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Fractional Flow Reserve Measurement Technique

  • Author: Eiman Jahangir, MD, FACC; Chief Editor: Karlheinz Peter, MD, PhD  more...
 
Updated: Dec 07, 2015
 

Approach Considerations

Typically, conscious sedation is administered as part of the cardiac catheterization. Unless the patient is uncomfortable, no other anesthesia is required. The patient is placed in the supine position.

To measure fractional flow reserve (FFR), the operator crosses the coronary stenosis with an FFR-specific guide wire designed to record the coronary arterial pressure distal to the stenosis. The pressure transducer is located approximately 20 mm proximal to the distal tip of the wire, and it can be seen fluoroscopically.

Once the transducer is distal to the stenosis, a hyperemic stimulus is administered by injection through the guide catheter, and the FFR is monitored for a significant change. To achieve maximum hyperemia, adenosine is typically used: a 15-30 µg bolus in the right coronary artery, a 20-40 µg bolus in the left coronary artery, or intravenous (IV) infusion for 3-4 minutes at 140 µg/kg/min. The mean arterial pressures from the pressure wire transducer and from the guide catheter are then used to calculate FFR.

An FFR value lower than 0.75 indicates a hemodynamically significant stenosis. An FFR value higher than 0.8 indicates a stenosis that is not hemodynamically significant. Values between 0.75 and 0.80 are indeterminate and should be considered in the context of patient’s clinical history to determine if revascularization is necessary.

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Specific Approaches to FFR Measurement

Volcano systems

Open the product packaging with sterile technique, and place the spiral on the sterile field. With the wire in the spiral, remove the cable from the spiral by pulling on the plug, and connect it to a compatible instrument. Verify that the nose is rotated to the locked position.

After the wire has been zeroed, carefully remove the connector body from the spiral clip, and withdraw the guide wire from the spiral. At this time, the guide wire tip may be shaped with standard tip-shaping practices, if desired.

Wet the working length of the guide wire with normal saline, and insert the wire through the appropriate introducer components and guiding catheter into the desired blood vessel. Slowly advance the guide wire tip under fluoroscopic guidance, using contrast injections to verify its location. Be careful not to kink the proximal contact bands of the wire. Ensure that the tip is rotating freely and that no resistance is felt when torque is applied.

Locate the pressure sensor adjacent to the tip of the guide catheter, and perform a normalization procedure with the instrument. Advance the sensor to the desired measurement location, and perform measurements with the instrument. If the FFR is greater than 0.75 at baseline, proceed with administering a hyperemic stimulus (eg, intracoronary adenosine in a dose of 15-40 µg or IV adenosine at 140 µg/kg/min), and monitor measurements.

Finally, withdraw the pressure sensor and verify that pressures are equal.

St Jude Medical system

Open the product packaging with sterile technique, and place the PressureWire on the sterile field. Remove the gray connector from its holder and connect it to the RadiAnalyzer Xpress. Place the coil flat, and flush with 10 mL of saline. Press Enter on the RadiAnalyzer Xpress to calibrate the PressureWire (see the video below).

Demonstration of calibrating and using a RadiAnalyzer Xpress.

Advance the sensor element so that it is just outside the guide catheter opening (see the first image below). Verify that aortic pressure and PressureWire pressure are equal at that position (see the second image below). If the 2 pressures are not equal, position the aortic transducer at the level of the patient’s heart, remove the guide wire introducer needle, close the valve tightly, flush any contrast remnants, press Equalize, and hold for 3 seconds.

PressureWire is placed outside of the guide cathet PressureWire is placed outside of the guide catheter but proximal to the lesion to equalize pressure wire and aortic pressures.
RadiAnalyzer Xpress demonstrating aortic and Press RadiAnalyzer Xpress demonstrating aortic and PressureWire pressures prior to crossing the lesion. Notice that the ratio is not equal to 1, indicating that further adjustments to the instruments are needed. Red line = aortic pressure. Green line = pressure at the wire tip.

Advance the sensor element to a point distal to the stenosis of interest (see the image below). Wait for stable baseline pressure values to be obtained.

PressureWire is placed distal to the lesion in the PressureWire is placed distal to the lesion in the right coronary artery.

Induce maximum hyperemia with intracoronary adenosine (15-40 µg) or IV adenosine (140 µg/kg/min). When maximum hyperemia is reached, press Stop/View to stop recording. The instrument then calculates the FFR automatically (see the image below).

