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Year 3 Cardiac physiology > CC8: PCI and Radi-wire FFR > Flashcards

CC8: PCI and Radi-wire FFR Flashcards

1
Q

What things could make PCI complex?

A

-Calcified lesions
-Bifurcation lesions
-Unprotected left main coronary lesions
-Chronic total occlusions
-Ostial lesion
-Graft PCI

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2
Q

How can calcified lesions affect stent?

A

-Stent under-expansion
-Stent malapposition

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3
Q

What is rotablation?

A

-Rapidly rotating burr to modify calcium
-Increase lumen size

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4
Q

Downsides of rotablation

A

-Higher complication rate compared to shockwave
-Causes trauma to vessel
-Doesn’t collect calcium so could flow downstream

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5
Q

What drugs are given during rotablation and why?

A

Heparin
-Prevents thrombus
Nitrate
-Prevents spasm
Verapamil
-no-reflow

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6
Q

Shockwave balloon and its benefits

A

-Sonic waves aim to fracture the intra-plaque calcium
-Reduced vascular intimal injury
-Ease of use

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7
Q

What needs to be considered when lesion is at bifurcation?

A

-There is a risk of losing the side branch when atheroma/thrombus is displaced
-So 2 wires are used to allow access to side branch if needed

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8
Q

Techniques for treating bifurcation lesions

A

-Jailed wires
-Post stent optimisation technique (POT)
-Kissing balloons

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9
Q

How to stent left main?

A

-Wires down LAD and Circ
-Megatron stent used because it can be over-expanded
-Likely to have pressure drop (have metaraminol)
-Left main inflations short as possible

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10
Q

Megatron stent and uses

A

-Can expand from 3.5 to 6mm
Used for:
-Tapered vessels
-Bifurcations
-Proximal optimisation technique (POT)

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11
Q

Issues with ostial stenting

A

-Ostium may be missed
-If struts extend to aorta, makes re-engaging coronary very difficult
-Stent struts can be flared

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12
Q

CTO antegrade technique

A

-Negotiate proximal cap
-Advance length of occluded segment
-Wire exchanges over micro-catheter
-Dilate and modify (rota/shockwave)
-Stent
-IVUS

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13
Q

CTO retrograde technique

A

-Soft wire negotiated through donor artery and collaterals into distal target vessel
-At site of occlusion, soft wire exchanged over microcatheter for stiff wire

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14
Q

Why is it easier to cross the fibrous cap retrogradely?

A

-Proximal cap is likely fibro-calcific
-Proximal cap is likely to be at a side branch ostium

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15
Q

Risks of graft PCI?

A

-Mean age of patients is older
-Higher burden of other disease
-Higher risk of no-reflow
-Higher risk of perforations

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16
Q

What factors could make PCI complex?

A

Patient comorbidites
-HF
-Diabetes
-Unstable angina/NSTEMI

Complex CAD
-Multi-vessel disease
-Left main disease
-Long lesion

Haemodynamic compromise
-Low EF
-Low CO

Operator experience
-Individual skills
-Personal experience

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17
Q

Why do we use pressure wire?

A

-Used for moderate/intermediate lesions to help decide whether or not a stenosis is significant
-Comparing blood pressure before and after stenosis provides information about blood flow

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18
Q

How is guide catheter used in pressure wire?

A

-Positioned at ostium of vessel
-Pressure is measured invasively via closed fluid system to transducer

19
Q

How is transducer used in pressure wire?

A

-Ensure transducer at patient’s heart level
-Ensure good aortic pressure trace before starting pressure wire study

20
Q

How to prepare pressure wire?

A

-Flush wire in packaging with saline
-Ensure pressure sensor fully immersed in saline, requires 20-30ml flush
-Allow pressure sensor to stabilise in saline solution for 1 min on flat surface before zeroing wire

21
Q

Describe the pressure wire

A

-Wire has 3cm radio-opaque tip before pressure wire sensor
-Sensor is 3cm from tip of wire

22
Q

4 steps in pressure wire

A

Step 1: Zero transducer
Step 2: Connect wire
Step 3: Equalise pressure wire
Step 4: Advance wire beyond lesion
(pressure sensor at least 2-3cm distal to lesion)

23
Q

How to introduce pressure wire

A

-Minimal shaping to tip of wire to prevent damage to pressure sensor
-Introducer needle helps advance and position
-But must be removed prior to any equalisation or measurements being made

24
Q

How are coronary spasms prevented in pressure wire study?

