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Kawase Y, Matsuo H. The Complexity of Physiology in the Evaluation of the Effect of Medication for Cardiovascular Disease. JACC. ASIA 2022; 2:704-705. [PMID: 36444325 PMCID: PMC9700002 DOI: 10.1016/j.jacasi.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Yoshiaki Kawase
- Address for correspondence: Dr Yoshiaki Kawase, Gifu Heart Center, 4-14-4, Yabutaminami, Gifu City, Gifu 500-8384, Japan.
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2
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Joh HS, Shin D, Lee JM, Lee SH, Hong D, Choi KH, Hwang D, Boerhout CKM, de Waard GA, Jung JH, Mejia-Renteria H, Hoshino M, Echavarria-Pinto M, Meuwissen M, Matsuo H, Madera-Cambero M, Eftekhari A, Effat MA, Murai T, Marques K, Doh JH, Christiansen EH, Banerjee R, Kim HK, Nam CW, Niccoli G, Nakayama M, Tanaka N, Shin ES, Chamuleau SAJ, van Royen N, Knaapen P, Koo BK, Kakuta T, Escaned J, Piek JJ, van de Hoef TP. Prognostic Impact of Coronary Flow Reserve in Patients With Reduced Left Ventricular Ejection Fraction. J Am Heart Assoc 2022; 11:e025841. [PMID: 35876408 PMCID: PMC9375477 DOI: 10.1161/jaha.122.025841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Intracoronary physiologic indexes such as coronary flow reserve (CFR) and left ventricular ejection fraction (LVEF) have been regarded as prognostic indicators in patients with coronary artery disease. The current study evaluated the association between intracoronary physiologic indexes and LVEF and their differential prognostic implications in patients with coronary artery disease. Methods and Results A total of 1889 patients with 2492 vessels with available CFR and LVEF were selected from an international multicenter prospective registry. Baseline physiologic indexes were measured by thermodilution or Doppler methods and LVEF was recorded at the index procedure. The primary outcome was target vessel failure, which was a composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization over 5 years of follow‐up. Patients with reduced LVEF <50% (162 patients [8.6%], 202 vessels [8.1%]) showed a similar degree of epicardial coronary artery disease but lower CFR values than those with preserved LVEF (2.4±1.2 versus 2.7±1.2, P<0.001), mainly driven by the increased resting coronary flow. Conversely, hyperemic coronary flow, fractional flow reserve, and the degree of microvascular dysfunction were similar between the 2 groups. Reduced CFR (≤2.0) was seen in 613 patients (32.5%) with 771 vessels (30.9%). Reduced CFR was an independent predictor for target vessel failure (hazard ratio, 2.081 [95% CI, 1.385–3.126], P<0.001), regardless of LVEF. Conclusions CFR was lower in patients with reduced LVEF because of increased resting coronary flow. Patients with reduced CFR showed a significantly higher risk of target vessel failure than did those with preserved CFR, regardless of LVEF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04485234.
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Affiliation(s)
- Hyun Sung Joh
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Doosup Shin
- Division of Cardiology, Department of Internal Medicine Duke University Medical Center Durham NC
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine Chonnam National University Hospital Gwangju Korea
| | - David Hong
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Doyeon Hwang
- Seoul National University Hospital Department of Internal Medicine, Cardiovascular Center Seoul Korea
| | - Coen K M Boerhout
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam the Netherlands
| | - Guus A de Waard
- Department of Cardiology NoordWest Ziekenhuisgroep Alkmaar the Netherlands
| | - Ji-Hyun Jung
- Sejong General Hospital Sejong Heart Institute Bucheon Korea
| | - Hernan Mejia-Renteria
- Hospital Clínico San Carlos IDISSC, and Universidad Complutense de Madrid Madrid Spain
| | - Masahiro Hoshino
- Department of Cardiology Tsuchiura Kyodo General Hospital Tsuchiura city Japan
| | - Mauro Echavarria-Pinto
- Hospital General ISSSTE Querétaro - Facultad de Medicina Universidad Autónoma de Querétaro Querétaro Mexico
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine Gifu Heart Center Gifu Japan
| | | | - Ashkan Eftekhari
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Mohamed A Effat
- Division of Cardiovascular Health and Disease University of Cincinnati Cincinnati OH
| | - Tadashi Murai
- Cardiovascular Center Yokosuka Kyosai Hospital Yokosuka Japan
| | - Koen Marques
- Department of Cardiology Amsterdam UMC - location VUmc Amsterdam the Netherlands
| | - Joon-Hyung Doh
- Department of Medicine Inje University Ilsan Paik Hospital Goyang Korea
| | | | - Rupak Banerjee
- Department of Mechanical and Materials Engineering University of Cincinnati, Veterans Affairs Medical Center Cincinnati OH
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center Chosun University Hospital, University of Chosun College of Medicine Gwangju Korea
| | - Chang-Wook Nam
- Department of Medicine Keimyung University Dongsan Medical Center Daegu Korea
| | - Giampaolo Niccoli
- Department of Cardiovascular Medicine, Institute of Cardiology Catholic University of the Sacred Heart Milano Italy
| | - Masafumi Nakayama
- Department of Cardiovascular Medicine Gifu Heart Center Gifu Japan.,Toda Central General Hospital Cardiovascular Center Toda Japan
| | - Nobuhiro Tanaka
- Tokyo Medical University Hachioji Medical Center Department of Cardiology Tokyo Japan
| | - Eun-Seok Shin
- Department of Cardiology Ulsan University Hospital, University of Ulsan College of Medicine Ulsan Korea
| | | | - Niels van Royen
- Department of Cardiology Radboud University Medical Center Nijmegen the Netherlands
| | - Paul Knaapen
- Department of Cardiology Amsterdam UMC - location VUmc Amsterdam the Netherlands
| | - Bon Kwon Koo
- Seoul National University Hospital Department of Internal Medicine, Cardiovascular Center Seoul Korea
| | - Tsunekazu Kakuta
- Department of Cardiology Tsuchiura Kyodo General Hospital Tsuchiura city Japan
| | - Javier Escaned
- Hospital Clínico San Carlos IDISSC, and Universidad Complutense de Madrid Madrid Spain
| | - Jan J Piek
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam the Netherlands
| | - Tim P van de Hoef
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam the Netherlands
