Assessment of Intermediate Severity Coronary Lesions in the Catheterization Laboratory
Jonathan Tobis, MD*,
Babak Azarbal, MD and
Leo Slavin, MD
David Geffen School of Medicine at UCLA, Department of Medicine (Division of Cardiology), Los Angeles, California
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Figure 1 Intermediate Lesion That According to an Expert Panel Requires an Intervention on the Basis of the Images Attained From Coronary Angiography
(A) A coronary angiogram that shows an intermediate lesion in the mid-left anterior descending artery (LAD) just distal to the bifurcation with the diagonal branch. This case was presented during an international live case presentation conference with a panel of 8 renowned interventional cardiologists. There was no accord among the cardiologists whether this angiogram represented a significant stenosis. There were conflicting recommendations whether to perform coronary angioplasty in the LAD. (B) Intravascular ultrasound (IVUS) imaging was performed. Representative cross-sectional IVUS images are shown. (Left) At the greatest area of stenosis, the smallest dimension of the lumen was 4.7 mm2. (Right) The IVUS image proximal to the bifurcation. (Middle) The IVUS cross-sectional image of the mid-LAD at the level of the bifurcation with the diagonal branch. Fractional flow reserve (FFR) was also performed and was measured at 0.85. Contrary to the panel's suggestions based on the angiogram, on the basis of the IVUS images and FFR, no intervention was performed.
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Figure 2 Fractional Flow Reserve
A schematic cartoon demonstrating the concept and derivation of fractional flow reserve (FFR). FFR = (Pd – Pv)/(Pa – Pv). The central venous pressure approaches 0; therefore, Pv is negligible and FFR = Pd/Pa. Pa = mean proximal coronary artery pressure; Pd = mean coronary artery pressure distal to the lesion; Pv = mean central venous pressure.
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