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When physiology defies anatomy cardiologists tend to get confused !

Posted May 18 2011 4:45am

Even as we make rapid strides in  conquering coronary atherosclerosis by all those fancy gadgets , the  fundamental coronary  hemodynamic principle   is poorly understood . Hence  there is no surprise  for the  “perennial ambiguity”  in the indication  and effectiveness of  coronary revascularization .

Why the hell ,   reliving  a  coronary obstruction  may  not provide the   expected hemodynamic benefit  or do not prevent future  heart attack  in many ?    One of my patients  asked ?

I told him . Wait , do not get  excited , we also do not know  . . .We are just beginning to understand mysteries of coronary  circulation.

It is a well documented fact  ( but a  debatable )   that  lesser the  severiity of a  lesion more likely it is prone for an acute coronary  event .( Vulnerability , shearing stress or is it a simply a statistical mirage !) While the  vulnerability aspect is  complex , the hemodynamic  impact of  coronary  lesions  is   relatively better  understood. Here is  an important  documentation from Dr B . K  Koo from  Seoul , South Korea  who has elegantly shown the behavior of  fractional flow reserve (FFR ) in various grades of  stenosis  .This study was done in jailed side branches following PCI.

FFR  shows a surprise   relationship  with severity of coronary stenosis  . Even severe lesions showed equal if not more flow  reserve ?

and mild lesions might have lost all its reserve.

 How is it possible ?  Can it be true ?

Yes , it is indeed a  fact . God generally  keeps a stong link between anatomy and physiology  , structure and function . But he adds a rider and keeps  a reserve in every  human cell   meant for  emergency  back up . FFR is  one aspect of this , we have  partially discovered .  When we fail to understand this we are bound to get confused and make a wrong decision in cath lab.

Simply stated ,  flow across a coronary  artery is much more depedent on the status of microvascualture  than the hurdles they face in the epicardial highways !

Link to this original article from JACC .

How to do the FFR procedure ?

Soon to follow . . .  If less severe lesions are more  dangerous why we are ignoring it in cath lab ?


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