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Rawal H, Nguyen TD, Igbinomwanhia E, Klein LW. Clinical effects of physiologic lesion testing in influencing treatment strategy for multi-vessel coronary artery disease. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 40:100378. [PMID: 38510505 PMCID: PMC10945951 DOI: 10.1016/j.ahjo.2024.100378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 03/22/2024]
Abstract
Background The application of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in multivessel coronary artery disease (CAD) patients has not been definitively explored. We herein assessed how treatment strategies were decided based on FFR/iFR values in vessels selected clinically. Specifically, we sought to determine whether treatment selection was based on whether the vessel tested was the clinical target stenosis. Methods 270 consecutive patients with angiographically determined multivessel disease who underwent FFR/iFR testing were included. Patients were classified initially based on their angiographic findings, then re-evaluated from FFR/iFR results (normal or abnormal). Tested lesions were classified into target or non-target lesions based on clinical and non-invasive evaluations. Results Abnormal FFR/iFR values were demonstrated in 51.9 % of patients, in whom 51.4 % received coronary stenting (PCI) and 44.3 % had bypass surgery (CABG). With two-vessel CAD patients, medical therapy was preferred when the target lesion was normal (72.6 %), while PCI was preferred when it was abnormal (78.4 %). In non-target lesions, PCI was preferred regardless of FFR/iFR results (78.0 %). With three-vessel CAD patients, CABG was preferred when the target lesion was abnormal (68.5 %), and there was no difference in the selected modality when it was normal. Furthermore, the incidence of tested lesions was higher in the left anterior descending (LAD) compared to other coronary arteries, and two-vessel CAD patients with LAD stenoses were more frequently treated by PCI. Conclusion The use of invasive physiologic testing in multivessel CAD patients may alter the preferred treatment strategy, leading to an overall increase in PCI selection.
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Affiliation(s)
- Harsh Rawal
- University of Connecticut, St Francis Hospital, Hartford, CT, United States of America
| | - Tung D. Nguyen
- Department of Physiology & Biophysics, University of Illinois at Chicago – College of Medicine, Chicago, IL, United States of America
| | - Efehi Igbinomwanhia
- Department of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States of America
| | - Lloyd W. Klein
- Department of Cardiology, University of California – San Francisco, San Francisco, CA, United States of America
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2
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Abbasciano RG, Layton GR, Torre S, Abbaker N, Copperwheat A, Lucarelli C, Bhandari S, Nijjer S, Mikhail G, Casula R, Zakkar M, Viviano A. Fractional flow reserve and instantaneous wave-free ratio in coronary artery bypass grafting: a meta-analysis and practice review. Front Cardiovasc Med 2024; 11:1348341. [PMID: 38516003 PMCID: PMC10955066 DOI: 10.3389/fcvm.2024.1348341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/20/2024] [Indexed: 03/23/2024] Open
Abstract
Objective Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are invasive methods to assess the functional significance of intermediate severity coronary lesions. Both indexes have been extensively validated in clinical trials in guiding revascularisation in patients with stable ischaemic heart disease undergoing percutaneous coronary intervention (PCI) with improved clinical outcomes. However, the role of these tools in coronary artery bypass grafting (CABG) is less clear. Methods A meta-analysis of randomised trials and observational studies was carried out to help in determining the optimal strategy for assessing lesion severity and selecting graft targets in patients undergoing CABG. Electronic searches were carried out on Embase, MEDLINE, and Web of Science. A group of four authors independently screened and then assessed the retrieved records. Cochrane's Risk of Bias and Robins-I tools were used for bias assessment. A survey was conducted among surgeons and cardiologists to describe current attitudes towards the preoperative use of functional coronary investigations in practice. Results Clinical outcomes including mortality at 30 days, perioperative myocardial infarction, number of grafts, incidence of stroke, rate of further need for revascularisation, and patient-reported quality of life did not differ in CABG guided by functional testing from those guided by traditional angiography.The survey revealed that in half of the surgical and cardiology units functional assessment is performed in CABG patients; there is a general perception that functional testing has improved patient care and its use would clarify the role of moderate coronary lesions that often need multidisciplinary rediscussions; moderate stenosis are felt to be clinically relevant; and anatomical considerations need to be taken into account together with functional assessment. Conclusions At present, the evidence to support the routine use of functional testing in intermediate lesions for planning CABG is currently insufficient. The pooled data currently available do not show an increased risk in mortality, myocardial injury, and stroke in the FFR/iFR-guided group. Further trials with highly selected populations are needed to clarify the best strategy. Systematic Review Registration ClinicalTrials.gov, identifier (CRD42023414604).
