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Fractional Flow Reserve: Intracoronary Versus Intravenous Adenosine Induced Maximal Coronary Hyperemia
APRIL 23e26, 2013
O R A L A B S T R A C T S
Previous studies showed correlation between anatomical parameters of epicardial coronary stenosis and FFR. Nevertheless, the correlation between anatomical parameters and FFR has been either moderate or good but with a large dispersion of FFR values for a similar angiographic degree of stenosis. The amount of myocardium supplied might also influence the FFR value. The dispersion may be partially related to the pooling of both small and large supply area together in the same study cohort. However the impact of the supply area on the FFR value have not been adequately investigated yet. Thus the current study was designed to assess the effect of the supply area on the functional significance of coronary lesion. Methods: A total of 296 lesions in 236 patients were assessed by quantitative coronary angiography and FFR. The supply area as percentage of left ventricle was estimated angiographically using a modified version of the Alberta Provivncia Project for Outcome Assessment in Coronary Heart Disease (APPROACH) score (3.25 to 47.75%). Results: FFR <0.75 was seen in 93 (31.4%) of the overall 296 lesions. There was a positive correlation between minimal lumen diameter (MLD) and FFR (R¼0.584, p<0.001), and negative correlation between lesion length and FFR (R¼-0.306, p<0.001), and between supply area (modified APPROACH score) and FFR (R¼-0.408, p <0.001). The independent determinants of functionally significant stenosis based on FFR were MLD (odds ratio [OR] 0.022; confidential interval [CI] 0.007-0.062; p<0.001), lesion length (OR 1.049; CI 1.020-1.079; p¼0.001), and the supply area (OR 1.102; CI 1.068-1.137; p<0.001). Conclusion: Not only the anatomical parameters of epicardial coronary stenosis but also its supply area affects the functional significance of coronary artery stenosis. Functional significance of coronary stenosis depends on the balance of the lesion severity and its supply area.
- AS-109 Experience with FFR. Paramdeep Singh Sandhu, Upendra Kaul. Fortis Escorts Heart Institute and Research Centre, New Delhi, India. Background: Fractional flow reserve (FFR) is a relatively recent tool to assess the functional significance of obstructive coronary lesions. Recent trials suggest that revascularization of moderate coronary stenoses can be safely deferred if the FFR is >0.80 and FFR can be used to guide therapy in multivessel disease. We have evaluated the usefulness of this method in our setting in patients being taken for PCI for multi vessel disease. Methods: During the period May 2010 to August 2011, a total of 203 patients (218 lesions were accessed (72%, males)) being taken up for Percutaneous Coronary Intervention (PCI) were studied in this ongoing study. The lesions were assessed by three different observers and were divided on the basis of extent of occlusion ranging from 50%70%, 71%-90%, 91%-99%. FFR was performed using the standard techniques with Radi Analyzer Xpress and Pressure wire Certus from St. Jude Medical. FFR was measured with a coronary pressure guidewire at maximal hyperemia induced by intravenous adenosine, which was administrated at a rate of 140mcg per kilogram of body weight per minute through a central vein or intracoronary adenosine as a bolus starting from 60mcg upto 120mcg. FFR was calculated as the mean distal coronary pressure (measured with the pressure wire) divided by the mean aortic pressure (measured simultaneously by guiding catheter) during maximum hyperemia. A FFR value of <0.80 identifies ischemia-causing coronary stenoses. Results: A total of 203 patients (218 lesions) with 72% males being taken up for PCI were studied. Of all the patients 41% were diabetics, 35% had hypertension and 10% had past history of myocardial infarction. All patients presented with chronic stable angina with 28% class 1, 29% class 2, 24% class 3 and 19% were class 4. Coronary angiography revealed single vessel disease in 26%, double vessel disease in 53% while 21% had triple vessel disease.
52B
Number of patients in 50-70%, 71-90% and 91-99% narrowing groups as assessed by 3 different observers were 136, 76 and 6 respectively, out of which 30, 38, 5 had FFR<0.80 in the respective groups. 73 lesions (with a FFR 0.80) out of total 218 lesions underwent revascularization and 145 lesions out of 218 lesions with a FFR > 0.80 were not taken up for PCI. Overall, 66.5% of lesions avoided revascularization on the basis of the FFR. The lesions with FFR 0.80 were taken up for PCI and stenting. Follow up of upto 2 years was done (mean 6.2 months). Total number of MACE was 1 (TLR¼1)(0.012%) with no death, myocardial infarction, CABG or repeat PCI. Cost Effectiveness of FFR: In this study, 198 patients (212 lesions) were identified under 50%-90% Occlusion, if PCI would have been considered for all the lesions, then 212 stents would have been used. By doing FFR, only 68 lesions were found ischemic out of 212 Lesions. It means 144 lesions were not considered for PCI. FFR procedure will add Rs 30k per patient. For 198 procedures¼5940000 Taking average cost per DES to be around 1 lakh to the lesion: 212000000-5940000¼15260000 (1.526 Crores) 73 patients (76 lesions) were identified under 70%- 90% Occlusion, if PCI would have been considered for all the lesions, then 76 stents would have been used. By doing FFR, only 38 lesions were found ischemic out of 76 Lesions. It means 38 lesions were not considered for PCIFFR procedure will add Rs. 30k per patient. For 73 procedures¼2190000 Taking average cost per DES to be around 1 lakh to the lesion: 7600000-2190000¼5410000 (54.10 lacs). Moreover, this cost includes only cost of stents and the savings will increase when hospital stay, other hardware used during the procedure will be taken into account. Conclusion: Our ongoing study indicates that measurement of FFR is clinically useful with a high impact on clinical decision making in the catheterization laboratory. FFR can be used to reclassify patients with multivessel stenoses, reducing the need for revascularization in the majority of cases.