A

-Nitrates given intra-coronary beforehand
-Ensures vessel is at maximum lumen diameter

25
Q

Why do we normalise/equalise pressure wire?

A

-Usually a small drift between catheter and pressure wire
-Normalising/equalising allows system to adjust for any drift
-Ensure catheter is well-flushed of contrast and medications prior to equalising

26
Q

What should you do if there is large difference in catheter and pressure wire pressures before equalising?

A

-Ensure introducer needle removed
-O ring/Y connector fully closed?

27
Q

What should pressure be after equalising

A

1.0
-No difference between catheter and pressure wire

28
Q

Equalisation in ostial lesion assessments

A

-For aorto-ostial lesions equalisation performed with catheter and pressure wire in the aorta

29
Q

What can cause damping of aortic waveform in pressure wire study?

A

-A wedged guide catheter in the ostium of the right or left main vessel

30
Q

What is FFR

A

Fractional Flow Reserve
-Adenosine given to dilate vessels and increase blood flow, inducing ‘maximum hyperaemia’
-Patients should have haemodynamic response to adenosine even if lesion is not significant

31
Q

Effect of giving adenosine

A

-Normally small pressure increase and then decrease indicates hyperaemia achieved
-Adenosine may cause heart block
-Patients feel SOB with hyperaemia

32
Q

What FFR value indicates lesion?

A

FFR<0.80 indicates significant lesion
FFR>0.80 no significant benefit by treating lesion

33
Q

How can a significant narrowing on angiogram not be causing ischaemia?

A

-FFR accounts for size of perfusion area
-FFR accounts for contribution of collaterals

34
Q

What is IFR/RFR?

A

RFR - Resting Full cycle Ratio
IFR - Instantaneous wave-free Ratio
-Non-stress measurement of intracoronary pressure difference
-Uses diastolic flow reserve and average of 3-5 beats
-Significant if <0.90

35
Q

When shoudl IFR/RFR be used instead of FFR?

A

-When adenosine is contraindicated
E.g. In asthmatic patients

36
Q

Advantages of IFR pullback?

A

-Provides the benefits of pullback measurements without the need for hyperaemia
-Live display of single-cycle iFR value
-Pullback assessment of multiple lesions

37
Q

How to do drift check?

A

-After taking a measurement check the wire has not drifted (sensor error)
-Pullback wire to the position it was normalised
-Flush catheter and ensure Pd/Pa value is back to 1.0
-If value is not within 0.98-1.02, then procedure should be repeated

38
Q

Reasons or drift

A

-Has guide catheter been adequately flushed with saline?
-Is pressure wire checked at same position as during equalisation?
-Is guiding catheter same position as during equalisation?
-Has the height of transducer changed?
-Is the introducer needle left in the Y-connector?
-Was the pressure wire prepared correctly? (placed flat and flushed with 20-30ml saline)

39
Q

When can you get a reverse pressure gradient (e.g. FFR 1.04)?

A

-In large RCA or Circ vessels
-As wire passes distally and falls below level of transducer
-Can confirm not drift by taking pressure sensor back to ostium of catheter

40
Q

What is Whipping artefact?

A

-Can occur when pressure sensor interacts with wall of coronary
-More likely in small vessels

41
Q

What is CT FFR?

A

-Newer FFR technology
-Non-invasive
-Coronary CT data sent to HeartFlow for analysis
-Creates personalised 3D digital model of coronary anatomy
-Can predict new FFR value after treating lesion

42
Q

What is CFR?

A

Coronary flow reserve
-Measures blood flow in epicardial arteries and the microvasculature
-Calculates difference in flow from resting and hyperaemia, decreases with microvascular disease
<2.5 is abnormal

43
Q

What is IMR?

A

Index of microcirculatory resistance
-Measures the blood flow in microvasculature
-Uses FFR to correct for epicardial flow
>25 is abnormal

Year 3 Cardiac physiology (30 decks)

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