Current developments and future applications of intracoronary hemodynamics

Intracoronary hemodynamic assessment of the physiologic significance of coronary lesions improves clinical outcomes in patients with coronary artery disease. Coronary flow velocity reserve, fractional flow reserve, instantaneous wave-free ratio, and index of microcirculatory resistance utilize sensor-mounted guidewires to approximate coronary flow. Coronary flow velocity reserve and fractional flow reserve rely on pharmacologic administration of adenosine to achieve hyperemia and diagnose epicardial lesion severity. As an adenosine-free index, the instantaneous wave-free ratio utilizes a wave-free period in the mid-late diastole during which resistance is constant and low to assess lesion significance. The index of microcirculatory resistance combines hyperemic pressure measurements with thermodilution to quantify microvascular resistance. We review the physiology, clinical trials, and clinical applications of these invasive hemodynamic assessments.