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Achenbach S, Rudolph T, Rieber J, Eggebrecht H, Richardt G, Schmitz T, Werner N, Boenner F, Möllmann H. Performing and Interpreting Fractional Flow Reserve Measurements in Clinical Practice: An Expert Consensus Document. Interv Cardiol 2017; 12:97-109. [PMID: 29588737 DOI: 10.15420/icr.2017:13:2] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Fractional flow reserve (FFR) measurements can determine the haemodynamic relevance of coronary artery stenoses. Current guidelines recommend their use in lesions in the absence of non-invasive proof of ischaemia. The prognostic impact of FFR has been evaluated in randomised trials, and it has been shown that revascularisation can be safely deferred if FFR is >0.80, while revascularisation of stenoses with FFR values ≤0.80 results in significantly lower event rates compared to medical treatment. Left main stenoses, aorto-ostial lesions, as well as patients with left ventricular hypertrophy and severely-impaired ejection fraction, have been excluded from large, randomised trials. While FFR measurements are relatively straightforward to perform, uncertainty about procedural logistics, as well as data acquisition and interpretation in specific situations, could explain why they are not widely used in clinical practice. We summarise the clinical data in support of FFR measurements, and provide recommendations for performing and interpreting the procedure.
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Affiliation(s)
- Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander University (FAU) Erlangen-Nuremberg, Germany
| | - Tanja Rudolph
- Department of Internal Medicine 3, University Hospital, Cologne, Germany
| | - Johannes Rieber
- Heart Centre, Municipal Hospitals of Munich, Munich, Germany
| | | | | | | | - Nikos Werner
- Department of Internal Medicine 2, University Hospital, Bonn, Germany
| | - Florian Boenner
- Department of Internal Medicine, University Hospital, Düsseldorf, Germany
| | - Helge Möllmann
- Department of Cardiology, St Johannes Hospital, Dortmund, Germany
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Kolli KK, Min JK, Ha S, Soohoo H, Xiong G. Effect of Varying Hemodynamic and Vascular Conditions on Fractional Flow Reserve: An In Vitro Study. J Am Heart Assoc 2016; 5:JAHA.116.003634. [PMID: 27364988 PMCID: PMC5015400 DOI: 10.1161/jaha.116.003634] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background The aim of this study was to investigate the impact of varying hemodynamic conditions on fractional flow reserve (ratio of pressure distal [Pd] and proximal [Pa] to stenosis under hyperemia) in an in vitro setting. Failure to achieve maximal hyperemia and the choice of hyperemic agents may have differential effects on coronary hemodynamics and, consequently, on the determination of fractional flow reserve. Methods and Results An in vitro flow system was developed to experimentally model the physiological coronary circulation as flow‐dependent stenosis resistance in series with variable downstream resistance. Five idealized models with 30% to 70% diameter stenosis severity were fabricated using VeroClear rigid material in an Objet260 Connex printer. Mean aortic pressure was maintained at 7 levels (60–140 mm Hg) from hypotension to hypertension using a needle valve that mimicked adjustable microcirculatory resistance. A range of physiological flow rates was applied by a steady flow pump and titrated by a flow sensor. The pressure drop and the pressure ratio (Pd/Pa) were assessed for the 7 levels of aortic pressure and differing flow rates. The in vitro experimental data were coupled with pressure–flow relationships from clinical data for populations with and without myocardial infarction, respectively, to evaluate fractional flow reserve. The curve for pressure ratio and flow rate demonstrated a quadratic relationship with a decreasing slope. The absolute decrease in fractional flow reserve in the group without myocardial infarction (with myocardial infarction) was on the order of 0.03 (0.02), 0.05 (0.02), 0.07 (0.05), 0.17 (0.13) and 0.20 (0.24), respectively, for 30%, 40%, 50%, 60%, and 70% diameter stenosis, for an increase in aortic pressure from 60 to 140 mm Hg. Conclusions The fractional flow reserve value, an index of physiological stenosis significance, was observed to decrease with increasing aortic pressure for a given stenosis in this idealized in vitro experiment for vascular groups with and without myocardial infarction.
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Affiliation(s)
- Kranthi K Kolli
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College, New York, NY
| | - James K Min
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College, New York, NY Departments of Radiology and Medicine, Weill Cornell Medical College, New York, NY
| | - Seongmin Ha
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College, New York, NY
| | - Hilary Soohoo
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College, New York, NY
| | - Guanglei Xiong
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College, New York, NY
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Fraktionelle Flussreserve in der Diagnostik der koronaren Herzerkrankung. DER KARDIOLOGE 2016. [DOI: 10.1007/s12181-016-0049-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Adiputra Y, Chen SL. Clinical Relevance of Coronary Fractional Flow Reserve: Art-of-state. Chin Med J (Engl) 2016; 128:1399-406. [PMID: 25963364 PMCID: PMC4830323 DOI: 10.4103/0366-6999.156805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: The objective was to delineate the current knowledge of fractional flow reserve (FFR) in terms of definition, features, clinical applications, and pitfalls of measurement of FFR. Data Sources: We searched database for primary studies published in English. The database of National Library of Medicine (NLM), MEDLINE, and PubMed up to July 2014 was used to conduct a search using the keyword term “FFR”. Study Selection: The articles about the definition, features, clinical application, and pitfalls of measurement of FFR were identified, retrieved, and reviewed. Results: Coronary pressure-derived FFR rapidly assesses the hemodynamic significance of individual coronary artery lesions and can readily be performed in the catheterization laboratory. The use of FFR has been shown to effectively guide coronary revascularization procedures leading to improved patient outcomes. Conclusions: FFR is a valuable tool to determine the functional significance of coronary stenosis. It combines physiological and anatomical information, and can be followed immediately by percutaneous coronary intervention (PCI) if necessary. The technique of FFR measurement can be performed easily, rapidly, and safely in the catheterization laboratory. By systematic use of FFR in dubious stenosis and multi-vessel disease, PCI can be made an even more effective and better treatment than it is currently. The current clinical evidence for FFR should encourage cardiologists to use this tool in the catheterization laboratory.
