Contrast Fractional Flow Reserve (cFFR): A pragmatic response to the call for simplification of invasive functional assessment
Section snippets
From coronary flow reserve to fractional flow reserve
Our knowledge of coronary physiology stems from the seminal studies by Lance Gould et al. [1] who first assessed the quantitative haemodynamic relationship between lumen reduction and Coronary Flow Reserve (CFR). They studied 12 consecutive dogs who underwent a progressive occlusion of the left circumflex coronary artery inducing hyperaemia by the intra-coronary (i.c.) injection of Sodium Diatrizoate, a high osmolality contrast medium. Their data demonstrated that resting coronary flow is not
Vasodilator agents for hyperaemia
The most potent stimulus to hyperaemia is reactive hyperaemia to coronary occlusion that was used in past to clinically validate CFR [12]. However the need for a more practical method to induce hyperaemia for clinical purposes lead to introduction of papaverine [13] and then of intra-venous (i.v.) adenosine [14]. I.v. administration of adenosine at 140 μg/Kg/min is considered the best combination between hyperaemia and side effects (including dyspnoea, chest pain, hypotension, flushing, anxiety
Resting indexes: Pd/Pa and iFR
In the attempt to obviate the need for the administration of vasodilator agents, attention has been paid to the possible use of resting indexes. Mamas et al. [26] investigated the relationship between resting Pd/Pa and FFR obtained during maximal hyperaemia. They retrospectively analysed 528 consecutive FFR (in which maximal hyperaemia was obtained by i.v. adenosine 140 μg/Kg/min) performed in 483 patients over a 2-year period. The authors demonstrated that resting Pd/Pa has a significant
cFFR: the “The egg of Columbus” [45]
The hyperaemic potential of radiographic contrast media is well recognized since 60s. In addition to potentially cardio-toxic effects, such as ischemic ST-depression, arrhythmias and LV function depression, all ionic contrast media showed the ability to induce a significant coronary hyperaemia [46]. On this basis, some years later, Lance Gould used Sodium Diatrizoate to induce hyperaemia in his pivotal studies of CFR [1]. More recently, the availability of non-ionic contrast media with a very
Conclusions
Pharmacological hyperaemia for FFR assessment is time-consuming, costly, frequently unpleasant for the patient and sometimes associated with serious side effects. On the contrary cFFR can be quickly obtained, at very low cost, in the absence of substantial side effects. Among alternative indexes, cFFR shows the best correlation with FFR but has not been yet tested in a randomized trial with clinical end-points [59]. If accuracy of cFFR were translated in favourable results on clinical
Conflicts of interest
A.M.L. received speaking honoraria from St. Jude Medical/Abbott and from Bracco Imaging, F.C., F.L.P. and M.A. have no conflicts of interest.
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