- AS-110 Fractional Flow Reserve: Intracoronary Versus Intravenous Adenosine Induced Maximal Coronary Hyperemia. Paramdeep Singh Sandhu, Upendra Kaul. Fortis Escorts Heart Institute and Research Centre, New Delhi, India. Background: Fractional Flow Reserve (FFR), a measure of coronary stenosis severity is based on achievement of maximal hyperemia of coronary microcirculation. The most widely used pharmacological agent is adenosine which is administered intravenously(IV). IV adenosine has more systemic side effects, is more time consuming and expensive as compared to intracoronary (IC) adenosine in a catheterization laboratory. Therefore this study was conducted to compare IV versus IC adenosine for the achievement of maximal hyperemia. Methods: FFR was assessed in 50 patients with 56 intermediate lesions using both IV and IC adenosine. IV adenosine was administered as a continuous infusion at the rate of 140, 160 and 180 mcg/kg/min until a steady state hyperemia was achieved. IC adenosine boluses were administered at doses of 60, 100 and 120mcg. FFR was calculated as the ratio of the distal coronary pressure to the aortic pressure at maximal hyperemia. Results: A total of 25 left anterior descending, 8 right, 21 left circumflex, and 2 left main coronary arteries were evaluated. The mean percent stenosis was 63.91. Conclusion: This study suggests that IC adenosine is equivalent to IV infusion for the determination of FFR. The administration of IC adenosine is easy to use, cost effective, safe and associated with fewer systemic events.
The American Journal of Cardiologyâ APRIL 23e26, 2013 ANGIOPLASTY SUMMIT ABSTRACTS/Oral
O R A L A B S T R A C T S
Previous studies showed correlation between anatomical parameters of epicardial coronary stenosis and FFR. Nevertheless, the correlation between anatomical parameters and FFR has been either moderate or good but with a large dispersion of FFR values for a similar angiographic degree of stenosis. The amount of myocardium supplied might also influence the FFR value. The dispersion may be partially related to the pooling of both small and large supply area together in the same study cohort. However the impact of the supply area on the FFR value have not been adequately investigated yet. Thus the current study was designed to assess the effect of the supply area on the functional significance of coronary lesion. Methods: A total of 296 lesions in 236 patients were assessed by quantitative coronary angiography and FFR. The supply area as percentage of left ventricle was estimated angiographically using a modified version of the Alberta Provivncia Project for Outcome Assessment in Coronary Heart Disease (APPROACH) score (3.25 to 47.75%). Results: FFR <0.75 was seen in 93 (31.4%) of the overall 296 lesions. There was a positive correlation between minimal lumen diameter (MLD) and FFR (R¼0.584, p<0.001), and negative correlation between lesion length and FFR (R¼-0.306, p<0.001), and between supply area (modified APPROACH score) and FFR (R¼-0.408, p <0.001). The independent determinants of functionally significant stenosis based on FFR were MLD (odds ratio [OR] 0.022; confidential interval [CI] 0.007-0.062; p<0.001), lesion length (OR 1.049; CI 1.020-1.079; p¼0.001), and the supply area (OR 1.102; CI 1.068-1.137; p<0.001). Conclusion: Not only the anatomical parameters of epicardial coronary stenosis but also its supply area affects the functional significance of coronary artery stenosis. Functional significance of coronary stenosis depends on the balance of the lesion severity and its supply area.