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Affiliation(s)
- R. G. Abbasciano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - G. R. Layton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - S. Torre
- Cardiac Surgery Unit, Giaccone Hospital, Palermo, Italy
| | - N. Abbaker
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - A. Copperwheat
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - C. Lucarelli
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - S. Bhandari
- Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - S. Nijjer
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - G. Mikhail
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - R. Casula
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - M. Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - A. Viviano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
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3
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Molossi S, Doan T, Sachdeva S. Anomalous Coronary Arteries: A State-of-the-Art Approach. Card Electrophysiol Clin 2024; 16:51-69. [PMID: 38280814 DOI: 10.1016/j.ccep.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Congenital coronary anomalies are not an infrequent occurrence and their clinical presentation typically occurs during early years, though may be manifested only in adulthood. In the setting of anomalous aortic origin of a coronary artery, this is particularly concerning as it inflicts sudden loss of healthy young lives. Risk stratification remains a challenge and so does the best management decision-making in these patients, particularly if asymptomatic. Standardized approach to evaluation and management, with careful data collection and collaboration among centers, will likely impact future outcomes in this patient population, thus allowing for exercise participation and healthier lives.
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Affiliation(s)
- Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA.
| | - Tam Doan
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
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4
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Sehatbakhsh S, Li W, Takahashi T, Takahashi K, Parikh MA, Kobayashi Y. Nonhyperemic Pressure Ratios-All the Same or Nuanced Differences? Cardiol Clin 2024; 42:13-19. [PMID: 37949534 DOI: 10.1016/j.ccl.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Fractional flow reserve (FFR) has become the gold standard for invasively assessing the functional significance of coronary artery disease (CAD) to guide revascularization. The amount of evidence supporting the role of FFR in the cardiac catheterization laboratory is large and still growing. However, FFR uptake in the daily practice is limited by a variety of factors such as invasive instrumentation of the coronary artery that requires extra time and need for vasodilator medications for hyperemia. In this review, we describe the details of wire-based alternatives to FFR, providing insights as to their development, clinical evidence, and limitations.
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Affiliation(s)
- Samineh Sehatbakhsh
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 210th Street, Bronx, NY 10467, USA
| | - Weijia Li
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, The Bronx, NY 10461, USA
| | - Tatsunori Takahashi
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, The Bronx, NY 10461, USA
| | - Kayo Takahashi
- Department of Cardiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Manish A Parikh
- Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, 506 6th Street, Brooklyn, NY 11215, USA
| | - Yuhei Kobayashi
- Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, 506 6th Street, Brooklyn, NY 11215, USA.
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Nijjer SS. Using Physiology Pullback for Percutaneous Coronary Intervention Guidance: Is this the Future? Cardiol Clin 2024; 42:41-53. [PMID: 37949539 DOI: 10.1016/j.ccl.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Modern coronary intervention requires integration of angiographic, physiologic, and intravascular imaging. This article describes the use and techniques needed to understand coronary physiology pullback data and how use it to make revascularization decisions. The article describes instantaneous wave-free ratio, fractional flow reserve, and the data that support their use and how they differ when used in tandem disease. Common practical mistakes and errors are discussed together with a brief review of the limited published research data.
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Affiliation(s)
- Sukhjinder Singh Nijjer
- Department of Cardiology, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, United Kingdom. https://twitter.com/SukhNijjer
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6
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Fawaz S, Cook CM. Understanding the Basis for Hyperemic and Nonhyperemic Coronary Pressure Assessment. Cardiol Clin 2024; 42:1-11. [PMID: 37949531 DOI: 10.1016/j.ccl.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Despite the now routine integration of invasive physiologic systems into coronary catheter laboratories worldwide, it remains critical that all operators maintain a sound understanding of the fundamental physiologic basis for coronary pressure assessment. More specifically, performing operators should be well informed regarding the basis for hyperemic (ie, fractional flow reserve) and nonhyperemic (ie, instantaneous wave-free ratio and other nonhyperemic pressure ratio) coronary pressure assessment. In this article, we provide readers a comprehensive history charting the inception, development, and validation of hyperemic and nonhyperemic coronary pressure assessment.
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Affiliation(s)
- Samer Fawaz
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom
| | - Christopher M Cook
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom.
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Joseph T, Foley M, Al-Lamee R. Physiology and Intravascular Imaging Coregistration-Best of all Worlds? Cardiol Clin 2024; 42:77-87. [PMID: 37949541 DOI: 10.1016/j.ccl.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Percutaneous coronary intervention is increasingly guided by coronary physiology and optimized using intravascular imaging. Pressure-based measurements determine the significance of a stenosis using hyperemic or nonhyperemic pressure ratios (eg, the instantaneous wave-free ratio). Intravascular ultrasound and optical coherence tomography provide cross-sectional and longitudinal detail regarding plaque composition and vessel characteristics. These facilitate lesion preparation and optimization of stent sizing and positioning. This review explores the evidence-base and practical aspects of coregistering pressure gradient assessment and intravascular imaging with angiography. We then discuss gaps in the evidence and what is needed to help integrate these techniques into clinical practice.
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Affiliation(s)
- Tobin Joseph
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W120HS, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London, W120HS, UK
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W120HS, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London, W120HS, UK.
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W120HS, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London, W120HS, UK; Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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8
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Foley M, Rajkumar CA, Ahmed-Jushuf F, Nour D, Fung CH, Seligman H, Pathimagaraj RH, Petraco R, Sen S, Nijjer S, Howard JP, Ahmad Y, Allahwala U, Bhindi R, Chamie D, Doi S, Kuwata S, Kaihara T, Koga M, Ishibashi Y, Higuma T, Tanabe Y, Nakayama M, Kawase Y, Watanabe A, Funayama N, Horinaka R, Hijikata N, Takahashi T, Matsuo H, Hansen PS, Manica A, Weaver J, Alzuhairi K, Yong TH, Warisawa T, Francis DP, Shun-Shin MJ, Al-Lamee RK. The ability of contemporary cardiologists to judge the ischemic impact of a coronary lesion visually. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 59:60-66. [PMID: 37612169 DOI: 10.1016/j.carrev.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Landmark trials showed that invasive pressure measurement (Fractional Flow Reserve, FFR) was a better guide to coronary stenting than visual assessment. However, present-day interventionists have benefited from extensive research and personal experience of mapping anatomy to hemodynamics. AIMS To determine if visual assessment of the angiogram performs as well as invasive measurement of coronary physiology. METHODS 25 interventional cardiologists independently visually assessed the single vessel coronary disease of 200 randomized participants in The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial (ORBITA). They gave a visual prediction of the FFR and Instantaneous Wave-free Ratio (iFR), denoted vFFR and viFR respectively. Each judged each lesion on 2 occasions, so that every lesion had 50 vFFR, and 50 viFR assessments. The group consensus visual estimates (vFFR-group and viFR-group) and individual cardiologists' visual estimates (vFFR-individual and viFR-individual) were tested alongside invasively measured FFR and iFR for their ability to predict the placebo-controlled reduction in stress echo ischemia with stenting. RESULTS Placebo-controlled ischemia improvement with stenting was predicted by vFFR-group (p < 0.0001) and viFR-group (p < 0.0001), vFFR-individual (p < 0.0001) and viFR-individual (p < 0.0001). There were no significant differences between the predictive performance of the group visual estimates and their invasive counterparts: p = 0.53 for vFFR vs FFR and p = 0.56 for viFR vs iFR. CONCLUSION Visual assessment of the angiogram by contemporary experts, provides significant additional information on the amount of ischaemia which can be relieved by placebo-controlled stenting in single vessel coronary artery disease.
