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Speaker's name: Barry Hennigan ☑ Speaker for Volcano Corp today

“How Coronary Flow Reserve Changed My Management ” Case Presentatio n Dr Barry Hennigan Professor Keith Oldroyd Interventional Cardiology Department West of Scotland Regional Heart and Lung Centre. Potential conflicts of interest. Speaker's name: Barry Hennigan

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Speaker's name: Barry Hennigan ☑ Speaker for Volcano Corp today

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  1. “How Coronary Flow Reserve Changed My Management”Case PresentationDr Barry HenniganProfessor Keith OldroydInterventional Cardiology DepartmentWest of Scotland Regional Heart and Lung Centre

  2. Potential conflicts of interest Speaker's name: Barry Hennigan ☑Speaker for Volcano Corp today

  3. Patient MW • 65 year old man • Presented July 2013 • CCS2 angina • CABG Feb 1st 2011 • LIMA to LAD Heavily calcified proximal lesion (failed PCI) • SVG to OM- (poor surgical target noted intra-op)

  4. Hx continued • T2DM • Obesity BMI 39 • HTN • Hyperlipidemia • Echo - mild Ant HK with good LV fx

  5. July 2013 LAO RCA • RAO RCA

  6. July 2013 • LAO Cranial LIMA to LAD RCA Caudal LIMA to LAD

  7. Angiogram July 2013 • LAO Caudal LCX LAO Cranial LCX

  8. Angiogram July 2013 Summary • Heavily calcified proximal LCX • Occluded SVG to OM • Patent LIMA to LAD • Patent native RCA • Medical therapy advised

  9. Clinical Course Nov 13-March 14 • Ongoing exertional chest pain • Interfering with ability to run business • On oral nitrate, ca++ channel blocker and BB • Keen for intervention

  10. ? Evidence of Ischemia • DSE-suboptimal image quality due to BMI • Daycase FFR +/- PCI to LCX

  11. March 2014 RAO Caudal • PA Caudal

  12. Combowire Assessment

  13. Combowire Design

  14. Case: Resting Perfusion

  15. Case: Hyperemic Perfusion

  16. Dilemma • Normal FFR • Abnormal CFR • Ongoing symptoms • Single probable ischemic territory • ? Optimal treatment

  17. PCI • Predilated with a 3.0 sprinter to 18 atm • Stented with a 4.0 by 18mm biomatrix to 14 atm • Post dilated 4.0 NC

  18. Hyperemic Perfusion Post PCI

  19. Clinical Progress • Painfree • Back running business • Walking 1 mile without symptoms • Exertional SOB on hills only • Actively losing weight • Completed further cardiac rehab course

  20. Case Summary • Discordant FFR/CFR results • ?causes – increased microvascular resistance • Convincing clinical scenario for ischemia • Single identifiable culprit territory • Excellent improvement in flow post intervention

  21. Relationship between FFR CFR Johnson et al. J Am Coll Cardiol Img. 2012;5(2):193-202

  22. Reasons for Discordant FFRwhere FFR>0.75 but CFR<2 • Diffuse microvascular disease • Previous infarcted territory • Distal stenosis

  23. Influencing Factors on CFR - Preload - Afterload • Contractility • Hypertension • Diabetes mellitus • Cardiomyopathy • Age - LVH • Recent MI

  24. Thermodilution Versus Doppler • Tmnhyperaemic/Tmnrestratio • Thermodilutionmay overestimate CFR • Mean values • IMR calculation rather than HMR • Good correlation with doppler • Uses APVH/APVB • In good hands >90% success in achieving good doppler signal • Learning curve European Heart Journal (2004) 25, 219–223

  25. Thermodilution vs Doppler ctd European Heart Journal (2004) 25, 219–223

  26. TIPS • Anterograde vs retrograde • Positioning- use audio cues • Use sidebranches • Know your console • Wire handling- avoid trauma to tip • Experienced Operator • Don’t give up

  27. Conclusion • Would we recommend this approach routinely? • No • Flow does add useful information • New wire technologies enable easier + rapid complementary dataset acquisition that improve decision making • Supplements pressure data • Should be interpreted carefully with attention to clinical scenario • Further validation in RCTs awaited

  28. Thank You Thank You

  29. Defer if CFR>2

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