- AS-109 Experience with FFR. Paramdeep Singh Sandhu, Upendra Kaul. Fortis Escorts Heart Institute and Research Centre, New Delhi, India. Background: Fractional flow reserve (FFR) is a relatively recent tool to assess the functional significance of obstructive coronary lesions. Recent trials suggest that revascularization of moderate coronary stenoses can be safely deferred if the FFR is >0.80 and FFR can be used to guide therapy in multivessel disease. We have evaluated the usefulness of this method in our setting in patients being taken for PCI for multi vessel disease. Methods: During the period May 2010 to August 2011, a total of 203 patients (218 lesions were accessed (72%, males)) being taken up for Percutaneous Coronary Intervention (PCI) were studied in this ongoing study. The lesions were assessed by three different observers and were divided on the basis of extent of occlusion ranging from 50%70%, 71%-90%, 91%-99%. FFR was performed using the standard techniques with Radi Analyzer Xpress and Pressure wire Certus from St. Jude Medical. FFR was measured with a coronary pressure guidewire at maximal hyperemia induced by intravenous adenosine, which was administrated at a rate of 140mcg per kilogram of body weight per minute through a central vein or intracoronary adenosine as a bolus starting from 60mcg upto 120mcg. FFR was calculated as the mean distal coronary pressure (measured with the pressure wire) divided by the mean aortic pressure (measured simultaneously by guiding catheter) during maximum hyperemia. A FFR value of <0.80 identifies ischemia-causing coronary stenoses. Results: A total of 203 patients (218 lesions) with 72% males being taken up for PCI were studied. Of all the patients 41% were diabetics, 35% had hypertension and 10% had past history of myocardial infarction. All patients presented with chronic stable angina with 28% class 1, 29% class 2, 24% class 3 and 19% were class 4. Coronary angiography revealed single vessel disease in 26%, double vessel disease in 53% while 21% had triple vessel disease.
52B
Number of patients in 50-70%, 71-90% and 91-99% narrowing groups as assessed by 3 different observers were 136, 76 and 6 respectively, out of which 30, 38, 5 had FFR<0.80 in the respective groups. 73 lesions (with a FFR 0.80) out of total 218 lesions underwent revascularization and 145 lesions out of 218 lesions with a FFR > 0.80 were not taken up for PCI. Overall, 66.5% of lesions avoided revascularization on the basis of the FFR. The lesions with FFR 0.80 were taken up for PCI and stenting. Follow up of upto 2 years was done (mean 6.2 months). Total number of MACE was 1 (TLR¼1)(0.012%) with no death, myocardial infarction, CABG or repeat PCI. Cost Effectiveness of FFR: In this study, 198 patients (212 lesions) were identified under 50%-90% Occlusion, if PCI would have been considered for all the lesions, then 212 stents would have been used. By doing FFR, only 68 lesions were found ischemic out of 212 Lesions. It means 144 lesions were not considered for PCI. FFR procedure will add Rs 30k per patient. For 198 procedures¼5940000 Taking average cost per DES to be around 1 lakh to the lesion: 212000000-5940000¼15260000 (1.526 Crores) 73 patients (76 lesions) were identified under 70%- 90% Occlusion, if PCI would have been considered for all the lesions, then 76 stents would have been used. By doing FFR, only 38 lesions were found ischemic out of 76 Lesions. It means 38 lesions were not considered for PCIFFR procedure will add Rs. 30k per patient. For 73 procedures¼2190000 Taking average cost per DES to be around 1 lakh to the lesion: 7600000-2190000¼5410000 (54.10 lacs). Moreover, this cost includes only cost of stents and the savings will increase when hospital stay, other hardware used during the procedure will be taken into account. Conclusion: Our ongoing study indicates that measurement of FFR is clinically useful with a high impact on clinical decision making in the catheterization laboratory. FFR can be used to reclassify patients with multivessel stenoses, reducing the need for revascularization in the majority of cases.
- AS-110 Fractional Flow Reserve: Intracoronary Versus Intravenous Adenosine Induced Maximal Coronary Hyperemia. Paramdeep Singh Sandhu, Upendra Kaul. Fortis Escorts Heart Institute and Research Centre, New Delhi, India. Background: Fractional Flow Reserve (FFR), a measure of coronary stenosis severity is based on achievement of maximal hyperemia of coronary microcirculation. The most widely used pharmacological agent is adenosine which is administered intravenously(IV). IV adenosine has more systemic side effects, is more time consuming and expensive as compared to intracoronary (IC) adenosine in a catheterization laboratory. Therefore this study was conducted to compare IV versus IC adenosine for the achievement of maximal hyperemia. Methods: FFR was assessed in 50 patients with 56 intermediate lesions using both IV and IC adenosine. IV adenosine was administered as a continuous infusion at the rate of 140, 160 and 180 mcg/kg/min until a steady state hyperemia was achieved. IC adenosine boluses were administered at doses of 60, 100 and 120mcg. FFR was calculated as the ratio of the distal coronary pressure to the aortic pressure at maximal hyperemia. Results: A total of 25 left anterior descending, 8 right, 21 left circumflex, and 2 left main coronary arteries were evaluated. The mean percent stenosis was 63.91. Conclusion: This study suggests that IC adenosine is equivalent to IV infusion for the determination of FFR. The administration of IC adenosine is easy to use, cost effective, safe and associated with fewer systemic events.
The American Journal of Cardiologyâ APRIL 23e26, 2013 ANGIOPLASTY SUMMIT ABSTRACTS/Oral