FFR

Fractional Flow Reserve :

•Angiographic results alone can guide the decision to perform a

percutaneous coronary intervention (PCI) .

•Angiography is used to visually assess the coronary anatomy and

determine the degree of stenosis, plaque or blockage in the coronary
artery .

• The blockage creates visual irregularities of the inner diameter of

coronary vessels on angiography and those irregularities are quantified
using a percentage .

•The degree of blockage is usually quantified with a percentage and

categorized into mild, moderate/intermediate or severe.
•The goal of angioplasty and stenting in the coronary
arteries is to increase blood flow to the heart and in turn,
relieve chest pain .

•FFR, shows that the flow is not significantly blocked, the

blockage or lesion does not need to be revascularized .

FFR is a guide wire-based procedure that can accurately

measure blood pressure and flow through an isolated
segment of a coronary artery.
FFR through a standard diagnostic catheter at the time of a
coronary angiogram or cardiac catheterization.
FFR has been demonstrated to be useful in the assessment of
“intermediate” blockages (coronary artery disease) to
determine the need for angioplasty or stenting.

FFR is obtained as part of diagnostic cardiac catheterization. A

guide catheter is utilized to advance the FFR-specific guide wire
to the coronary artery orifice.

At which point, a coronary artery pressure proximal to the

stenotic lesion (Pa) is obtained
•The operator (or interventional cardiologist) then advances the FFR-
specific guide wire and crosses the intermediate stenotic lesion
allowing for coronary artery pressure distal to the stenosis ( Pd) to be
obtained.

• The pressure sensor can be visualized angiographically by the

operator.

•FFR measurements must be obtained during a period of maximal

blood flow or maximal hyperemia.

•To achieve maximal hyperemia, a hyperemic stimulus is

administered either intravenously or intracoronary through the guide
catheter, FFR is monitored for a period of 3 to 4 minutes. Intravenous
(IV) adenosine is the most widely used method to induce maximal
hyperemia.
•Equation

•FFR is defined as the ratio of maximum achievable blood flow

through a blockage (area of stenosis) to the maximum achievable
blood flow in the same vessel in the hypothetical absence of the
blockage.

•It is calculated using a pressure ratio of pressure measured distal

to the blockage (Pd) and pressure proximal to the blockage (Pa) .

•The ‘‘normal’’ ratio is expected to be 1.

•For example, an FFR value of 0.80 means that the maximum

blood flow in the coronary artery being measured is 80% of what
it would be if the artery were completely normal.
•FFR = Pd / Pa

•Pd = pressure distal to the lesion (blockage)

•Pa = pressure proximal to the lesion (blockage)

•FFR Measurement/Treatment :

•Ischemia-producing stenosis (FFR less than 0.75)/Revascularization

•Non–ischemia-producing stenosis (FFR greater than 0.80)/Medical

Therapy

•Gray zone (FFR 0.75 to 0.80)/Revascularization versus Medical

therapy
Instantaneous Wave-Free Ratio :

•IFR is a newer physiologic measurement that utilizes similar principles

to FFR but does not require the use of a hyperemic agent.

•In IFR, the same pressure wires utilized in FFR get passed to a point
distal to a stenotic lesion.

•During a period of diastole known as the “wave-free period,” IFR then

calculates the ratio of the distal coronary artery pressure (Pd) to the
pressure within the aortic outflow tract (Pa).

•During this timeframe completing blood flow complicating these

measurements is negligible.
•Lesions found to have a Pd/Pa ratio less than 0.89, are
determined to be significant and have been shown to be
non-inferior to the FFR cutoff of 0.8.

•Indications for IFR are in patients with stable CAD and

indeterminate lesions, between 40% and 70% stenosis.

•CLINICAL SIGNIFICANCE :
•IFR may be utilized to assess indeterminate coronary artery
stenosis further, for lesions anywhere from 40% to 90%, but
recommendations do not include patients with ACS .
•Patients with clinical symptoms or non-invasive testing
consistent with ischemia, and an IFR of 0.89 or less are candidates
for PCI.

