Hydrostatic pressure and FFR measurements
What is hydrostatic pressure?
Hydrostatic pressure is naturally exerted by the weight of the fluid above a certain measurement point. Hydrostatic pressure is what you feel in your ears when diving deep into deep water.
The more traditional explanation says:
"Hydrostatic pressure is the pressure exerted by a fluid at equilibrium at a given point within the fluid, due to the force of gravity. Hydrostatic pressure increases in proportion to depth measured from the surface because of the increasing weight of fluid exerting downward force from above." — dictionary.com
Blood pressure changes with height
The incremental change in blood pressure due to gravity accounts for 0.77 mmHg per cm height difference (1).
Since both aortic and venous pressure is equally affected by gravity, the hydrostatic pressure will not affect flow.
99% of
population
How does hydrostatic pressure affect measuring accuracy?
Traditional pressure wires have a pressure sensor located 3cm from the tip. Before performing measurements, wire pressure (Pd) and aortic pressure (Pa) are equalized, with the wire pressure sensor at the same proximal position in the vessel as the guide catheter tip.
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As the wire sensor is inserted in a distal RCA, it travels lower in the body, and Pd pressure becomes higher, due to hydrostatic pressure
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As the wire sensor is inserted in a distal LAD, it travels higher in the body, and Pd pressure becomes lower, due to hydrostatic pressure
Why does the hydrostatic pressure error not affect the fluid filled Wirecath® wire?
Fluid-filled wires/catheters are immune to hydrostatic error, since their saline-filled interior compensates for hydrostatic pressure in the body. The fact that the pressure transducer is external - located outside of the body, and always positioned at the same level, is also critical for measuring accuracy.
Hydrostatic pressure errors in traditional sensor-tipped wires
Hydrostatic error occurs due to the height difference between the ostium and the distal measuring point (1, 2, 3).
Usually, equalization minimizes the pressure difference between Pa and Pd before the procedure starts. However, since the pressure sensor in a sensor-tipped wire is advanced into the distal coronary vessel after equalization, the height difference between the sensor (Pd) and the catheter (Pa) can lead to a significant pressure error.
This is of particular importance since this hydrostatic error is not obvious to the physician.
Pd in distal vessels
When using sensor-tipped wires:
99% of
population
Data on effect of hydrostatic pressure error
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In the LAD (most common case), the average height difference is 5.8 cm (4.5 mmHg) in men and 4.3 cm (3.3 mmHg) in females (2).
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Hydrostatic pressure errors causes up to 22% vessel misclassification (2, 4, 5)
- 13% for hyperemic (FFR) measurements
- 21% for dPR measurements
- 22% for resting Pd/Pa measurements
The effect of removing hydrostatic error on existing study results
Studies (6-9) show that post-PCI FFR is generally much lower in LAD than in non-LAD arteries. Hydrostatic-error free measurements would have made the rate of successful post-PCI FFR higher in the LAD and lower in non-LAD, and therefore the success rate in LAD and non-LAD would have been more similar.
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Hwang et al. (6) studying 835 patients concluded the optimal cut-off values of post-PCI FFR for predicting target vessel failure were 0.82 and 0.88 in the LAD and non-LAD, respectively. These cut-offs correspond to the difference in hydrostatic error between LAD and non-LAD (2, 3).
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Collison et al. (7) studying 260 patients found that the proportion of patients achieving a final post-PCI FFR value ≥0.90 were 7.2% of the LAD, 74% of the LCX and 64% of the RCA arteries. If the hydrostatic error would have been avoided, the results would have been more equal for LAD and non-LAD.
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Piroth et al. (8) studying 461 patients from the FAME-3 trial found that the median post-PCI FFR in the LAD was 0.87, whereas in non-LAD vessels it was 0.92. This correspond to the difference in hydrostatic error between LAD and non-LAD (2, 3).
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Shin et al. (9) studying 588 patients found that post-PCI FFR ≤0.80 were 55% more common among LADs than among non-LADs, while post-PCI Pd/Pa ≤0.92 were 250% more common among LADs than among non-LADs. The ability to predict target vessel failure (TVF) was poor for post-PCI Pd/Pa compared to post-PCI FFR and the same for iFR and dPR as for Pd/Pa. If hydrostatic errors had been avoided, post-PCI FFR and Pd/Pa may have had better ability to predict TVF.
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Csanádi et al. (10) studying 434 patients found that post-PCI FFR was an independent predictor of TVF as well as of the composite of CD and MI. No uniform target post-PCI FFR value exists; in order to improve the predictive power of post-PCI FFR, different cut-off values may have to be applied in LAD as opposed to non-LAD vessels, 0.83 and 0.91.
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Cavis Technologies data on file.
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Hwang D. et al. Influence of target vessel on prognostic relevance of fractional flow reserve after coronary stenting. EuroIntervention. 2019 Aug 29;15(5):457-464.
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Collison D. et al. Post-stenting fractional flow reserve vs coronary angiography for optimization of percutaneous coronary intervention (TARGET-FFR). Eur Heart J. 2021 Dec 1;42(45):4656-4668.