systems Systems

≤0.80 ≤0.91 ≤0.89

Complex Clinical Outcome
FFR/NPHR Key points
Scenarios Studies?
Bifurcation lesions FFR/NPHR Deceptive angio, difficult access yes
IV adeno for ostial, LM. LM+LAD use FFR
Ostial, LM FFR Yes
>0.6. IVUS for <0.6
Diffuse/Serial
Pullback Pressure ΔP hyperemia/rest w co-registration No
Disease
MVD not need CABG of all vessels.
CABG FFR SVG biology trumps physiology but Yes
assessment correct
Primulti and Danami say yes to non-
STEMI/NSTEMI FFR/NPHR, IMR culprit if <0.8. IMR >40u worse Yes
outcomes
CTO FFR Δmyoc bed and Collateral flow indices Yes
TAVR FFR/NPHR CBF increases after TAVR, FFR decreases No
 FFR Outcomes

Meta-analysis:
FAME2
DANAMI
COMPARE Acute

n=2400
Safety of the Deferral of Coronary
Revascularization on the Basis of iFR and
FFR in Stable CAD and ACS

Javier Escaned et al. JCIN 2018;11:1437-1449

LAD FFR before and after RCA CTO stents
FFR=0.74 FFR=0.82
Circ Cardiovasc Interv. 2015
Angiographically Intermediate with hemodynamically significant CFX,
Ramus and marginal LAD, LM equivalent
 FFR CFX with Pull back to ostium

CFX wire position ostial wire position

 FFR in Ramus

Wire in Ramus

FFR in LAD

Wire in LAD
Simplifying FFR for LM + LAD CAD

Fearon W et al. J Am Coll Cardiol Intv. 2015;8(3):398-403.

Impact of Downstream Coronary Stenosis on
FFR for LM CAD: Human Validation

If LAD+LM FFR <0.60, use IVUS

Fearon W et al. J Am Coll Cardiol Intv. 2015;8(3):398-403.

Focal vs Serial or Diffuse Stenoses
Man with severe aortic stenosis, preoperative
angiography for AVR.
iFR, FFR at mid LAD
Focal disease = abrupt step up on iFR pullback
Where is most of the pressure drop occurring? IFR pullback

4
3

Each red dot represents a unit

of pressure loss
Focal vs Diffuse Disease and Choosing stent length

iFR 0.07 FOCAL

(high iFR intensity)

iFR 0.05
DIFFUSE
(low iFR intensity)
FFR/NHPR: Complex Anatomy and Outcomes
• FFR and NHPR provide objective data for better decisions
• iFR vs FFR are non-inferior (2 studies)
• Class effect of NHPRs. Clinical outcomes pending
• Deferring PCI based on iFR/NHPR appears safe in low risk pts.
• For LM,
• FFR >0.80 defer PCI with good outcomes x 5yrs
• When FFR of LM+LAD <0.60, use IVUS CSA (<6mm2 )
• NHPR data pending
In ACS, non-culprit FFR is valid
Diffuse disease and Post PCI physiology best done with pullback.