Case Challenge on FFR-Guided PCI for Stable Coronary Artery Disease
Given the moderate LAD disease, which of the following is the best option for treatment?
Show Answer
The correct answer is: D. Perform fractional flow reserve (FFR) to assess LAD; if FFR is <0.80, proceed to stent LAD.
The LAD was assessed with FFR. Using intravenous adenosine infusion 140 mcg/kg/min for two minutes, FFR was 0.78, indicating flow limitation (Figures 3a, b). The LAD was then successfully stented. The post-stent result showed no residual narrowing (Figures 4a, b).
The FAME 2 study supports the FFR (ischemia)-guided approach for ischemia for best outcomes in patients with stable CAD compared to medical therapy alone. In the FAME study, nonST-segment myocardial infarction (NSTEMI) patients also benefitted from FFR (ischemia)-guided stenting.
IVUS minimal lumen diameter (MLD) does not provide certainty regarding the presence of ischemia. The threshold for IVUS MLD of >4.0 mm2 is associated with nonischemic FFR, but the contrary MLD <4.0 mm2 has a 50% chance of ischemic/nonischemic FFR. Cardiothoracic surgery is possible but, given the low syntax score, would not provide a superior outcome compared to stenting.
Figure 3a
Hemodynamic pressure signals obtained during the FFR measurements (complete study).
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Figure 3b
Hemodynamic pressure signals obtained during the FFR measurements (short segment recording at faster speed display).
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Figure 4a
Cineangiographic frame in the RAO caudal projections showing post stent images with residual narrowing of <5% in the treated segments.
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Figure 4b
Cineangiographic frame in the LAO caudal projections showing post stent images with residual narrowing of <5% in the treated segments.
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References
- De Bruyne B, Fearon WF, Pijls NH, et al. Fractional flow reserve-guided PCI for stable coronary artery disease. N Engl J Med 2014;371:1208-17.
- 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;334:1703-8.
- Tonino PA, Fearon WF, De Bruyne B, et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J Am Coll Cardiol 2010;55:2816-21.