1. Simplifying Serial Lesion Assessment
Justin Davies, MBBS, PhD
Interventional Cardiologist
Hammersmith Hospital,
Imperial College London
CRT, 2017

2. 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
Grant/Research Support
Consulting Fees/Honoraria
Royalty Income
Intellectual Property Rights
Volcano Philips

3. How would you treat?
Patient 1
Patient 2

4. FFR and iFR interpretation is easy?No GO
FFR >0.81
iFR >0.89
FFR <=0.80 GO
iFR <=0.89

5. How would you treat? DIFFUSE FOCAL Atheroma present Diffuse atheroma
Often no clear landing zone
Likely small increase in flow
Atheroma present
Often clear landing zone
Likely large increase in flow

6. FFR in serial lesion assessment
Not possible to independently and reliabily interrogate tandem lesions
3-5 beat averaging means unable to demarcate beginning-end of stenosis
Not possible to visualize some stenoses

7. iFR Scout used to identify the physiological most significant lesion

8. iFR Scout used to identify the physiological most significant lesion
FFR Pullback ( IV adenosine infusion)
FFR
0,35
iFR Pullback (no adenosine required)

9. Solution to problem Complex Time Consuming
Must balloon at least one stenosis
Overestimate predicted pressure gradient
Not work if more than 2 stenoses

10. Tandem Lesions Assessed with FFR
Hyperemic Flow x
Increase in hyperemic flow after PCI
Coronary Flow
Rest Flow
Minimal change in
rest flow after PCI
Stenosis severity
Pre-PCI
Post-PCI
Adapted from Nijjer Sukhinder

11. Difference between virtual and measured post-PCI iFR
iFR Pullback Study
Pre-PCI iFR: ± 0.03
Predicted iFR: ± 0.01
Observed iFR: ± 0.03
p=0.48
Difference between virtual and measured post-PCI iFR
Nijjer SS, Davies J et al JACC: Cardiovascular Interventions. 2014;7:1386–1396

12. PREDICTION OF IFR USING IFR-SCOUT
Post
1st
PCI
Xience Xpedition
2.75 x 48
Post
2nd
PCI
Xience Prime
2.75 x 23

13. Future of physiological evaluation: Serial lesion assessment
iFR Co-Registration
CT-FFR

14. CASE 1 – Hammersmith Hospital
75 Male
6 month history of chest pain
Presented with NSTEMI
Troponin positive
Preserved LV systolic function
Normal Labs

15. Is there a focal LAD lesion to treat?

16. Is there a focal LAD lesion to treat?

17. Yes- focal lesion present

18. Calibrated length

22. CASE 2 – Hammersmith Hospital
65 Male
2 month history of chest pain
Presented with Stable CAD
Troponin negative
Preserved LV systolic function
Normal Labs

28. Learning points
Complex coronary disease requires differentiation between diffuse and focal disease
iFR and iFR Co-Registration enables serial stenoses to be interrogate

29. Learning points
Predict the likely improvement in physiology prior to PCI
Better targeted stenting
Greater angina relief

30. FFR pull-back before treatment
69 years old gentleman with hypertension and hypercholesterolemia; minimal chest pain; enrolled into the ILUMIEN I study
FFR pull-back before treatment
∆FFR 0.07
∆FFR 0.17
Slides courtesy of Carlo Di Mario: Advances in Coronary Physiology Course 2016

31. FFR pull-back before treatment
69 years old gentleman with hypertension and hypercholesterolemia; minimal chest pain; enrolled into the ILUMIEN I study
FFR pull-back before treatment
Slides courtesy of Carlo Di Mario: Advances in Coronary Physiology Course 2016

32. FFR pull-back before treatment
69 years old gentleman with hypertension and hypercholesterolemia; minimal chest pain; enrolled into the ILUMIEN I study
FFR pull-back before treatment ?
∆FFR 0.17
Slides courtesy of Carlo Di Mario: Advances in Coronary Physiology Course 2016

33. Stent to the Distal Lesion and New FFR assessment
Actual
∆FFR 0.17
Slides courtesy of Carlo Di Mario: Advances in Coronary Physiology Course 2016

34. Stent to the Distal Lesion and New FFR assessment
Slides courtesy of Carlo Di Mario: Advances in Coronary Physiology Course 2016

35. Distal FFR after OCT Optimised Stent Deployment to the Proximal and Distal lesion
4 FFR pull-backs, 3 adenosine syringes changed from iv pump, 2 pressure wires used
Approx. 25 more minutes and significant extra-cost added
Slides courtesy of Carlo Di Mario: Advances in Coronary Physiology Course 2016