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Affiliation(s)
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital of Nanjing Medical University, Nanjing, Jiangsu 210006, China
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Park SD, Lee MJ, Woo SI, Baek YS, Shin SH, Kim DH, Kwan J, Park KS. Epicardial Artery Stenosis with a High Index of Microcirculatory Resistance Is Frequently Functionally Insignificant as Estimated by Fractional Flow Reserve (FFR). Intern Med 2016; 55:97-103. [PMID: 26781006 DOI: 10.2169/internalmedicine.55.4080] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Differences in microvascular integrity can diversely influence the functional assessment of epicardial coronary artery disease in each patient. We investigated the relevance of the index of microcirculatory resistance (IMR) and fractional flow reserve (FFR) of intermediate coronary lesions. Methods The IMR and FFR were measured in 67 intermediate coronary lesions of the left anterior descending artery of 67 patients, by using a pressure sensor/thermistor-tipped guidewire. Results To assess the differences in FFR in relationship to the IMR value, patients were divided into tertile IMR groups as follows: Low-IMR (n=22, IMR 14±3), Mid-IMR (n=23, IMR 21±2), and High-IMR (n=22, IMR 36±10). An analysis of variance showed that the High-IMR group had significantly higher FFR values (0.87±0.07) than the Low-IMR group (0.81±0.08) (p=0.03). Functionally significant lesions with FFR ≤0.8 accounted for 9% of lesions in the High-IMR group, 36% in the Low-IMR group and 22% in the Mid-IMR group (p=0.02). In the multivariate logistic analysis, the IMR value was an independent determinant of FFR ≤0.8 (p=0.03). Conclusion In patients with a high IMR, intermediate lesions as identified with visual estimation were more frequently functionally insignificant. The IMR can provide additional information in understanding the mismatch between the anatomical and functional severity of intermediate coronary stenosis.
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Affiliation(s)
- Sang-Don Park
- Department of Internal Medicine, Inha University Hospital, South Korea
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Leite L, Moura Ferreira J, Silva Marques J, Jorge E, Matos V, Guardado J, Calisto J, Pego M. Fractional flow reserve of non-culprit vessel post-myocardial infarction: is it reliable? BMC Cardiovasc Disord 2015; 15:127. [PMID: 26467002 PMCID: PMC4606848 DOI: 10.1186/s12872-015-0122-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/01/2015] [Indexed: 11/24/2022] Open
Abstract
Background Multi-vessel disease is frequent in patients presenting with myocardial infarction and have an important prognostic impact. The decision to proceed to revascularization in non-culprit vessels can be postponed until ischemia is proven in non-invasive stress tests. On the other hand, there is an increasing evidence to support the role of fractional flow reserve (FFR) in acute coronary syndrome setting. Case presentation We report a case in which a FFR-guided strategy for non-culprit vessels, 3 weeks after an ST-segment elevation myocardial infarction, was followed by a short-term sub-occlusion of the evaluated vessel. Conclusion The timing of the coronary microcirculation recovery post-myocardial infarction, avoiding a possible false negative FFR, and the diagnostic gaps between ischemia and plaque vulnerability are under discussion. An FFR-guided strategy in this setting should be interpreted with caution.
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Affiliation(s)
- Luís Leite
- Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Joana Moura Ferreira
- Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - João Silva Marques
- Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Elisabete Jorge
- Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Vítor Matos
- Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Jorge Guardado
- Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - João Calisto
- Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
| | - Mariano Pego
- Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal.
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Masrani Mehta S, Depta JP, Novak E, Patel JS, Patel Y, Raymer D, Facey G, Zajarias A, Lasala JM, Singh J, Bach RG, Kurz HI. Association of Lower Fractional Flow Reserve Values With Higher Risk of Adverse Cardiac Events for Lesions Deferred Revascularization Among Patients With Acute Coronary Syndrome. J Am Heart Assoc 2015; 4:e002172. [PMID: 26289346 PMCID: PMC4599472 DOI: 10.1161/jaha.115.002172] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background The safety of deferring revascularization based on fractional flow reserve (FFR) during acute coronary syndrome (ACS) is unclear. We evaluated the association of FFR and adverse cardiac events among patients with coronary lesions deferred revascularization based on FFR in the setting of ACS versus non-ACS. Methods and Results The study population (674 patients; 816 lesions) was divided into ACS (n=334) and non-ACS (n=340) groups based on the diagnosis when revascularization was deferred based on FFR values >0.80 between October 2002 and July 2010. The association and interaction between FFR and clinical outcomes was evaluated using Cox proportional hazards models within each group (mean follow-up of 4.5±2.1 years). Subsequent revascularization of a deferred lesion was classified as a deferred lesion intervention (DLI), whereas the composite of DLI or myocardial infarction (MI) attributed to a deferred lesion was designated as deferred lesion failure (DLF). In the non-ACS group, lower FFR values were not associated with any increase in adverse cardiac events. In the ACS group, every 0.01 decrease in FFR was associated with a significantly higher rate of cardiovascular death, MI, or DLI (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.03 to 1.12), MI or DLI (HR, 1.09; 95% CI: 1.04 to 1.14), DLF (HR, 1.12; 95% CI, 1.06 to 1.18), MI (HR, 1.07; 95% CI, 1.00 to 1.14), and DLI (HR, 1.12; 95% CI, 1.06 to 1.18). Conclusion Lower FFR values among ACS patients with coronary lesions deferred revascularization based on FFR are associated with a significantly higher rate of adverse cardiac events. This association was not observed in non-ACS patients.