• IFR greater than 0.93 typically qualifies for optimization of

medical therapy (OMT), Those with a ratio of 0.90 to 0.93 should
have a follow-up with FFR.

•In a patient with clinical symptoms not consistent with

ischemia, PCI is recommended for IFR under 0.86.

•In those with an IFR ratio over 0.89, OMT is recommended.

•Patients with IFR ratios between 0.86 and 0.89 are recommended
for FFR confirmation.
complications :

They are the same as that of a standard cardiac catheterization with

angiography and PCI and include the following:

•Bleeding .
•Access site hematoma and pseudoaneurysm
•Acute kidney injury caused by the contrast agent
•Anaphylaxis caused by the contrast agent
•Coronary artery dissection .
Coronary flow reserve :

•The coronary flow reserve and its value in assessing the coronary
blood flow from both epicardial as well as the coronary
microcirculation .

•CFR is an index which is the ratio of coronary blood during maximal

vasodilation divided by coronary blood flow during resting
conditions .

•CFR can be measured by either a temperature-sensitive guide wire

applying the coronary thermodilution technique or a Doppler
sensor equipped guide wire measuring Doppler flow velocity.

•Coronary thermodilution measurements require brisk saline

injections during resting and hyperemic conditions to calculate CFR
based on the average mean transit time of three saline boluses.
• Although it is considered correlate well to absolute coronary
flow in research settings .

•This method is prone to measurement errors due to the

sensitivity to the saline injections, due to rapid saline injections
may disturb coronary hemodynamics , which is specifically
deceptive in capturing basal flow values .

•However, is only identified when specific care is taken to obtain

reasonably correlating mean transit times before calculation of
CFR .
CFR less than 2 is used to distinguish coronary lesions that are likely
to trigger myocardial ischemia .

Coronary Doppler Flow Velocity :

•coronary Doppler guidewire measures the velocity of red blood

cells moving past the ultrasound emitter/receiver on the end of a
Doppler-tipped angioplasty guidewire.

•Coronary flow velocity is calculated from the difference between

the transmitted and returning frequency (called the Doppler
frequency shift).

•When the transducer beam is nearly parallel to blood flow velocity

can be accurately measured.
•Changes in blood flow velocity are reflected by changes in the
Doppler frequency shift.

•The Doppler technique measures red blood cell velocity

directly.

• Because the Doppler guidewire has a cross_sectional area of

0.164 mm2, it is generally considered to be nonobstructive
within any, but most severe, coronary stenosis.
•The coronary thermodilution technique uses thermistors on a
pressure-sensor angioplasty guidewire and measures the arrival
time of room-temperature saline bolus indicator .

•lnJections through the guiding catheter into the coronary artery .

•A microsensor mounted 3 cm from the tip also enables

simultaneous high-fidelity pressure measurements.

•Pressure and temperature are sampled at a frequency of 500 Hz.

•Thermodilution CFR (CFR1hermo) is defined as the ratio of

hyperemic flow to resting coronary flow (F).
•Diagnostic accuracy of CFR for inducible myocardial
ischemia on non-invasive stress testing was 81%, at an
optimal cutoff value of 1.9, exactly the same as the accuracy
for FFR .

•normal CFR is considered to be greater than 2.0 and in most

patients should be somewhere between 3 and 5.

•The technical aspects have limited widespread adoption

due to a lack of expertise with the techniques, and the
associated increase in procedural time
•limitations of invasively measured CFR .

•it can be difficult to measure with a Doppler wire because of the

challenge in obtaining a suitable Doppler signal.

•Because CFR relies on resting flow for its calculation, the

repeatability of measurements is less than optimal .

•Any hemodynamic perturbation such as a change in heart rate,

blood pressure, or LV contractility will significantly change the CFR
value as a result of the change in resting flow .
•Because there is a range of normal CFR values between
approximately 2.5 and 6,
•in one patient a value of 3.0 might be normal
•whereas in another patient normal CFR may be 5.0

•Therefore a recorded value of 3.0 could be quite abnormal.

•The lack of a clear cut-off between a normal and abnormal

CFR makes it difficult to use for clinical decisions.
Thank you