Abstract 14685: Efficacy of Combined Administration of Intracoronary Papaverine and Intravenous Adenosine 5’-Triphosphate in Assessment of Fractional Flow Reserve

Abstract

Purpose: Inducing maximal coronary hyperemia is important to measure fractional flow reserve (FFR) accurately. Administration of intracoronary (IC) papaverine and intravenous (IV) adenosine 5’-triphosphate (ATP) have been used to achieve maximal hyperemia in the assessment of FFR. However, they may not induce maximal hyperemia in all patients. We aimed to evaluate combined effect of IC papaverine and IV ATP on FFR measurements. Methods: FFR measurements using administration of IC papaverine (12 mg in the left coronary artery and 8 mg in the right coronary artery), IV ATP (140 μg/kg/min), and the combination of IC papaverine plus IV ATP (additional IC bolus infusion of papaverine during IV ATP) were performed in 57 lesions of 52 consecutive patients. FFR values, symptoms, development of atrioventricular block (AVB), and ventricular arrhythmia were recorded. Results: Mean FFR values with IC papaverine, IV ATP, and the combination of IC papaverine and IV ATP were comparable (0.75 ± 0.13 vs. 0.76 ± 0.13 vs. 0.75 ± 0.13, p = 0.87). The proportion of lesions with a positive FFR (FFR ≤0.80) were not significantly different between the 3 methods (54.4% vs. 47.4% vs. 64.9%, p = 0.17). IC papaverine and IV ATP detected 25 lesions and 32 lesions with a negative FFR (FFR > 0.80), respectively. Of these, 7 (28%) and 11 lesions (34%) showed positive FFR with the combination of IC papaverine and IV ATP. Within the region of physiologically intermediate FFR values (0.75 to 0.85 obtained by IV ATP), there were significant differences in the FFR values (0.81 ± 0.02 vs. 0.79 ± 0.03, p = 0.01) and the proportion of positive FFR (48.3% vs. 66.7%, p < 0.01) between IV ATP and the combination of IC papaverine and IV ATP. IC papaverine increased ventricular premature contraction in 2%. IV ATP caused flushing in 48%, chest oppression in 27%, shortness of breath in 10%, and transient 2nd degree AVB in 3%. The combination of IC papaverine and IV ATP caused transient 2nd degree AVB in 2%. Conclusions: The hyperemic efficacy of IC papaverine or IV ATP alone is suboptimal in some patients. Combined administration of IC papaverine and IV ATP can achieve optimal hyperemia in such patients and has the potential to assist in making clinical decisions on patients with physiologically intermediate lesions.