1. Pressure Wire Evaluation of the Left Main Stem Dr Phil MacCarthy Consultant Cardiologist King’s Cardiac Centre Left Main 5+ at AA2007, Jan 24 th, 2007.

2. No conflicts of interest

3. Assessment of critical LMS disease is sometimes easy…

4. A more common clinical scenario

5. How do you currently establish the haemodynamic importance of a LMS lesion? Surgery!

6. The stakes are high…

7. The angiogram is a 2D representation of a complex 3D structure Topol and Nissen, Circulation 1995

8. Correlation between LMS anatomy and physiology Jasti et al, Circulation 2004

9. Studies of LMS FFR vs Outcome ReferencenFFR<0.75 FFR>0.75 (Deferred) F/U (months) Mortality in deferred group Bech et al Heart 2001 543024290 Jimenez- Navarro et al J Inv Cardiol 2004 27720260 Jasti et al Circulation 2004 55144138 3 (all non- cardiac) Suemaru et al Heart Vessels 2005 157832.50 Legutko et al Kardiol Pol 2005 381820240 Lindstaedt et al Am Heart J 2006 512724290

10. 54 patients with equivocal LMS stenosis – FFR>0.75 in 24 (medical), FFR<0.75 in 30 (CABG) Bech et al Heart 2001; 86: 547

11. Jasti et al, Circulation 2004

12. 51 patients – 24 FFR>0.75 treated medically, 27 FFR<0.75 treated surgically Lindstaedt et al, Am Heart J 2006; 152: 156

13. Left main disease in the stable patient

14. Case 1 - Stable

16. Case 2 - Stable

17. Pressure-wire study LMS Pressure-wire study LMS FFR 0.88 – No significant step-up on hyperaemic pull-back FFR 0.88 – No significant step-up on hyperaemic pull-back Proceed to PCI of RCA CTO…. Proceed to PCI of RCA CTO….

18. Case 2 - Stable

19. Left main disease in acute coronary syndromes

20. Case 1 - Unstable

22. Case 2 - Unstable

23. 5.5mm 2

24. Case 2 - Unstable

25. Practical Tips Intravenous, centrally administered adenosine Intravenous, centrally administered adenosine Guide catheter engagement/damping Guide catheter engagement/damping Beware distal disease Beware distal disease Differing FFRs in the LAD and Cx Differing FFRs in the LAD and Cx

26. Intravenous Infusion of Adenosine 140 µg/kg/min Adenosine IV Femoral

27. Pull-back under maximal hyperaemia

28. Practical Tips Intravenous, centrally administered adenosine Intravenous, centrally administered adenosine Guide catheter engagement/damping Guide catheter engagement/damping Beware distal disease Beware distal disease Differing FFRs in the LAD and Cx Differing FFRs in the LAD and Cx

29. 3 mm 1.8 mm 2.1 mm 2.4 mm 64% 49 % 36 % AreaStenosis 8F 7F 6F Guiding Catheter in Ostium = Stenosis

30. Practical Tips Intravenous, centrally administered adenosine Intravenous, centrally administered adenosine Guide catheter engagement/damping Guide catheter engagement/damping Beware distal disease Beware distal disease Differing FFRs in the LAD and Cx Differing FFRs in the LAD and Cx

31. PaPaPaPa B A PmPmPmPm PdPdPdPd FFR(A) pred = P d - (P m /P a ) P w P a - P m + P d -P w FFR(B) pred = (P a - P w ) (P m - P d ) (P a - P w ) (P m - P d ) P a (P m - P w ) P w = Coronary occlusive pressure De Bruyne et al, Circulation 2000

32. Practical Tips Intravenous, centrally administered adenosine Intravenous, centrally administered adenosine Guide catheter engagement/damping Guide catheter engagement/damping Beware distal disease Beware distal disease Differing FFRs in the LAD and Cx Differing FFRs in the LAD and Cx

34. FFR = 0.90 FFR = 0.63

35. Conclusions Pressure wire assessment of the LMS is technically easy Pressure wire assessment of the LMS is technically easy Medical treatment when the FFR>0.75 seems safe Medical treatment when the FFR>0.75 seems safe Use central, iv adenosine and disengage the guide catheter before measuring Use central, iv adenosine and disengage the guide catheter before measuring Beware underestimating FFR with downstream disease Beware underestimating FFR with downstream disease