Coronary Physiology for the

Interventionalist

Morton J. Kern, MD
Professor of Medicine
Chief Cardiology LBVA
Associate Chief Cardiology
University California Irvine
Orange, California
Disclosure:

Morton J. Kern, MD

Within the past 12 months, the presenter or their

spouse/partner have had a financial interest/arrangement
or affiliation with the organization listed below.

Company Name Relationship

St. Jude Medical (Radi) Speakers Bureau
Volcano Therapeutics Speakers Bureau
Merrit Medical Inc. Consultant
InfraredEx Consultant
 The Lesion Severity Depends on Your Point of View
When should I assess
structure (IVUS, OCT, etc)
or Function (FFR, CFR) ?

It depends on what you

want to know.

If the question is Does

this stenosis limit blood
flow?, then function.

If the question is How

big is the artery or whats
inside? then structure.

FFR, CFR = Physiology

IVUS, OCT, etc = Anatomy
Coronary Pressure and Flow Relationships can be measured in
the Cath lab and determine who will have ischemia or angina.
Entrance effects Separation losses
Pressure derived FFR,
Pa Pd/Pa

Pd 100 mm Hg
FFR = 0.96

Friction loss

50 mm Hg

FFR=0.78 Flush Off

IC Doppler
0 mm Hg

P CVR

Flow velocity
CVR
 Physiologic measurements to separate epicardial and
microvascular resistances
FFR = 0.96
Pressure derived FFR=0.78
100 mm Hg
HSRv=Pa-Pv/APVhyper
Pa
50 mm Hg
P
Pd
Flush Off
0 mm Hg Q or v

CVR/ rCVR
FFR=0.78
Thermodilution Flow
IC Doppler
IMR=Pa*Tmn [(PdPw)/(PaPw)]

Flow velocity
FFR is a lesion-specific Stress
test which is done in the lab.
One stop decision making.

Use of FFR helps make decision

at the time of diagnostic cath
rather than out of lab testing
and return.

What would you like? One cath

or two?
 What is physiologic
significance of single cross
sectional area?
Pressure Flow (Q) Diameter
(mm Hg) 5
(mm) Reference
(mL/min)
Diameter
0.5 100 200 4.0 (mm)
< 4 mm =
significant stenosis ?
0.6 100 150 3.5 4

1.0 100 100 3.0

1.3 100 75 2.5 3

2.0 100 50 2.0

4.0 100 25 1.5 2

50 25 0
% Diameter Stenosis for an
APEX Cross Sectional Area of 4 mm

Courtesy of Dr. Bernard DeBruyne

Relationship between FFR and tomographic parameters

Takagi, A. et al. Circulation 1999;100:250-255

 Catheter-based Anatomic and
Physiologic Criteria Associated with
Clinical Outcomes

Application IVUS CVR IMR FFR

Ischemia <3-4mm2 <2.0 ? <0.75-

detection 0.80
Deferred -- >2.0 -- >0.75
angioplasty
Multivessel -- -- -- >0.80
FFR guided PCI
Endpoint of >9mm2 -- -- >0.94
stenting >80% ref area,
full apposition
FFR Studies to Know

DEFER
SVG study
Nuclear Scans MVD
FAME
RW. 59 yo man with Angina, inferior perf defect
3V CAD? Is this the Courage Patient?
FFR=0.71

Now 3V CAD
New approach
 Does Stenosis Severity of Native Vessels Influence
Bypass Graft Patency? A Prospective Fractional Flow
ReserveGuided Study
1 year f/u % Occluded Grafts

Angiographic Stenosis Severity FFR Stenosis Severity

Botman CJ et al Ann Thorac Surg 2007;83:20937

 FFR=0.48
Only LAD was ischemic by Nuc

FFR=0.78

FFR=0.64

Am J Cardiol 2007;99:896 902

 Kaplan-Meier Survival Curves According to Study Group

MACE Survival

MI Repeat Revasc

Tonino P et al. N Engl J Med 2009;360:213-224

 Cost

DCA CABG
ROTO
Clinical Effectiveness DES

FAME
Med rx?
 Question: Why do FFR?

I dont know whether this

lesion is significant.

The angiogram cannot always

tell us what we want to know.

Treating ischemia has clinical

benefit when present.

Answer: So you dont have to live with Uncertainty