Physiologic Lesion Assessment: Advantages and Pitfalls Allen Jeremias, MD, MSc Director, Interventional Cardiology Research Assoc. Director, Cardiac Catheterization St. Francis Hospital, Roslyn, NY Director, Physiology Core Laboratory Cardiovascular Research Foundation, NY, NY

Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Consulting Fees/Honoraria Astra Zeneca Volcano/Philips Abbott Vascular Medtronic St. Jude Medical

Shiono Y et al., Catheter Cardiovasc Interv 2014;1;84(3):406-13. Impact of myocardial supply area on transstenotic hemodynamics as determined by FFR Representative cases with mismatch between QCA and FFR. A: Intermediate stenosis (percent diameter stenosis = 53%) was seen in a proximal LAD which had a large‐sized diagonal branch. Because the myocardial area supplied by the coronary artery distal to the stenosis was large (modified APPROACH score = 47.75%), the FFR value was below the ischemic threshold (FFR = 0.58). B: Severe stenosis (percent diameter stenosis = 80%) was found in mid RCA with small myocardial supply area (modified APPROACH score = 9.25%). Then, the FFR value was above the ischemic threshold (FFR = 0.91). APPROACH score, Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease score; FFR, fractional flow reserve; LAD, left anterior descending artery; QCA, quantitative coronary angiography; RCA, right coronary artery. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON PERMISSIONS@WILEY.COM OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. Shiono Y et al., Catheter Cardiovasc Interv 2014;1;84(3):406-13.  

Shiono Y et al., Catheter Cardiovasc Interv 2014;1;84(3):406-13. Impact of Myocardial Supply Area on Transstenotic Hemodyamics as Determined by FFR Percent Diameter Stenosis Myocardial Supply Area Shiono Y et al., Catheter Cardiovasc Interv 2014;1;84(3):406-13.  

Consensus Statement on Use of FFR Lotfi A, Jeremias A, et al. Catheter Cardiovasc Interv, 2014

5 Steps to Accurate FFR Measurements Insert wire into guide and equalize wire/guide pressures in aorta at tip of the guide Cross lesion at least 2-3cm distal with pressure transducer Flush guide with saline and confirm adequate aortic wave form Watch for ventricularization during hyperemia Confirm absence of drift with pressure pull back

CONTRAST Study Core Lab Analysis 763 patients, 4946 tracings Drift > ±0.03 No drift Adequate wave-form Ventricularization Distortion Ventricularization and Distortion Matsumura M, Jeremias A. JACC Cardiovasc Interv 2017, in press

CONTRAST Study Core Lab Analysis - Drift * Matsumura M, Jeremias A. JACC Cardiovasc Interv 2017, in press

CONTRAST Study Core Lab Analysis - Drift 763 patients, 4946 tracings 19.3% 80.7% 17.5% Matsumura M, Jeremias A. JACC Cardiovasc Interv 2017, in press

CONTRAST Study Core Lab Analysis - Drift Matsumura M, Jeremias A. JACC Cardiovasc Interv 2017, in press

CONTRAST Study Core Lab Analysis – Adequate FFR Tracing Pa Pd Matsumura M, Jeremias A. JACC Cardiovasc Interv 2017, in press

Dicrotic Notch in Normal Tracing Parallel Dicrotic Notch

Loss of Dicrotic Notch Loss of Dicrotic Notch

Diastolic Dipping Not Parallel

Distal Pressure Ventricularization and Loss of Dicrotic Notch

CONTRAST Study Core Lab Analysis – Aortic Pressure Ventricularization Matsumura M, Jeremias A. JACC Cardiovasc Interv 2017, in press

CONTRAST Study Core Lab Analysis – Wave Form Distortion Matsumura M, Jeremias A. JACC Cardiovasc Interv 2017, in press

CONTRAST Study Core Lab Analysis – Wave Form Abnormalities 4217 tracings (655 patients) without drift % Matsumura M, Jeremias A. JACC Cardiovasc Interv 2017, in press

CONTRAST Study Core Lab Analysis – Wave Form Abnormalities 655 patients 763 patients % % Matsumura M, Jeremias A. JACC Cardiovasc Interv 2017, in press

Predictors of Aortic Pressure Ventricularization Contrast FRR 3.04 [1.79-5.17] IV Adenosine 2.54 [1.44-4.49] IC Adenosine 7.30 [4.41-12.1] 0.1 10 Matsumura M, Jeremias A. JACC Cardiovasc Interv 2017, in press

Predictors of Distorted Aortic Wave Form IC Adenosine 0.13 [0.05-0.33] 5F Guide 6.30 [3.22-12.32] 0.1 10 Matsumura M, Jeremias A. JACC Cardiovasc Interv 2017, in press

Reverse Wave Form Distortion Pullback to Guide

Inadequate Tracing for FFR Calculation

FFR – Practical Considerations

Effect of Wire Introducer

Equalization in Setting of Ostial Disease

Equalization Equalization

Guiding Catheter Damping Impacting FFR Measurement Small ostium Ostial disease Too large guiding catheter Non co-axial guide position Solve by dislodging guiding catheter and using IV adenosine This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 49

Conclusions FFR is a more accurate predictor of myocardial ischemia than angiography, incorporating myocardial mass and lesion severity However, erroneous FFR measurements are common and may influence results Attention to detail is critically important when performing FFR De Bruyne B, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012 Sep13;367(11):991-1001 Pijls NH, et al. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study. J Am Coll Cardiol. 2007 May 29;49(21):2105-11.