Physiology-Based Revascularization of Left Main Coronary Artery Disease

Abstract

It is of critical importance to correctly assess the significance of a left main lesion. Underestimation of significance beholds the risk of inappropriate deferral of revascularization, whereas overestimation may trigger major but unnecessary interventions. This article addresses the invasive physiological assessment of left main disease and its role in deciding upon revascularization. It mainly focuses on the available evidence for fractional flow reserve and instantaneous wave-free ratio, their interpretation, and limitations. We also discuss alternative invasive physiological indices and imaging, as well as the link between physiology, ischemia, and prognosis.

Intravascular Imaging versus Physiological Assessment versus Biomechanics—Which Is a Better Guide for Coronary Revascularization

“…The current gold standard of lesion-specific coronary revascularization decisions in patients with stable CAD-FFR is well-correlated with values measured using established equations and accurate 3-dimensional IVUS imaging [ 43 , 82 ]. This invasive visualization technique became a new standard in cases with younger patients, who have less high-risk clinical features, and have more complex lesions such as left main and multivessel disease in which IVUS yields the largest benefit in reducing MACE and target-lesion revascularization [ 83 , 84 ].…”

Fractional flow reserve: physiological bases, clinical applications and limitations

“…Table 2 presents prospective cohort studies, which evaluated the role of FFR-guided revascularization of LMCA lesions. 43 In practice, important caveats of FFR assessment of LMCA lesions need to be acknowledged. LMCA is usually accompanied by downstream disease in the left anterior descending (LAD) and left circumflex (LCx) arteries.…”