With the administration of intravenous adenosine, With the administration of intravenous adenosine, the fractional flow ratio decreases to 0.67, indicating that the lesion is hemodynamically significant and will benefit from revascularization. Red line = aortic pressure. Green line = pressure at the wire tip.
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Complications

Complications associated with cardiac catheterization include the following:

  • Coronary vessel dissection, occlusion, or perforation
  • Embolism (coronary, cerebral, or other arterial)
  • Coronary artery spasm
  • Local or systemic infection
  • Stroke
  • Serious arrhythmias
  • Death
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Contributor Information and Disclosures
Author

Eiman Jahangir, MD, FACC Consultative Cardiologist, Department of Cardiovascular Medicine, Ochsner Medical Center

Eiman Jahangir, MD, FACC is a member of the following medical societies: American College of Cardiology, American Heart Association, Tennessee Medical Association, Society for Vascular Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

John A McPherson, MD, FACC, FACP Professor of Medicine, Sol and Marvin Rosenblum Chair in Medical Education, Vice-Chair for Education, Department of Medicine, Vanderbilt University Medical Center

John A McPherson, MD, FACC, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Association of Program Directors in Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Karlheinz Peter, MD, PhD Professor of Medicine, Monash University; Head of Centre of Thrombosis and Myocardial Infarction, Head of Division of Atherothrombosis and Vascular Biology, Associate Director, Baker Heart Research Institute; Interventional Cardiologist, The Alfred Hospital, Australia

Karlheinz Peter, MD, PhD is a member of the following medical societies: American Heart Association, German Cardiac Society, Cardiac Society of Australia and New Zealand

Disclosure: Nothing to disclose.

References
  1. Silber S, Albertsson P, Aviles FF, et al. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J. 2005 Apr. 26(8):804-47. [Medline].

  2. Bartunek J, Sys SU, Heyndrickx GR, Pijls NH, De Bruyne B. Quantitative coronary angiography in predicting functional significance of stenoses in an unselected patient cohort. J Am Coll Cardiol. 1995 Aug. 26(2):328-34. [Medline].

  3. Pijls NH, De Bruyne B, Peels K, et al. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med. 1996 Jun 27. 334(26):1703-8. [Medline].

  4. Fischer JJ, Samady H, McPherson JA, et al. Comparison between visual assessment and quantitative angiography versus fractional flow reserve for native coronary narrowings of moderate severity. Am J Cardiol. 2002 Aug 1. 90(3):210-5. [Medline].

  5. Pijls NH, van Schaardenburgh P, Manoharan G, 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. [Medline].

  6. Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009 Jan 15. 360(3):213-24. [Medline].

  7. Coronary physiology: overview. Volcano Corporation. Available at http://www.volcanocorp.com/products/functional-measurement.asp. Accessed: 5/28/2010.

  8. St Jude Medical. Available at http://www.radi.se/kc_home.aspx?n=start&r=1. Accessed: 5/28/2010.

  9. Diletti R, Van Mieghem NM, Valgimigli M, et al. Rapid exchange ultra-thin microcatheter using fibre-optic sensing technology for measurement of intracoronary fractional flow reserve. EuroIntervention. 2015 Aug. 11(4):428-32. [Medline].

  10. Verdier-Watts F, Rioufol G, Mewton N, et al. Influence of arterial hypotension on fractional flow reserve measurements. EuroIntervention. 2015 Aug. 11(4):416-20. [Medline].

 
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Angiography of the right coronary artery demonstrates an intermediate-grade lesion in the mid vessel. Intermediate-grade lesions such as this should be further evaluated with fractional flow reserve measurement.
RadiAnalyzer Xpress when initially powered on.
PressureWire is placed outside of the guide catheter but proximal to the lesion to equalize pressure wire and aortic pressures.
RadiAnalyzer Xpress demonstrating aortic and PressureWire pressures prior to crossing the lesion. Notice that the ratio is not equal to 1, indicating that further adjustments to the instruments are needed. Red line = aortic pressure. Green line = pressure at the wire tip.
PressureWire is placed distal to the lesion in the right coronary artery.
With the administration of intravenous adenosine, the fractional flow ratio decreases to 0.67, indicating that the lesion is hemodynamically significant and will benefit from revascularization. Red line = aortic pressure. Green line = pressure at the wire tip.
Angiography of the right coronary artery after percutaneous coronary intervention.
Demonstration of calibrating and using a RadiAnalyzer Xpress.
 
 
 
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