Skip to main content

Abstract

The potential benefit of revascularization depends on the presence and extent of myocardial ischemia. Performing percutaneous coronary intervention (PCI) on ischemia-inducing coronary stenoses improves both symptoms and outcome, while performing PCI on non-ischemia-inducing stenoses has no benefit and is potentially harmful. Noninvasive testing and the coronary angiogram have limited ability to distinguish specific ischemic territories and responsible stenoses, especially in multivessel coronary disease. To overcome these shortcomings, fractional flow reserve (FFR) has been developed as a stenosis-specific index to determine whether a coronary stenosis has ischemic potential. FFR-guided PCI improves both symptoms and outcome. As such, knowledge of coronary physiology and FFR has become imperative in daily coronary decision making.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 149.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 199.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 279.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Hachamovitch R, Berman DS, Shaw LJ, Kiat H, Cohen I, Cabico JA, et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation. 1998;97(6):535–43. Large SPECT study demonstrating the relationship between the extent of inducible ischemia and outcome.

    Article  PubMed  CAS  Google Scholar 

  2. Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, et al. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008;117(10):1283–91. Substudy of the COURAGE trial, which demonstrated that if ischemia is substantially reduced by PCI, the prognosis improves.

    Article  PubMed  Google Scholar 

  3. Pijls NH, van Schaardenburgh P, Manoharan G, Boersma E, Bech JW, van't Veer M, et al. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER study. J Am Coll Cardiol. 2007;49(21):2105–11. Key study demonstrating the excellent prognosis of hemodynamically nonsignificant stenoses without added benefit of performing PCI on these lesions.

    Article  PubMed  Google Scholar 

  4. Zimmermann FM, Ferrara A, Johnson NP, van Nunen LX, Escaned J, Albertsson P, et al. Deferral vs. performance of percutaneous coronary intervention of functionally non-significant coronary stenosis: 15-year follow-up of the DEFER trial. Eur Heart J. 2015;36(45):3182–8. Longest follow-up of a randomized trial using FFR.

    Article  PubMed  Google Scholar 

  5. Tonino PA, Fearon WF, De Bruyne B, Oldroyd KG, Leesar MA, Ver Lee PN, et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J Am Coll Cardiol. 2010;55(25):2816–21.

    Article  PubMed  Google Scholar 

  6. Toth GG, Johnson NP, Jeremias A, Pellicano M, Vranckx P, Fearon WF, et al. Standardization of fractional flow reserve measurements. J Am Coll Cardiol. 2016;68(7):742–53.

    Article  PubMed  Google Scholar 

  7. Pijls NH, De Bruyne B, Peels K, Van Der Voort PH, Bonnier HJ, Bartunek JKJ, et al. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med. 1996;334(26):1703–8. Key paper showing high sensitivity (90%) and specificity (100%) of FFR versus a unique gold standard.

    Article  PubMed  CAS  Google Scholar 

  8. Tonino PA, De Bruyne B, Pijls NH, Siebert U, Ikeno F, Veer M, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009;360(3):213–24. Landmark study showing superiority of FFR-guided PCI to angiography-guided PCI in patients with multivessel disease.

    Article  PubMed  CAS  Google Scholar 

  9. van Nunen LX, Zimmermann FM, Tonino PA, Barbato E, Baumbach A, Engstrøm T, et al. Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomised controlled trial. Lancet. 2015;386(10006):1853–60.

    Article  PubMed  Google Scholar 

  10. De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012;367(11):991–1001. Key study on the benefit of FFR-guided PCI versus medical therapy in patients with stable stable coronary artery disease and functionally significant stenoses.

    Article  PubMed  CAS  Google Scholar 

  11. Li J, Elrashidi MY, Flammer AJ, Lennon RJ, Bell MR, Holmes DR, et al. Long-term outcomes of fractional flow reserve-guided vs. angiography-guided percutaneous coronary intervention in contemporary practice. Eur Heart J. 2013;34(18):1375–83.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  12. Park SJ, Ahn JM, Park GM, Cho YR, Lee JY, Kim WJ, et al. Trends in the outcomes of percutaneous coronary intervention with the routine incorporation of fractional flow reserve in real practice. Eur Heart J. 2013;34(43):3353–61.

    Article  PubMed  Google Scholar 

  13. Hamilos M, Muller O, Cuisset T, Ntalianis A, Chlouverakis G, Sarno G, et al. Long-term clinical outcome after fractional flow reserve-guided treatment in patients with angiographically equivocal left main coronary artery stenosis. Circulation. 2009;120(15):1505–12. Largest study on the use of FFR to guide revascularization of equivocal left main stenosis.

