Pressure Wire Evaluation of the Left Main Stem

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Pressure Wire Evaluation of the Left Main Stem

• Dr Phil MacCarthy
• Consultant Cardiologist
• Kings Cardiac Centre

Left Main 5 at AA2007, Jan 24th, 2007.
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No conflicts of interest
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Assessment of critical LMS disease is sometimes
easy
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A more common clinical scenario
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How do you currently establish the haemodynamic
importance of a LMS lesion?
Surgery!
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The stakes are high
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The angiogram is a 2D representation of a complex
3D structure
Topol and Nissen, Circulation 1995
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Correlation between LMS anatomy and physiology
Jasti et al, Circulation 2004
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Studies of LMS FFR vs Outcome
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54 patients with equivocal LMS stenosis
FFRgt0.75 in 24 (medical), FFRlt0.75in 30 (CABG)
Bech et al Heart 2001 86 547
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Jasti et al, Circulation 2004
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51 patients 24 FFRgt0.75 treated medically, 27
FFRlt0.75 treated surgically
Lindstaedt et al, Am Heart J 2006 152 156
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Left main disease in the stable patient
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Case 1 - Stable
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Case 1 - Stable
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Case 2 - Stable
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Case 2 - Stable

• Pressure-wire study LMS
• FFR 0.88 No significant step-up on hyperaemic
  pull-back
• Proceed to PCI of RCA CTO.

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Case 2 - Stable
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Left main disease in acute coronary syndromes
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Case 1 - Unstable
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Case 1 - Unstable
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Case 2 - Unstable
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Case 2 - Unstable
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Case 2 - Unstable
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Practical Tips

• Intravenous, centrally administered adenosine
• Guide catheter engagement/damping
• Beware distal disease
• Differing FFRs in the LAD and Cx

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Intravenous Infusion of Adenosine 140 µg/kg/min
Adenosine IV Femoral
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Pull-back under maximal hyperaemia
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Practical Tips

• Intravenous, centrally administered adenosine
• Guide catheter engagement/damping
• Beware distal disease
• Differing FFRs in the LAD and Cx

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Guiding Catheter in Ostium Stenosis
8F
Area Stenosis
3 mm
2.4 mm
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7F
3 mm
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2.1 mm
6F
3 mm
1.8 mm
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Practical Tips

• Intravenous, centrally administered adenosine
• Guide catheter engagement/damping
• Beware distal disease
• Differing FFRs in the LAD and Cx

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Pa
Pd - (Pm/Pa) Pw
FFR(A)pred
A
Pa - Pm Pd -Pw
Pm
B
Pd
Pw Coronary occlusive pressure
De Bruyne et al, Circulation 2000
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Practical Tips

• Intravenous, centrally administered adenosine
• Guide catheter engagement/damping
• Beware distal disease
• Differing FFRs in the LAD and Cx

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(No Transcript)
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FFR 0.63
FFR 0.90
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Conclusions

• Pressure wire assessment of the LMS is
  technically easy
• Medical treatment when the FFRgt0.75 seems safe
• Use central, iv adenosine and disengage the guide
  catheter before measuring
• Beware underestimating FFR with downstream disease