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Affiliation(s)
- Shriti Masrani Mehta
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
| | - Jeremiah P Depta
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
| | - Eric Novak
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
| | - Jayendrakumar S Patel
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
| | - Yogesh Patel
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
| | - David Raymer
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
| | - Gabrielle Facey
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
| | - Alan Zajarias
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
| | - John M Lasala
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
| | - Jasvindar Singh
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
| | - Richard G Bach
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
| | - Howard I Kurz
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (S.M.M., J.P.D., E.N., J.S.P., Y.P., D.R., G.F., A.Z., J.M.L., J.S., R.G.B., H.I.K.)
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Kobayashi Y, Tremmel JA. The relationship between fractional flow reserve and index of microcirculatory resistance: be careful with whom you associate. Catheter Cardiovasc Interv 2015; 85:593-4. [PMID: 25702909 DOI: 10.1002/ccd.25850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 01/18/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Yuhei Kobayashi
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California
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Murai T, Lee T, Yonetsu T, Isobe M, Kakuta T. Influence of microvascular resistance on fractional flow reserve after successful percutaneous coronary intervention. Catheter Cardiovasc Interv 2014; 85:585-92. [DOI: 10.1002/ccd.25499] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 03/12/2014] [Accepted: 03/23/2014] [Indexed: 11/12/2022]
Affiliation(s)
- Tadashi Murai
- Department of Cardiology; Tsuchiura Kyodo General Hospital; Tsuchiura Japan
| | - Tetsumin Lee
- Department of Cardiology; Tsuchiura Kyodo General Hospital; Tsuchiura Japan
| | - Taishi Yonetsu
- Department of Cardiology; Kameda Medical Center; Kamogawa Japan
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine; Tokyo Medical and Dental University; Tokyo Japan
| | - Tsunekazu Kakuta
- Department of Cardiology; Tsuchiura Kyodo General Hospital; Tsuchiura Japan
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D’Souza GA, Peelukhana SV, Banerjee RK. Diagnostic Uncertainties During Assessment of Serial Coronary Stenoses: An In Vitro Study. J Biomech Eng 2014; 136:021026. [DOI: 10.1115/1.4026317] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 12/23/2013] [Indexed: 02/02/2023]
Abstract
Currently, the diagnosis of coronary stenosis is primarily based on the well-established functional diagnostic parameter, fractional flow reserve (FFR: ratio of pressures distal and proximal to a stenosis). The threshold of FFR has a “gray” zone of 0.75–0.80, below which further clinical intervention is recommended. An alternate diagnostic parameter, pressure drop coefficient (CDP: ratio of trans-stenotic pressure drop to the proximal dynamic pressure), developed based on fundamental fluid dynamics principles, has been suggested by our group. Additional serial stenosis, present downstream in a single vessel, reduces the hyperemic flow, Q˜h, and pressure drop, Δp˜, across an upstream stenosis. Such hemodynamic variations may alter the values of FFR and CDP of the upstream stenosis. Thus, in the presence of serial stenoses, there is a need to evaluate the possibility of misinterpretation of FFR and test the efficacy of CDP of individual stenoses. In-vitro experiments simulating physiologic conditions, along with human data, were used to evaluate nine combinations of serial stenoses. Different cases of upstream stenosis (mild: 64% area stenosis (AS) or 40% diameter stenosis (DS); intermediate: 80% AS or 55% DS; and severe: 90% AS or 68% DS) were tested under varying degrees of downstream stenosis (mild, intermediate, and severe). The pressure drop-flow rate characteristics of the serial stenoses combinations were evaluated for determining the effect of the downstream stenosis on the upstream stenosis. In general, Q˜h and Δp˜ across the upstream stenosis decreased when the downstream stenosis severity was increased. The FFR of the upstream mild, intermediate, and severe stenosis increased by a maximum of 3%, 13%, and 19%, respectively, when the downstream stenosis severity increased from mild to severe. The FFR of a stand-alone intermediate stenosis under a clinical setting is reported to be ∼0.72. In the presence of a downstream stenosis, the FFR values of the upstream intermediate stenosis were either within (0.77 for 80%–64% AS and 0.79 for 80%–80% AS) or above (0.88 for 80%–90% AS) the “gray” zone (0.75–0.80). This artificial increase in the FFR value within or above the “gray” zone for an upstream intermediate stenosis when in series with a clinically relevant downstream stenosis could lead to misinterpretation of functional stenosis severity. In contrast, a distinct range of CDP values was observed for each case of upstream stenosis (mild: 8–10; intermediate: 47–54; and severe: 130–155). The nonoverlapping range of CDP could better delineate the effect of the downstream stenosis from the upstream stenosis and allow for the accurate diagnosis of the functional severity of the upstream stenosis.