    Article  PubMed  Google Scholar 

  14. Yong AS, Daniels D, De Bruyne B, Kim HS, Ikeno F, Lyons J, et al. Fractional flow reserve assessment of left main stenosis in the presence of downstream coronary stenoses. Circ Cardiovasc Interv. 2013;6(2):161–5.

    Article  PubMed  Google Scholar 

  15. Koo BK, Park KW, Kang HJ, Cho YS, Chung WY, Youn TJ, et al. Physiological evaluation of the provisional side-branch intervention strategy for bifurcation lesions using fractional flow reserve. Eur Heart J. 2008;29(6):726–32. Study demonstrating the usefulness of FFR to guide treatment decisions in the treatment of side branches.

    Article  PubMed  Google Scholar 

  16. Chen SL, Ye F, Zhang JJ, Xu T, Tian NL, Liu ZZ, et al. Randomized comparison of FFR-guided and angiography-guided provisional stenting of true coronary bifurcation lesions: the DKCRUSH-VI trial (Double Kissing Crush Versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions VI). JACC Cardiovasc Interv. 2015;8(4):536–46.

    Article  PubMed  Google Scholar 

  17. Ntalianis A, Sels JW, Davidavicius G, Tanaka N, Muller O, Trana C, et al. Fractional flow reserve for the assessment of nonculprit coronary artery stenoses in patients with acute myocardial infarction. JACC Cardiovasc Interv. 2010;3(12):1274–81. Paper demonstrating that FFR of non-culprit stenoses at the time of myocardial infarction is reliable.

    Article  PubMed  Google Scholar 

  18. Engstrøm T, Kelbæk H, Helqvist S, Høfsten DE, Kløvgaard L, Holmvang L, et al. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015;386(9994):665–71.

    Article  PubMed  Google Scholar 

  19. Botman CJ, Schonberger J, Koolen S, Penn O, Botman H, Dib N, et al. Does stenosis severity of native vessels influence bypass graft patency? A prospective fractional flow reserve-guided study. Ann Thorac Surg. 2007;83(6):2093–7.

    Article  PubMed  Google Scholar 

  20. Pellicano M, De Bruyne B, Toth GG, Casselman F, Wijns W, Barbato E. Fractional flow reserve to guide and to assess coronary artery bypass grafting. Eur Heart J. 2016;pii:ehw505. https://doi.org/10.1093/eurheartj/ehw505. [Epub ahead of print]

    Article  Google Scholar 

  21. Pijls NH, Klauss V, Siebert U, Powers E, Takazawa K, Fearon WF, et al. Coronary pressure measurement after stenting predicts adverse events at follow-up: a multicenter registry. Circulation. 2002;105(25):2950–4.

    Article  PubMed  Google Scholar 

  22. Tonino PA, Johnson NP. Why is fractional flow reserve after percutaneous coronary intervention not always 1.0? JACC Cardiovasc Interv. 2016;9(10):1032–5.

    Article  PubMed  Google Scholar 

  23. Jeremias A, Maehara A, Généreux P, Asrress KN, Berry C, De Bruyne B, et al. Multicenter core laboratory comparison of the instantaneous wave-free ratio and resting Pd/Pa with fractional flow reserve: the RESOLVE study. J Am Coll Cardiol. 2014;63(13):1253–61. Comprehensive core laboratory analysis showing the accuracy of resting Pd/Pa and iFR to identify inducible ischemia of only 80%.

    Article  PubMed  Google Scholar 

  24. Zimmermann FM, De Bruyne B, Pijls NH, Desai M, Oldroyd KG, Park SJ, et al. Rationale and design of the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) 3 trial: a comparison of fractional flow reserve–guided percutaneous coronary intervention and coronary artery bypass graft surgery in patients with multivessel coronary artery disease. Am Heart J. 2015;170(4):619–626.e2.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to W. A. L. Tonino MD, PhD .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Zimmermann, F., Pijls, N., Tonino, W. (2018). Fractional Flow Reserve. In: Lanzer, P. (eds) Textbook of Catheter-Based Cardiovascular Interventions. Springer, Cham. https://doi.org/10.1007/978-3-319-55994-0_18

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-55994-0_18

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-55993-3

  • Online ISBN: 978-3-319-55994-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics