P5747The effect of additional intracoronary papaverine administration during hyperemia with intravenous adenosine triphosphate infusion, on fractional flow reserve values

Abstract

Abstract Introduction Fractional flow reserve (FFR) measurement requires the achievement of steady-state maximum hyperemia. One of the main agents used for the induction of hyperemia is adenosine-triphosphate (ATP). But, in some cases, hyperemia may be insufficient, which leads to an underestimation of the true value of the FFR. Purpose To determine the effect of additional intracoronary papaverine administration during hyperemia with intravenous ATP infusion, on FFR values in a group of patients with borderline values. Methods A total of 165 measurements of FFR were performed in 119 patients. Intravenous infusion of ATP 140 μg/kg/min was used in all patients. In the group of patients with borderline FFR values (28 pts, 0.79–0.86), during achieved ongoing hyperemia, papaverine was additionally administered intracoronary (20 mg for LCA and 12 mg for RCA) with a reassessment of FFR values. The change in the FFR values and hemodynamic parameters were determined. Results The average values of FFR during hyperemia with ATP were 0.82±0,02. After additional administration of papaverine, a significant decrease in the mean values of FFR to 0.79±0,03 (p<0.001) occurred. Wherein a decrease in the FFR value by 0.03 or more was noted in 12 patients (43%), a decrease by 0.01–0.02 - in 12 patients (43%), unchanged in 4 patients (14%). In 15 patients (53%), a change in FFR led to a crossing of the threshold value of 0.80 and a change in treatment strategy. With intravenous infusion of ATP, was observed a decrease in systolic blood pressure (BP) by 10.6% (132 vs 118 mm Hg, p<0.001), a decrease in mean BP by 12% (101 vs 88 mm Hg, p<0.001) compared to the base pressure. With additional administration of papaverine, systolic BP decreased by more 12% (to 104 mm Hg, p<0.001), mean BP – by more 11% (to 78 mm Hg, p<0.001). Changes in blood pressure Rest ATP Papaverine Systolic BP, mm Hg 132±22 118±23 104±19 Mean BP, mm Hg 100±13 88±14 79±11 Changes in the values of FFR Conclusions Additional intracoronary papaverine administration during hyperemia with intravenous adenosine triphosphate infusion led to a decrease in FFR values of 0.02 or more in 68% of cases. It may indicate a insufficiency of the initial hyperemia induced by only one vasodilator and require a combination of pharmacological agents to achieve lower and more accurate values. At borderline values of FFR obtained by induction of hyperemia with a single hyperemic agent (ATP), the additional administration of a second hyperemic agent (papaverine) in 53% led to a crossing of the threshold value of 0.80 and a change in treatment strategy.