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Affiliation(s)
- Gavin A. D’Souza
- School of Dynamic Systems, Mechanical Engineering Program, University of Cincinnati, Cincinnati, OH 45221
| | - Srikara V. Peelukhana
- School of Dynamic Systems, Mechanical Engineering Program, University of Cincinnati, Cincinnati, OH 45221
| | - Rupak K. Banerjee
- School of Dynamic Systems, Mechanical Engineering Program, University of Cincinnati, Cincinnati, OH 45221 e-mail:
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Banerjee RK, Peelukhana SV, Goswami I. Influence of newly designed monorail pressure sensor catheter on coronary diagnostic parameters: An in vitro study. J Biomech 2014; 47:617-24. [DOI: 10.1016/j.jbiomech.2013.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 12/01/2013] [Accepted: 12/06/2013] [Indexed: 01/10/2023]
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Yoshino S, Cassar A, Matsuo Y, Herrmann J, Gulati R, Prasad A, Lennon RJ, Lerman LO, Lerman A. Fractional flow reserve with dobutamine challenge and coronary microvascular endothelial dysfunction in symptomatic myocardial bridging. Circ J 2014; 78:685-92. [PMID: 24463708 DOI: 10.1253/circj.cj-13-0846] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Myocardial bridging (MB) results in compression of the coronary artery lumen in systole, extending into diastole with resultant hemodynamic alternation as reflected by fractional flow reserve (FFR). MB has also been associated with coronary endothelial dysfunction. The objective of this study was to investigate relationship between FFR with dobutamine challenge and coronary microvascular endothelial dysfunction in symptomatic MB. METHODS AND RESULTS Seventeen consecutive patients who had cardiac catheterization assessment of MB were enrolled. The patients were divided into 2 groups according to normal (% increase in coronary blood flow [%CBF] ≥50%, n=7) or impaired (%CBF <50%, n=10) coronary microvascular endothelial function assessed on vasoreactivity in the coronary artery with intracoronary infusion of acetylcholine (Ach). Myocardial ischemia was then assessed using FFR at rest and during i.v. dobutamine infusion challenge across the MB with intracoronary pressure wires. FFR was significantly decreased at peak dobutamine infusion compared to at rest in the impaired group (0.85±0.06 vs. 0.91±0.05, P=0.001), but not in the normal group (0.93±0.05 vs. 0.91±0.07, P=0.618). Both FFR at rest and at peak dobutamine infusion had a positive correlation with %CBF by Ach in the impaired group (r(2)=0.46, P=0.030; r(2)=0.52, P=0.018, respectively). CONCLUSIONS Microvascular endothelial dysfunction was associated with decreased FFR at peak dobutamine stress in patients with symptomatic MB.
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Affiliation(s)
- Satoshi Yoshino
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and College of Medicine
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Goswami I, Peelukhana SV, Al-Rjoub MF, Back LH, Banerjee RK. Influence of Variable Native Arterial Diameter and Vasculature Status on Coronary Diagnostic Parameters. J Biomech Eng 2013; 135:91005. [DOI: 10.1115/1.4024682] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 05/31/2013] [Indexed: 12/26/2022]
Abstract
In current practice, diagnostic parameters, such as fractional flow reserve (FFR) and coronary flow reserve (CFR), are used to determine the severity of a coronary artery stenosis. FFR is defined as the ratio of hyperemic pressures distal (p˜rh) and proximal (p˜ah) to a stenosis. CFR is the ratio of flow at hyperemic and basal condition. Another diagnostic parameter suggested by our group is the pressure drop coefficient (CDP). CDP is defined as the ratio of the pressure drop across the stenosis to the upstream dynamic pressure. These parameters are evaluated by invasively measuring flow (CFR), pressure (FFR), or both (CDP) in a diseased artery using guidewire tipped with a sensor. Pathologic state of artery is indicated by lower CFR (<2). Similarly, FFR lower than 0.75 leads to clinical intervention. Cutoff for CDP is under investigation. Diameter and vascular condition influence both flow and pressure drop, and thus, their effect on FFR and CDP was studied. In vitro experiment coupled with pressure-flow relationships from human clinical data was used to simulate pathophysiologic conditions in two representative arterial diameters, 2.5 mm (N1) and 3 mm (N2). With a 0.014 in. (0.35 mm) guidewire inserted, diagnostic parameters were evaluated for mild (∼64% area stenosis (AS)), intermediate (∼80% AS), and severe (∼90% AS) stenosis for both N1 and N2 arteries, and between two conditions, with and without myocardial infarction (MI). Arterial diameter did not influence FFR for clinically relevant cases of mild and intermediate stenosis (difference < 5%). Stenosis severity was underestimated due to higher FFR (mild: ∼9%, intermediate: ∼ 20%, severe: ∼ 30%) for MI condition because of lower pressure drops, and this may affect clinical decision making. CDP varied with diameter (mild: ∼20%, intermediate: ∼24%, severe: by 2.5 times), and vascular condition (mild: ∼35%, intermediate: ∼14%, severe: ∼ 9%). However, nonoverlapping range of CDP allowed better delineation of stenosis severities irrespective of diameter and vascular condition.
