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Fractional flow reserve and non-hyperemic indices: Essential tools for percutaneous coronary interventions
Amine Mamoun Boutaleb1,2, Chadi Ghafari3, Claudiu Ungureanu3,4
1Department of Cardiology, Ibn Rochd University Hospital, Casablanca 20230, Casablanca, Morocco.
Insights
Fractional flow reserve (FFR) guides coronary artery disease treatment, improving outcomes by identifying significant lesions. Non-invasive methods and a hybrid approach offer new ways to assess intermediate lesions.
Area of Science:
- Cardiology
- Medical Imaging
- Interventional Cardiology
Background:
- Fractional flow reserve (FFR) is crucial for assessing coronary artery stenosis functional significance.
- FFR guides therapeutic strategies, deferring unnecessary procedures for lesions with FFR > 0.8.
- Optimal post-intervention FFR values are > 0.9 post-stenting and > 0.8 post-drug-eluting balloons.
Purpose of the Study:
- To review the role of FFR in evaluating coronary artery lesions.
- To introduce non-invasive FFR estimation using quantitative flow ratio (QFR).
- To propose a hybrid approach for managing intermediate coronary lesions.
Main Methods:
- Review of FFR guidelines and clinical applications.
- Discussion of non-hyperemic pressure ratios (NHPR) and their limitations.
- Illustration of non-invasive FFR estimation from 3-D angiograms using QFR.
Main Results:
- FFR is the gold standard for invasive ischemia assessment.
- NHPR may overestimate lesion significance but are useful when hyperemic agents are contraindicated.
- Non-invasive FFR estimation via QFR is presented as a viable option.
Conclusions:
- FFR significantly improves patient management and clinical outcomes in coronary artery disease.
- Non-invasive QFR offers a complementary tool for hemodynamic assessment.
- A hybrid approach for intermediate lesions (DFR 0.85-0.95) can optimize clinical decision-making.
Abstract:
Hemodynamical evaluation of a coronary artery lesion is an important diagnostic step to assess its functional impact. Fractional flow reserve (FFR) received a class IA recommendation from the European Society of Cardiology for the assessment of angiographically moderate stenosis. FFR evaluation of coronary artery disease offers improvement of the therapeutic strategy, deferring unnecessary procedures for lesions with a FFR > 0.8, improving patients' management and clinical outcome. Post intervention, an optimal FFR > 0.9 post stenting should be reached and > 0.8 post drug eluting balloons. Non-hyperemic pressure ratio measurements have been validated in previous studies with a common threshold of 0.89. They might overestimate the hemodynamic significance of some lesions but remain useful whenever hyperemic agents are contraindicated. FFR remains the gold standard reference for invasive assessment of ischemia. We illustrate this review with two cases introducing the possibility to estimate also non-invasively FFR from reconstructed 3-D angiograms by quantitative flow ratio. We conclude introducing a hybrid approach to intermediate lesions (DFR 0.85-0.95) potentially maximizing clinical decision from all measurements.
