A 70-year-old male patient with a medical history of hypertension, hyperlipidemia, and prostate cancer status post-prostatectomy is having dyspnea on exertion for the past 1 month. An echocardiogram was done showing normal left ventricular ejection fraction and no significant valvular abnormalities. The patient subsequently had a nuclear stress test that identified decreased uptake with reversibility in the distal anterolateral and inferoapical walls. Given these findings, the patient was referred for cardiac catheterization. He was found to have double vessel disease: 90% stenosis of the distal left circumflex and tandem lesions in the left anterior descending artery (LAD) with 70% stenosis of the proximal segment and 75% of the distal segment. A drug-eluting stent was placed in the distal circumflex, and the patient was scheduled for staged percutaneous coronary intervention. On follow-up procedure, an instantaneous wave-free ratio (iFR) was performed on the LAD with a distal value of 0.38.
What is the best next step in managing this patient?
Show Answer
The correct answer is: D. Perform iFR pullback in the LAD
There are a variety of types of non-hyperemic pressure ratios, and each type has a cutoff value of ≤0.89 being abnormal.1 In this case, an iFR value of 0.38 indicates a large ischemic burden of the anterolateral wall. A distal FFR will be positive as well; however, given the fact that there is a tandem lesion, FFR will not be able to discriminate which lesion is the culprit lesion because there is an interplay between the proximal and distal stenoses.2 Because we do not know which lesion is causing the abnormal value, stenting either lesion would not be the next best step. Performing an iFR pullback will create a physiological map, allowing the operator to determine each lesions' contribution to the combined iFR value3 and identifying an appropriate treatment plan.
References
Davies JE, Sen S, Dehbi HM, et al. Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI. N Engl J Med 2017;376:1824-34.
Wolfrum M, Fahrni G, de Maria GL, et al. Impact of impaired fractional flow reserve after coronary interventions on outcomes: a systematic review and meta-analysis. BMC Cardiovasc Disord 2016;16:177.
Kikuta Y, Cook CM, Sharp ASP, et al. Pre-Angioplasty Instantaneous Wave-Free Ratio Pullback Predicts Hemodynamic Outcome In Humans With Coronary Artery Disease: Primary Results of the International Multicenter iFR GRADIENT Registry. JACC Cardiovasc Interv 2018;11:757-67.
Log in to MyACC