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Affiliation(s)
| | | | - Marwan F. Al-Rjoub
- School of Dynamic Systems, Mechanical Engineering Program, University of Cincinnati, Cincinnati, OH 45221
| | - Lloyd H. Back
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA 91125
| | - Rupak K. Banerjee
- School of Dynamic Systems, Mechanical Engineering Program, University of Cincinnati, Cincinnati, OH 45221 e-mail:
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Matsuo A, Fujita H, Ueoka A, Maruyama N, Shimoda Y, Kishita E, Tsubakimoto Y, Sakatani T, Inoue K, Kitamura M, Nishimura M. Importance of measuring the fractional flow reserve in patients receiving hemodialysis. Cardiovasc Interv Ther 2011; 26:215-21. [DOI: 10.1007/s12928-011-0061-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Accepted: 03/06/2011] [Indexed: 11/30/2022]
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ESEN ALIM, ACAR GOKSEL, ESEN OZLEM, EMIROGLU YUNUS, AKCAKOYUN MUSTAFA, PALA SELCUK, KARAPINAR HEKIM, KARGIN RAMAZAN, BARUTCU IRFAN, TURKMEN MUHSIN. The Prognostic Value of Combined Fractional Flow Reserve and TIMI Frame Count Measurements in Patients with Stable Angina Pectoris and Acute Coronary Syndrome. J Interv Cardiol 2010; 23:421-8. [DOI: 10.1111/j.1540-8183.2010.00579.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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18
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Rees M. The relationship between myocardial SPECT and fractional flow reserve: is it drifting apart? Int J Cardiovasc Imaging 2009; 26:215-6. [PMID: 20033785 DOI: 10.1007/s10554-009-9558-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 12/04/2009] [Indexed: 11/24/2022]
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Beleslin B, Ostojic M, Djordjevic-Dikic A, Vukcevic V, Stojkovic S, Nedeljkovic M, Stankovic G, Orlic D, Milic N, Stepanovic J, Giga V, Saponjski J. The value of fractional and coronary flow reserve in predicting myocardial recovery in patients with previous myocardial infarction. Eur Heart J 2008; 29:2617-24. [DOI: 10.1093/eurheartj/ehn418] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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20
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Courtis J, Rodés-Cabau J, Larose E, Déry JP, Nguyen CM, Proulx G, Gleeton O, Roy L, Barbeau G, Noël B, DeLarochellière R, Bertrand OF. Comparison of medical treatment and coronary revascularization in patients with moderate coronary lesions and borderline fractional flow reserve measurements. Catheter Cardiovasc Interv 2008; 71:541-8. [DOI: 10.1002/ccd.21406] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kühl HP, Katoh M, Buhr C, Krombach GA, Hoffmann R, Rassaf T, Neizel M, Buecker A, Kelm M. Comparison of magnetic resonance perfusion imaging versus invasive fractional flow reserve for assessment of the hemodynamic significance of epicardial coronary artery stenosis. Am J Cardiol 2007; 99:1090-5. [PMID: 17437733 DOI: 10.1016/j.amjcard.2006.11.061] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2006] [Revised: 11/27/2006] [Accepted: 11/27/2006] [Indexed: 11/25/2022]
Abstract
This study evaluated whether first-pass perfusion cardiovascular magnetic resonance (FP-CMR) could predict the hemodynamic significance of epicardial coronary artery stenosis as defined by invasively determined fractional flow reserve at coronary angiography. In 19 patients with known coronary artery disease (CAD), the hemodynamic relevance of 22 stenoses (mean angiographic severity 73 +/- 9%) was determined using fractional flow reserve measurements (cutoff 0.75). Results were compared with a territorial index of myocardial perfusion reserve (MPR) derived from FP-CMR. In addition, 9 age-matched patients with low prevalence of risk factors and without CAD at angiography served as a control group. A cutoff of 1.5 for MPR separated hemodynamically relevant from nonrelevant stenoses with a sensitivity and specificity of 92% and 92%, respectively. The area under the receiver-operator characteristic curve was 0.97. In the patient group, territories supplied by arteries without significant stenosis (<or=50%) showed a lower MPR compared with the control group (p <0.0001), suggesting the presence of microvascular dysfunction. In conclusion, FP-CMR may be useful for assessment of the hemodynamic relevance of angiographically undetermined CAD.
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Affiliation(s)
- Harald P Kühl
- Medical Clinic I, University Hospital RWTH, Aachen, Germany.
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Tobis J, Azarbal B, Slavin L. Assessment of intermediate severity coronary lesions in the catheterization laboratory. J Am Coll Cardiol 2007; 49:839-48. [PMID: 17320741 DOI: 10.1016/j.jacc.2006.10.055] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Revised: 09/07/2006] [Accepted: 10/16/2006] [Indexed: 12/19/2022]
Abstract
The management of intermediate coronary lesions, defined by a diameter stenosis of 40% to 70%, continues to be a therapeutic dilemma for cardiologists. The 2-dimensional representation of the arterial lesion provided by angiography is limited in distinguishing intermediate lesions that require stenting from those that simply need appropriate medical therapy. In the era of drug-eluting stents, some might propose that stenting all intermediate coronary lesions is an appropriate solution. However, the possibility of procedural complications such as coronary dissection, no reflow phenomenon, in-stent restenosis, and stent thrombosis requires accurate stratification of patients with intermediate coronary lesions to appropriate therapy. Intravascular ultrasound (IVUS) and fractional flow reserve index (FFR) provide anatomic and functional information that can be used in the catheterization laboratory to designate patients to the most appropriate therapy. The purpose of this review is to discuss the critical information obtained from IVUS and FFR in guiding treatment of patients with intermediate coronary lesions. In addition, the importance of IVUS and FFR in the management of patients with serial stenosis, bifurcation lesions, left main disease, saphenous vein graft disease, and acute coronary syndrome will be discussed.
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Affiliation(s)
- Jonathan Tobis
- David Geffen School of Medicine at UCLA, Department of Medicine, Division of Cardiology, Los Angeles, California 90095-1717, USA.