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Affiliation(s)
- Michael Foley
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Fiyyaz Ahmed-Jushuf
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Daniel Nour
- James Cook University, Queensland, Australia
| | - Chi Ho Fung
- Imperial College Healthcare NHS Trust, London, England, UK
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | | | - Ricardo Petraco
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Sukhjinder Nijjer
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | | | | | - Daniel Chamie
- Yale School of Medicine, Yale University, New Haven, CT, USA; Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Shunich Doi
- St Marianna University School of Medicine, Kawasaki, Japan
| | - Shingo Kuwata
- St Marianna University School of Medicine, Kawasaki, Japan
| | | | - Masashi Koga
- St Marianna University School of Medicine, Kawasaki, Japan
| | - Yuki Ishibashi
- St Marianna University School of Medicine, Kawasaki, Japan
| | - Takumi Higuma
- St Marianna University School of Medicine, Kawasaki, Japan
| | | | - Masafumi Nakayama
- Gifu Heart Center, Gifu, Japan; Toda Chuo General Hospital, Toda, Japan
| | | | | | | | | | | | | | | | | | - Andre Manica
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, Brazil
| | - James Weaver
- Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, Australia
| | | | - Thon-Hon Yong
- Imperial College Healthcare NHS Trust, London, England, UK
| | - Takayuki Warisawa
- National Heart and Lung Institute, Imperial College London, UK; St Marianna University School of Medicine, Kawasaki, Japan; Gifu Heart Center, Gifu, Japan
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Rasha K Al-Lamee
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK.
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9
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de Winter RW, van Diemen PA, Schumacher SP, Jukema RA, Somsen YBO, Hoek R, van Rossum AC, Twisk JWR, de Waard GA, Nap A, Raijmakers PG, Driessen RS, Knaapen P, Danad I. Hemodynamic Insights into Combined Fractional Flow Reserve and Instantaneous Wave-Free Ratio Assessment Through Quantitative [ 15O]H 2O PET Myocardial Perfusion Imaging. J Nucl Med 2024; 65:279-286. [PMID: 38176722 DOI: 10.2967/jnumed.123.265973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 11/01/2023] [Indexed: 01/06/2024] Open
Abstract
In patients evaluated for obstructive coronary artery disease (CAD), guidelines recommend using either fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) to guide coronary revascularization decision-making. The hemodynamic significance of lesions with discordant FFR and iFR measurements is debated. This study compared [15O]H2O PET-derived absolute myocardial perfusion between vessels with concordant and discordant FFR and iFR measurements. Methods: We included 197 patients suspected of obstructive CAD who had undergone [15O]H2O PET perfusion imaging and combined FFR/iFR interrogation in 468 vessels. Resting myocardial blood flow (MBF), hyperemic MBF, and coronary flow reserve (CFR) were compared among 4 groups: FFR low/iFR low (n = 79), FFR high/iFR low (n = 22), FFR low/iFR high (n = 22), and FFR high/iFR high (n = 345). Predefined [15O]H2O PET thresholds for ischemia were 2.3 mL·min-1·g-1 or less for hyperemic MBF and 2.5 or less for CFR. Results: Hyperemic MBF was lower in the concordant low (2.09 ± 0.67 mL·min-1·g-1), FFR high/iFR low (2.41 ± 0.80 mL·min-1·g-1), and FFR low/iFR high (2.40 ± 0.69 mL·min-1·g-1) groups compared with the concordant high group (2.91 ± 0.84 mL·min-1·g-1) (P < 0.001, P = 0.004, and P < 0.001, respectively). A lower CFR was observed in the concordant low (2.37 ± 0.76) and FFR high/iFR low (2.64 ± 0.84) groups compared with the concordant high group (3.35 ± 1.07, P < 0.01 for both). However, for vessels with either low FFR or low iFR, quantitative hyperemic MBF and CFR values exceeded the ischemic threshold in 38% and 49%, respectively. In addition, resting MBF exhibited a negative correlation with iFR (P < 0.001) and was associated with FFR low/iFR high discordance compared with concordant low FFR/low iFR measurements, independent of clinical and angiographic characteristics, as well as hyperemic MBF (odds ratio [OR], 0.41; 95% CI, 0.26-0.65; P < 0.001). Conclusion: We found reduced myocardial perfusion in vessels with concordant low and discordant FFR/iFR measurements. However, FFR/iFR combinations often inaccurately classified vessels as either ischemic or nonischemic when compared with hyperemic MBF and CFR. Furthermore, a lower resting MBF was associated with a higher iFR and the occurrence of FFR low/iFR high discordance. Our study showed that although combined FFR/iFR assessment can be useful to estimate the hemodynamic significance of coronary lesions, these pressure-derived indices provide a limited approximation of [15O]H2O PET-derived quantitative myocardial perfusion as the physiologic standard of CAD severity.
