Intracoronary Hemodynamics

  • James E. Harvey
  • Stephen G. Ellis
Part of the Contemporary Cardiology book series (CONCARD)


Selective coronary angiography is the gold standard for evaluating the presence and extent of epicardial coronary artery disease. Despite advances in fluoroscopic imaging and catheterization techniques, the evaluation of the intermediate coronary stenosis (luminal diameter narrowing between 40% and 70%) remains a challenge for invasive cardiologists secondary to multiple issues. Vessel characteristics and limitations related to image acquisition impair the accuracy of lesion severity assessment despite obtaining coronary angiograms in multiple fluoroscopic views. Intravascular visualization techniques such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT) augment anatomical analysis but do not necessarily provide information on the functional significance of a lesion. Coronary flow reserve (CFR), fractional flow reserve (FFR), and instantaneous wave-free radio (iFR) have been developed to evaluate the physiologic or functional significance of coronary lesions in the cardiac catheterization suite.


FFR CFR iFR Angiography Intracoronary Hemodynamics Catheterization Assessment 


  1. 1.
    Grondin CM, Dyrda I, Pasternac A, Campeau L, Bourassa MG, Lesperance J. Discrepancies between cineangiographic and postmortem findings in patients with coronary artery disease and recent myocardial revascularization. Circulation. 1974;49:703–8.CrossRefGoogle Scholar
  2. 2.
    Hutchins GM, Bulkley BH, Ridolfi RL, Griffith LS, Lohr FT, Piasio MA. Correlation of coronary arteriograms and left ventriculograms with postmortem studies. Circulation. 1977;56:32–7.CrossRefGoogle Scholar
  3. 3.
    Arnett EN, Isner JM, Redwood DR, et al. Coronary artery narrowing in coronary heart disease: comparison of cineangiographic and necropsy findings. Ann Intern Med. 1979;91:350–6.CrossRefGoogle Scholar
  4. 4.
    Fisher LD, Judkins MP, Lesperance J, et al. Reproducibility of coronary arteriographic reading in the coronary artery surgery study (CASS). Catheter Cardiovasc Diagn. 1982;8:565–75.CrossRefGoogle Scholar
  5. 5.
    Gould KL, Lipscomb K, Hamilton GW. Physiologic basis for assessing critical coronary stenosis. Instantaneous flow response and regional distribution during coronary hyperemia as measures of coronary flow reserve. Am J Cardiol. 1974;33:87–94.CrossRefGoogle Scholar
  6. 6.
    Gould KL, Kirkeeide RL, Buchi M. Coronary flow reserve as a physiologic measure of stenosis severity. J Am Coll Cardiol. 1990;15:459–74.CrossRefGoogle Scholar
  7. 7.
    Doucette JW, Corl PD, Payne HM, et al. Validation of a Doppler guide wire for intravascular measurement of coronary artery flow velocity. Circulation. 1992;85:1899–911.CrossRefGoogle Scholar
  8. 8.
    Labovitz AJ, Anthonis DM, Cravens TL, Kern MJ. Validation of volumetric flow measurements by means of a Doppler-tipped coronary angioplasty guide wire. Am Heart J. 1993;126:1456–61.CrossRefGoogle Scholar
  9. 9.
    Miller DD, Donohue TJ, Younis LT, et al. Correlation of pharmacological 99mTc-sestamibi myocardial perfusion imaging with poststenotic coronary flow reserve in patients with angiographically intermediate coronary artery stenoses. Circulation. 1994;89:2150–60.CrossRefGoogle Scholar
  10. 10.
    Heller LI, Cates C, Popma J, et al. Intracoronary Doppler assessment of moderate coronary artery disease: comparison with 201Tl imaging and coronary angiography. FACTS study group. Circulation. 1997;96:484–90.CrossRefGoogle Scholar
  11. 11.
    Akasaka T, Yoshida K, Hozumi T, et al. Retinopathy identifies marked restriction of coronary flow reserve in patients with diabetes mellitus. J Am Coll Cardiol. 1997;30:935–41.CrossRefGoogle Scholar
  12. 12.
    Lorenzoni R, Gistri R, Cecchi F, et al. Coronary vasodilator reserve is impaired in patients with hypertrophic cardiomyopathy and left ventricular dysfunction. Am Heart J. 1998;136:972–81.CrossRefGoogle Scholar
  13. 13.
    Czernin J, Muller P, Chan S, et al. Influence of age and hemodynamics on myocardial blood flow and flow reserve. Circulation. 1993;88:62–9.CrossRefGoogle Scholar
  14. 14.
    Schafer S, Kelm M, Mingers S, Strauer BE. Left ventricular remodeling impairs coronary flow reserve in hypertensive patients. J Hypertens. 2002;20:1431–7.CrossRefGoogle Scholar
  15. 15.
    Voudris V, Avramides D, Koutelou M, et al. Relative coronary flow velocity reserve improves correlation with stress myocardial perfusion imaging in assessment of coronary artery stenoses. Chest. 2003;124:1266–74.CrossRefGoogle Scholar