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23
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Fischer JJ, Wang XQ, Samady H, Sarembock IJ, Powers ER, Gimple LW, Ragosta M. Outcome of patients with acute coronary syndromes and moderate coronary lesions undergoing deferral of revascularization based on fractional flow reserve assessment. Catheter Cardiovasc Interv 2006; 68:544-8. [PMID: 16969847 DOI: 10.1002/ccd.20748] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To determine the outcome of consecutive patients with and without acute coronary syndromes (ACS) in whom revascularization was deferred on the basis of fractional flow reserve (FFR). BACKGROUND FFR < 0.75 correlates with ischemia on noninvasive tests and deferral of treatment on the basis of FFR is associated with low event rates in selected populations. Whether these low event rates apply to patients undergoing assessment of moderate stenoses in association with an ACS is not known and is an important clinical question. METHODS Retrospective analysis and 12 month follow-up of consecutive, moderate (50-70%) de novo coronary lesions assessed with FFR. RESULTS Revascularization was deferred in 120 lesions (111 patients) with FFR > or = 0.75. ACS was present in 35 patients (40 lesions). The clinical, angiographic and coronary hemodynamic characteristics of patients with and without ACS were similar. Among the 35 patients with ACS, there were 3 deaths, 1 MI, and 6 target vessel revascularizations (TVRs) (15% of lesions). Among the 76 patients without ACS, there were 5 deaths, 1 MI, and 7 TVR's (9% of lesions). CONCLUSIONS Deferral of revascularization based on FFR in patients with ACS and moderate coronary stenoses is associated with acceptable and low event rates at 1 year.
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Affiliation(s)
- Joshua J Fischer
- The Cardiovascular Division, Department of Medicine, University of Virginia Health Systems, Charlottesville, Virginia 22908, USA
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Katritsis DG, Korovesis S, Karvouni E, Giazitzoglou E, Karabinos I, Tzanalaridou E, Panagiotakos D, Webb-Peploe MM. Handgrip-enhanced myocardial fractional flow reserve for assessment of coronary artery stenoses. Am Heart J 2006; 151:1107.e1-7. [PMID: 16644345 DOI: 10.1016/j.ahj.2005.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2005] [Accepted: 09/29/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Fractional flow reserve (FFR) may yield false-negative results in up to 12% of lesions tested, and there is a zone of uncertainty at borderline values. METHODS Forty-eight patients were investigated by means of dobutamine stress echocardiography (DSE), coronary angiography, and FFR assessment of 48 coronary lesions before, during, and immediately after handgrip exercise. RESULTS Mean FFR values were lower during and immediately after handgrip exercise as compared with baseline (0.86 +/- 0.09 vs 0.87 +/- 0.08 vs 0.88 +/- 0.08, P < .05, respectively). The sensitivity of FFR < or = 0.75 for predicting myocardial ischemia on DSE was 17.6% before handgrip exercise, 52.9% during, and 35.5% immediately after exercise. The specificity of FFR < or = 0.75 before, during, and immediate after exercise was 100%, 93.5%, and 96.8%, respectively. In 10 patients, FFR values > 0.75 before handgrip became < or = 0.75 during or immediately after handgrip exercise (P = .01). All these patients had angina and/or DSE indicating ischemia in the territory of the vessel studied, and underwent coronary intervention. At 6 months follow-up, all patients were asymptomatic with negative DSE tests. CONCLUSIONS The addition of handgrip exercise can significantly lower the FFR and potentially improve its ability to detect physiologically significant stenoses.
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Katsouras CS, Kotsla A, Michalis LK. Coronary pressure measurements in post-myocardial infarction patients. ACUTE CARDIAC CARE 2006; 8:7-12. [PMID: 16720421 DOI: 10.1080/14628840500456522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The development of pressure monitoring guide-wires has facilitated the measurements of coronary pressures distal to a stenosis. The ratio of the distal coronary and aortic pressures (P(d)/P(a)) measured during maximal hyperaemia is a useful index for diagnosis and monitoring the treatment of patients with coronary artery disease and for guiding percutaneous coronary intervention. However, the role of coronary pressure measurements in post- myocardial infarction (MI) patients is not well established. Coronary pressure measurements should be used with caution during the acute phase of MI due to serious micro-vascular impairment. The hyperaemic pressure P(d)/P(a) ratio can identify ischaemic myocardial territories in patients with recent MI. Theoretically, coronary pressure measurements may be of value in predicting myocardial recovery after revascularization in post-MI patients with a moderate stenosis of the infarct-related artery and without angiographically evident collaterals.
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Affiliation(s)
- Christos S Katsouras
- Department of Cardiology, School of Medicine, Greece and Michaelidion Cardiac Center, University of Ioannina, Ioannina, Greece
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McClish JC, Ragosta M, Powers ER, Barringhaus KG, Gimple LW, Fischer J, Garnett J, Siadaty M, Sarembock IJ, Samady H. Effect of acute myocardial infarction on the utility of fractional flow reserve for the physiologic assessment of the severity of coronary artery narrowing. Am J Cardiol 2004; 93:1102-6. [PMID: 15110200 DOI: 10.1016/j.amjcard.2004.01.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2003] [Revised: 01/15/2004] [Accepted: 01/15/2004] [Indexed: 11/25/2022]
Abstract
Fractional flow reserve (FFR) has been shown to be a useful physiologic index of coronary lesion severity in myocardial beds of patients without prior infarction and in those with remote infarction. Acute myocardial infarction (AMI) causes myocardial necrosis and microvascular stunning, embolization, and damage. Whether FFR remains a useful index of epicardial flow in the setting of recent myocardial infarction is not established. Cardiac risk factors, serum troponin I, angiographic minimal lumen diameter (MLD), percent diameter stenosis (DS), lesion length, vessel reference diameter, hyperemic central aortic pressure, hyperemic pressure distal to stenosis, and FFR were compared in 43 vessels subtending recent AMI beds to 25 control vessels, matched by lesion length and MLD, in patients without AMI. There were no differences in DS, MLD, lesion length, or reference diameter between AMI and non-AMI groups. Patients with AMI had mean troponin I levels of 91.8 +/- 162 ng/ml. Left ventricular ejection fraction was significantly lower in patients with than without AMI (55 +/- 9% vs 62 +/- 8%, p <0.05). There were no significant differences in hyperemic central aortic pressure (92 +/- 13 vs 99 +/- 15 mm Hg, p = NS), hyperemic pressure distal to the stenosis (62 +/- 17 vs 66 +/- 19 mm Hg, p = NS), or FFR (0.67 +/- 17 vs 0.68 +/- 17, p = NS) between recent AMI and non-AMI control patients. There was a significant correlation between DS and FFR for both patients with (p <0.001) and without (p = 0.003) infarctions. Thus, FFR and the relation between FFR and DS of lesions subtending AMI was not significantly different from FFR of angiographically matched lesions in patients without AMI.
