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Pressure Wire Evaluation of the Left Main Stem

Pressure Wire Evaluation of the Left Main Stem. Dr Phil MacCarthy Consultant Cardiologist King’s Cardiac Centre. Left Main 5+ at AA2007, Jan 24 th , 2007. No conflicts of interest. Assessment of critical LMS disease is sometimes easy…. A more common clinical scenario.

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Pressure Wire Evaluation of the Left Main Stem

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  1. Pressure Wire Evaluation of the Left Main Stem Dr Phil MacCarthy Consultant Cardiologist King’s Cardiac Centre Left Main 5+ at AA2007, Jan 24th, 2007.

  2. No conflicts of interest

  3. Assessment of critical LMS disease is sometimes easy…

  4. A more common clinical scenario

  5. How do you currently establish the haemodynamic importance of a LMS lesion? Surgery!

  6. The stakes are high…

  7. The angiogram is a 2D representation of a complex 3D structure Topol and Nissen, Circulation 1995

  8. Correlation between LMS anatomy and physiology Jasti et al, Circulation 2004

  9. Studies of LMS FFR vs Outcome

  10. 54 patients with equivocal LMS stenosis – FFR>0.75 in 24 (medical), FFR<0.75in 30 (CABG) Bech et al Heart 2001; 86: 547

  11. Jasti et al, Circulation 2004

  12. 51 patients – 24 FFR>0.75 treated medically, 27 FFR<0.75 treated surgically Lindstaedt et al, Am Heart J 2006; 152: 156

  13. Left main disease in the stable patient

  14. Case 1 - Stable

  15. Case 1 - Stable

  16. Case 2 - Stable

  17. Case 2 - Stable • Pressure-wire study LMS • FFR 0.88 – No significant step-up on hyperaemic pull-back • Proceed to PCI of RCA CTO….

  18. Case 2 - Stable

  19. Left main disease in acute coronary syndromes

  20. Case 1 - Unstable

  21. Case 1 - Unstable

  22. Case 2 - Unstable

  23. 5.5mm2 Case 2 - Unstable

  24. Case 2 - Unstable

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

  26. Intravenous Infusion of Adenosine 140 µg/kg/min Adenosine IV Femoral

  27. Pull-back under maximal hyperaemia

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

  29. Guiding Catheter in Ostium = Stenosis 8F Area Stenosis 2.4 mm 3 mm 64% 7F 49 % 3 mm 2.1 mm 6F 36 % 3 mm 1.8 mm

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

  31. (Pa - Pw) (Pm - Pd) FFR(B)pred = Pa (Pm - Pw) 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

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

  33. FFR = 0.63 FFR = 0.90

  34. Conclusions • Pressure wire assessment of the LMS is technically easy • Medical treatment when the FFR>0.75 seems safe • Use central, iv adenosine and disengage the guide catheter before measuring • Beware underestimating FFR with downstream disease

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