  16. 16.
    Bugiardini R, Bairey Merz CN. Angina with “normal” coronary arteries: a changing philosophy. JAMA. 2005;293:477–84.CrossRefGoogle Scholar
  17. 17.
    Reis SE, Holubkov R, Conrad Smith AJ, et al. Coronary microvascular dysfunction is highly prevalent in women with chest pain in the absence of coronary artery disease: results from the NHLBI WISE study. Am Heart J. 2001;141:735–41.CrossRefGoogle Scholar
  18. 18.
    Pijls NH, van Son JA, Kirkeeide RL, De Bruyne B, Gould KL. Experimental basis of determining maximum coronary, myocardial, and collateral blood flow by pressure measurements for assessing functional stenosis severity before and after percutaneous transluminal coronary angioplasty. Circulation. 1993;87:1354–67.CrossRefGoogle Scholar
  19. 19.
    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.CrossRefGoogle Scholar
  20. 20.
    Kern MJ, de Bruyne B, Pijls NH. From research to clinical practice: current role of intracoronary physiologically based decision making in the cardiac catheterization laboratory. J Am Coll Cardiol. 1997;30:613–20.CrossRefGoogle Scholar
  21. 21.
    Di Segni E, Higano ST, Rihal CS, Holmes DR Jr, Lennon R, Lerman A. Incremental doses of intracoronary adenosine for the assessment of coronary velocity reserve for clinical decision making. Catheter Cardiovasc Interv. 2001;54:34–40.CrossRefGoogle Scholar
  22. 22.
    Wilson RF, White CW. Intracoronary papaverine: an ideal coronary vasodilator for studies of the coronary circulation in conscious humans. Circulation. 1986;73:444–51.CrossRefGoogle Scholar
  23. 23.
    Bartunek J, Wijns W, Heyndrickx GR, de Bruyne B. Effects of dobutamine on coronary stenosis physiology and morphology: comparison with intracoronary adenosine. Circulation. 1999;100:243–9.CrossRefGoogle Scholar
  24. 24.
    de Bruyne B, Bartunek J, Sys SU, Pijls NH, Heyndrickx GR, Wijns W. Simultaneous coronary pressure and flow velocity measurements in humans. Feasibility, reproducibility, and hemodynamic dependence of coronary flow velocity reserve, hyperemic flow versus pressure slope index, and fractional flow reserve. Circulation. 1996;94:1842–9.CrossRefGoogle Scholar
  25. 25.
    Caymaz O, Fak AS, Tezcan H, et al. Correlation of myocardial fractional flow reserve with thallium-201 SPECT imaging in intermediate-severity coronary artery lesions. J Invasive Cardiol. 2000;12:345–50.PubMedGoogle Scholar
  26. 26.
    Leesar MA, Abdul-Baki T, Akkus NI, Sharma A, Kannan T, Bolli R. Use of fractional flow reserve versus stress perfusion scintigraphy after unstable angina. Effect on duration of hospitalization, cost, procedural characteristics, and clinical outcome. J Am Coll Cardiol. 2003;41:1115–21.CrossRefGoogle Scholar
  27. 27.
    Bech GJ, De Bruyne B, Bonnier HJ, et al. Long-term follow-up after deferral of percutaneous transluminal coronary angioplasty of intermediate stenosis on the basis of coronary pressure measurement. J Am Coll Cardiol. 1998;31:841–7.CrossRefGoogle Scholar
  28. 28.
    Bech GJ, De Bruyne B, Pijls NH, et al. Fractional flow reserve to determine the appropriateness of angioplasty in moderate coronary stenosis: a randomized trial. Circulation. 2001;103:2928–34.CrossRefGoogle Scholar
  29. 29.
    Kern MJ, Donohue TJ, Aguirre FV, et al. Clinical outcome of deferring angioplasty in patients with normal translesional pressure-flow velocity measurements. J Am Coll Cardiol. 1995;25:178–87.CrossRefGoogle Scholar
  30. 30.
    Chamuleau SA, Meuwissen M, Koch KT, et al. Usefulness of fractional flow reserve for risk stratification of patients with multivessel coronary artery disease and an intermediate stenosis. Am J Cardiol. 2002;89:377–80.CrossRefGoogle Scholar
  31. 31.
    Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009;360:213–24.CrossRefGoogle Scholar
  32. 32.
    Pijls NH, De Bruyne B, Bech GJ, et al. Coronary pressure measurement to assess the hemodynamic significance of serial stenoses within one coronary artery: validation in humans. Circulation. 2000;102:2371–7.CrossRefGoogle Scholar
  33. 33.
    De Bruyne B, Pijls NH, Heyndrickx GR, Hodeige D, Kirkeeide R, Gould KL. Pressure-derived fractional flow reserve to assess serial epicardial stenoses: theoretical basis and animal validation. Circulation. 2000;101:1840–7.CrossRefGoogle Scholar
  34. 34.
    Mintz GS, Kent KM, Pichard AD, Satler LF, Popma JJ, Leon MB. Contribution of inadequate arterial remodeling to the development of focal coronary artery stenoses. An intravascular ultrasound study. Circulation. 1997;95:1791–8.CrossRefGoogle Scholar
  35. 35.