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Affiliation(s)
- J Christopher McClish
- Cardiovascular Division, Department of Medicine, University of Virginia Health Systems, Charlottesville, Virginia, USA
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Herrmann SC, El-Shafei A, Kern MJ. Current concepts in coronary physiology for the interventionalist. INTERNATIONAL JOURNAL OF CARDIOVASCULAR INTERVENTIONS 2003; 5:109-31. [PMID: 12959728 DOI: 10.1080/14628840310017357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Coronary angiography remains the 'gold standard' for the diagnosis of epicardial coronary disease. However, precise quantification of stenosis severity is limited because of the complex three-dimensional geometry of epicardial plaques. To assist the angiographer in lesion assessment, several physiologic measurements have been developed to evaluate stenosis severity, including coronary flow reserve, relative coronary flow reserve and fractional flow reserve. Physiologic lesion assessment can also be an invaluable tool in coronary intervention, evaluating efficacy of angioplasty and stent deployment.
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Leesar MA, Abdul-Baki T, Yalamanchili V, Hakim J, Kern M. Conflicting functional assessment of stenoses in patients with previous myocardial infarction. Catheter Cardiovasc Interv 2003; 59:489-95. [PMID: 12891614 DOI: 10.1002/ccd.10550] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The utility of fractional flow reserve, absolute and relative flow reserve, and intravascular ultrasound may have an impact on decision-making for percutaneous coronary intervention in patients with previous myocardial infarction and microvascular dysfunction. The role for fractional flow reserve, absolute and relative flow reserve, and intravascular ultrasound is discussed.
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Affiliation(s)
- Massoud A Leesar
- Division of Cardiology, University of Louisville, Louisville, Kentucky 40292, USA.
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Everett AD, Matherne GP. Feasibility of pulmonary artery pressure measurements in infants through aorto-pulmonary shunts using a micromanometer pressure wire. Pediatr Cardiol 2003; 24:336-7. [PMID: 12360387 DOI: 10.1007/s00246-002-0315-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Assessment of pulmonary artery pressure is an essential element in the evaluation of children palliated with surgical aorto-pulmonary shunts prior to definitive surgical repair. We report the ease of use and accuracy of a 0.014 inch micromanometer pressure wire for the measurement of pulmonary artery pressures in children with aorto-pulmonary artery shunts. The study population consisted of 11 infants and children with either a 3.5 mm modified Blalock-Taussig shunt from the subclavian artery to the branch pulmonary artery after stage 1 Norwood repair for hypoplastic left heart syndrome or palliative staged repair for tetralogy of Fallot, or a central shunt for pulmonary atresia or double outlet right ventricle. The unique features of the micromanometer pressure wire allowed rapid access and accurate measurement of pulmonary pressures in all patients studied. We conclude that the micromanometer pressure wire is a unique and accurate alternative device for rapid and safe determinations of pulmonary artery pressures in children with aorto-pulmonary artery shunts.
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Affiliation(s)
- A D Everett
- Division of Pediatric Cardiology, Department of Pediatrics and the Cardiovascular Research Center, University of Virginia Health System, PO Box 801356, Charlottesville, VA 22908-1356, USA
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Brosh D, Higano ST, Kern MJ, Lennon RJ, Holmes DR, Lerman A. Pulse transmission coefficient: A nonhyperemic index for physiologic assessment of procedural success following percutaneous coronary interventions. Catheter Cardiovasc Interv 2003; 61:95-102. [PMID: 14696166 DOI: 10.1002/ccd.10716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracoronary pressure measurements and the determination of fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) predict adverse events. Coronary lesions may impair the transmission of pressure waves across a stenosis, potentially acting as a high-frequency filter. The pulse transmission coefficient (PTC) is a nonhyperemic parameter that calculates the transmission of high-frequency components of the pressure signal through a stenosis. It was shown recently that PTC is highly correlated with FFR. This study was designed to examine the change of PTC as compared to FFR following PCI. Pressure signals were obtained by pressure guidewire in 27 lesions pre- and post-PCI and were analyzed with an algorithm that identifies the high-frequency component in the pressure signal. The PTC was calculated at baseline as the ratio between distal and proximal high-frequency components of the pressure waveform across the lesion. FFR measurements were assessed with intracoronary adenosine. There was a significant increase in PTC following PCI (0.15 +/- 0.17 at baseline vs. 0.84 +/- 0.11 post-PCI; P < 0.001). Comparable changes were observed for FFR (0.58 +/- 0.12 at baseline vs. 0.91 +/- 0.05 post-PCI; P < 0.001). PTC is a nonhyperemic parameter for physiologic assessment of coronary artery stenoses. Similar to FFR, PTC is significantly increased following PCI. Thus, it may serve as an adjunct index for the functional assessment of procedural success following PCI.
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Affiliation(s)
- David Brosh
- Cardiovascular Division, Mayo Clinic Foundation, Rochester, Minnesota 55902, USA
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Affiliation(s)
- J M Hodgson
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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