1. Fractional Flow Reserve Workshop
Daniel M Kolansky MD Associate Professor of Medicine University of Pennsylvania Medical Center Director, Cardiac Care Unit Hospital of the University of Pennsylvania Philadelphia, Pennsylvania USA August 2011

2. Disclosure Information
No relevant disclosures or conflict of interest

3. FFR Formula At maximal hyperemia: FFR = Mean Pd / Mean Pa
Usually performed using pressure wire and intravenous Adenosine at 140 – 180 ug/kg/min

4. =1 P = FFR Normal FFR = 1.0 Pd Pd = Pa Pa 100 100
In a vessel without any stenosis the FFR is one (1.0). Nothing in the vessel disturbs the pressure. =1 P =
FFR a d
myo

5. FFR in the presence of a stenosis
100 70 Pd Pa
Pd < Pa
In the presence of a stenosis the pressure drops distal to the stenosis (compare to a kinked garden hose – the pressure after the kink isn't as high as before the kink).
The FFR is < 1; in this case 0.70 (Pd=70/Pa=100)
<1 P =
FFR a d
myo

6. Why Use FFR FFR is a lesion specific index
FFR is independent of other hemodynamic parameters
FFR takes into account collateral flow
Has been validated for intermediate lesions
Useful for decision making on intervention in intermediate (50-75% ) stenoses

7. Kern, M. J. et al. J Am Coll Cardiol 2010;55:173-185
Intermediate Left Anterior Descending Coronary Artery Stenosis
Kern, M. J. et al. J Am Coll Cardiol 2010;55:

8. Kern, M. J. et al. J Am Coll Cardiol 2010;55:173-185
FAME Study: Kaplan-Meier Survival Curves for 1-Year Follow-Up of the FAME Patients
Kern, M. J. et al. J Am Coll Cardiol 2010;55:

9. FFR CASE EXAMPLES

10. FFR Case 1 Clinical Summary STEMI and Multivessel Disease
84 yo woman presents after acute coronary syndrome, with transient inferior ST elevation
Also had a stroke on presentation
Cath on day 2 showed 100% RCA, 75% Circumflex, and % LAD
RCA stented
Returns for staged left coronary PCI

11. FFR Case 1: Angiogram RCA
RCA occlusion
RCA after stenting

12. FFR Case 1: Angiogram Left Circ
Before stent
After stent

13. FFR Case 1: Angiogram LAD Intermediate Stenosis

14. FFR Case 1 – Recording in LAD

15. FFR Case 2 Clinical Summary RCA stenosis
67 yo man with atrial fibrillation and shortness of breath with exertion
New LV dysfunction with LVEF 35%
Coronary angiogram with 50% RCA stenosis

16. FFR Case 2: Angiogram RCA
RCA Ostial Stenosis

17. FFR Case 2 Recording in RCA

18. FFR Case 3 Clinical Summary Multivessel Disease, prior negative FFR
76 yo woman with history of CAD
2007 cath with 60% LAD stenosis with non-significant FFR assessment at that time
Presents with increasing angina in 2011
Cath:
80% LAD
60 % RCA
% circumflex OM

19. FFR Case 3: Angiogram Circumflex and RCA
Moderate Circumflex OM-1 and RCA disease

20. FFR Case 3: Angiogram LAD
LAD Lesion 2007
LAD Lesion 2011

21. FFR Case 3 – LAD Recording (2011)

22. FFR Case 3 – RCA Recording (2011)

23. FFR Case 4 Clinical Summary stent edge stenosis
67 yo man with prior mid LAD stent in 2007
Presented with chest pain and positive enzymes (NSTEMI)
Cath showed patent stent with edge stenosis
FFR performed

24. FFR Case 4: LAD Angiograms
2007 pre stent
2007 post stent
2011 angiogram

25. FFR Case 4 – LAD Recording
Resting gradient .87
FFR 0.73

26. FFR Case 4: LAD Angiogram 2011
LAD Edge Restenosis
LAD Stent Deployment
LAD post stent

27. FFR Case 5 Clinical Summary Ostial LAD disease
54 yo woman with 2-3 months exertional chest pain
Cath:
Ostial LAD stenosis

28. FFR Case 5: Angiogram LAD

29. FFR Case 5 – LAD Recording
FFR 0.66 across ostial LAD

30. FFR Case 5 – Pullback Recording to Left Main
FFR = 0.91 across Left Main