    Bech GJ, Droste H, Pijls NH, et al. Value of fractional flow reserve in making decisions about bypass surgery for equivocal left main coronary artery disease. Heart. 2001;86:547–52.CrossRefGoogle Scholar
  36. 36.
    Ziaee A, Parham WA, Herrmann SC, Stewart RE, Lim MJ, Kern MJ. Lack of relation between imaging and physiology in ostial coronary artery narrowings. Am J Cardiol. 2004;93:1404–7, A9.CrossRefGoogle Scholar
  37. 37.
    Engler RL, Schmid-Schonbein GW, Pavelec RS. Leukocyte capillary plugging in myocardial ischemia and reperfusion in the dog. Am J Pathol. 1983;111:98–111.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Claeys MJ, Bosmans JM, Hendrix J, Vrints CJ. Reliability of fractional flow reserve measurements in patients with associated microvascular dysfunction: importance of flow on translesional pressure gradient. Catheter Cardiovasc Interv. 2001;54:427–34.CrossRefGoogle Scholar
  39. 39.
    De Bruyne B, Pijls NH, Bartunek J, et al. Fractional flow reserve in patients with prior myocardial infarction. Circulation. 2001;104:157–62.CrossRefGoogle Scholar
  40. 40.
    Hanekamp CE, Koolen JJ, Pijls NH, Michels HR, Bonnier HJ. Comparison of quantitative coronary angiography, intravascular ultrasound, and coronary pressure measurement to assess optimum stent deployment. Circulation. 1999;99:1015–21.CrossRefGoogle Scholar
  41. 41.
    Pijls NH, Klauss V, Siebert U, et al. Coronary pressure measurement after stenting predicts adverse events at follow-up: a multicenter registry. Circulation. 2002;105:2950–4.CrossRefGoogle Scholar
  42. 42.
    Rieber J, Schiele TM, Erdin P, et al. Fractional flow reserve predicts major adverse cardiac events after coronary stent implantation. Z Kardiol. 2002;91(Suppl 3):132–6.CrossRefGoogle Scholar
  43. 43.
    Koo BK, Kang HJ, Youn TJ, et al. Physiologic assessment of jailed side branch lesions using fractional flow reserve. J Am Coll Cardiol. 2005;46:633–7.CrossRefGoogle Scholar
  44. 44.
    Colombo A, Moses JW, Morice MC, et al. Randomized study to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions. Circulation. 2004;109:1244–9.CrossRefGoogle Scholar
  45. 45.
    Jeremias A, Filardo SD, Whitbourn RJ, et al. Effects of intravenous and intracoronary adenosine 5′-triphosphate as compared with adenosine on coronary flow and pressure dynamics. Circulation. 2000;101:318–23.CrossRefGoogle Scholar
  46. 46.
    Nijjer SS, de Waard GA, Sen S, et al. Coronary pressure and flow relationships in humans: phasic analysis of normal and pathological vessels and the implications for stenosis assessment: a report from the Iberian-Dutch-English (IDEAL) collaborators. Eur Heart J. 2016;37:2069–80.CrossRefGoogle Scholar
  47. 47.
    Sen S, Escaned J, Malik IS, et al. Development and validation of a new adenosine-independent index of stenosis severity from coronary wave-intensity analysis: results of the ADVISE (ADenosine Vasodilator Independent Stenosis Evaluation) study. J Am Coll Cardiol. 2012;59:1392–402.CrossRefGoogle Scholar
  48. 48.
    Escaned J, Echavarria-Pinto M, Garcia-Garcia HM, et al. Prospective assessment of the diagnostic accuracy of instantaneous wave-free ratio to assess coronary stenosis relevance: results of ADVISE II international, multicenter study (ADenosine Vasodilator Independent Stenosis Evaluation II). JACC Cardiovasc Interv. 2015;8:824–33.CrossRefGoogle Scholar
  49. 49.
    Davies JE, Sen S, Dehbi HM, et al. Use of the instantaneous wave-free ratio or fractional flow reserve in PCI. N Engl J Med. 2017;376:1824–34.CrossRefGoogle Scholar
  50. 50.
    Gotberg M, Christiansen EH, Gudmundsdottir IJ, et al. Instantaneous wave-free ratio versus fractional flow reserve to guide PCI. N Engl J Med. 2017;376:1813–23.CrossRefGoogle Scholar
  51. 51.
    Escaned J, Ryan N, Mejia-Renteria H, et al. Safety of the deferral of coronary revascularization on the basis of instantaneous wave-free ratio and fractional flow reserve measurements in stable coronary artery disease and acute coronary syndromes. JACC Cardiovasc Interv. 2018;11:1437–49.CrossRefGoogle Scholar
  52. 52.
    Kim HL, Koo BK, Nam CW, et al. Clinical and physiological outcomes of fractional flow reserve-guided percutaneous coronary intervention in patients with serial stenoses within one coronary artery. JACC Cardiovasc Interv. 2012;5:1013–8.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • James E. Harvey
    • 1
  • Stephen G. Ellis
    • 2
  1. 1.York HospitalWellSpan Health SystemYorkUSA
  2. 2.Cleveland ClinicClevelandUSA

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