Case Challenge on FFR-Guided PCI for Stable Coronary Artery Disease

Dec 17, 2014 | Morton J. Kern, MD, FACC

A 58-year-old man with progressive chest pain is admitted to the coronary care unit. He is treated for hypertension and hypercholesterolemia. He does not have diabetes and does not smoke. His physical exam is unremarkable. His electrocardiogram (ECG) shows sinus rhythm with non-specific T and ST changes. Troponin is elevated to 4.0 (nl 0-0.04 units). Coronary angiography showed severe (>80%) circumflex stenosis with a moderate left anterior descending (LAD) artery with 50-60% stenosis.

The circumflex stenosis was treated with a 3.0 x 18 mm drug eluting stent reducing the narrowing to 0% (Figures 1a, 1b, 1c, and 2).

Figure 1a

Cineangiographic frame of left coronary artery in the left anterior oblique (LAO) cranial projection showing moderate left anterior descending (LAD) artery stenosis with severe circumflex narrowing.

Figure 1b

Cineangiographic frames of left coronary artery in the LAO caudal projection showing moderate LAD stenosis with severe circumflex narrowing.

Figure 1c

Cineangiographic frame of left coronary artery in the right anterior oblique (RAO) cranial projection showing moderate left anterior descending (LAD) artery stenosis with sever circumflex narrowing.

Figure 2

Cineangiographic frame of left coronary artery in the RAO caudal projection showing the post circumflex stent result and a 0.014 in. pressure sensor wire in the LAD to measure fractional flow reserve (FFR).

Given the moderate LAD disease, which of the following is the best option for treatment?

A. Continue medical therapy and risk stratification.
B. Proceed to stent the LAD based on the angiographic findings alone.
C. Perform intravascular ultrasound (IVUS) to assess LAD; if minimal luminal diameter is <4.0mm2, proceed to stent.
D. Perform fractional flow reserve (FFR) to assess LAD; if FFR is <0.80, proceed to stent LAD.
E. Consult cardiothoracic surgeon for left internal mammary artery (LIMA) to LAD.

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, non–ST-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).

Figure 3b

Hemodynamic pressure signals obtained during the FFR measurements (short segment recording at faster speed display).

Figure 4a

Cineangiographic frame in the RAO caudal projections showing post stent images with residual narrowing of <5% in the treated segments.

Figure 4b

Cineangiographic frame in the LAO caudal projections showing post stent images with residual narrowing of <5% in the treated segments.

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.

Case Challenge on FFR-Guided PCI for Stable Coronary Artery Disease

Figure 1a

Figure 1b

Figure 1c

Figure 2

Given the moderate LAD disease, which of the following is the best option for treatment?

Figure 3a

Figure 3b

Figure 4a

Figure 4b

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