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Affiliation(s)
- Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yvemarie B O Somsen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roel Hoek
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and
| | - Guus A de Waard
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology, Nuclear Medicine, and PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands;
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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10
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Molossi S, Doan T, Sachdeva S. Anomalous Coronary Arteries: A State-of-the-Art Approach. Interv Cardiol Clin 2024; 13:51-70. [PMID: 37980067 DOI: 10.1016/j.iccl.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Congenital coronary anomalies are not an infrequent occurrence and their clinical presentation typically occurs during early years, though may be manifested only in adulthood. In the setting of anomalous aortic origin of a coronary artery, this is particularly concerning as it inflicts sudden loss of healthy young lives. Risk stratification remains a challenge and so does the best management decision-making in these patients, particularly if asymptomatic. Standardized approach to evaluation and management, with careful data collection and collaboration among centers, will likely impact future outcomes in this patient population, thus allowing for exercise participation and healthier lives.
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Affiliation(s)
- Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA.
| | - Tam Doan
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
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11
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Shi Y, Zheng J, Zhang Y, Sun Q, Shen J, Gao Y, Sun J, Yang N, Zhou X, Li S, Weir-McCall JR, Xia P, Teng Z. The influence of flow distribution strategy for the quantification of pressure- and wall shear stress-derived parameters in the coronary artery: A CTA-based computational fluid dynamics analysis. J Biomech 2023; 161:111857. [PMID: 37939424 DOI: 10.1016/j.jbiomech.2023.111857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 10/15/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
For image-based computational fluid dynamics (CFD) analysis to characterize the local coronary hemodynamic environment, the accuracy depends on the flow rate which is in turn associated with outlet branches' morphology. A good flow distribution strategy is important to mitigate the effect when certain branches cannot be considered. In this study, stenotic coronary arteries from 13 patients were used to analyze the effect of missing branches and different flow distribution strategies. Pressure- and wall shear stress (WSS)-derived parameters around the stenotic region (ROI) were compared, including fractional flow reserve (CT-FFR), instantaneous wave-free ratio (CT-iFR), resting distal to aortic coronary pressure (CT-Pd/Pa), time-averaged WSS, oscillatory shear index (OSI) and relative residence time (RRT). Three flow distribution strategies were the Huo-Kassab model at distal outlets (Type I), flow distribution based on outlet resistances (Type II), and a developed algorithm distributing flow at each bifurcation until the final outlets (Type III). Results showed that Type III strategy for models with truncated branch(es) had a good agreement in both pressure- and WSS-related results (interquatile range less than 0.12% and 4.02%, respectively) with the baseline model around the ROI. The relative difference of pressure- and WSS-related results were correlated with the flow differences in the ROI to the baseline mode. Type III strategy had the best performance in maintaining the flow in intermediate branches. It is recommended for CFD analysis. Removal of branches distal to a stenosis can be undertaken with an improved performance and maintained accuracy, while those proximal to the ROI should be kept.
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Affiliation(s)
- Yibing Shi
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Jin Zheng
- Department of Radiology, University of Cambridge, UK
| | - Ying Zhang
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Quanlin Sun
- Department of Radiology, University of Cambridge, UK; Nanjing Jingsan Medical Science and Technology, Ltd., Jiangsu, China
| | - Jinhua Shen
- Nanjing Jingsan Medical Science and Technology, Ltd., Jiangsu, China
| | - Yongguang Gao
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Jingxi Sun
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Ning Yang
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Xuanxuan Zhou
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Suqing Li
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Jonathan R Weir-McCall
- Department of Radiology, University of Cambridge, UK; Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | - Ping Xia
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China.
| | - Zhongzhao Teng
- Department of Radiology, University of Cambridge, UK; Nanjing Jingsan Medical Science and Technology, Ltd., Jiangsu, China.
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12
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Luo Y, Mao M, Wu F, Ma K, Chang J, Xiang R. Diagnostic performance of resting full-cycle ratio in identifying coronary lesions causing myocardial ischaemia: a meta-analysis. Acta Cardiol 2023; 78:1103-1109. [PMID: 37811658 DOI: 10.1080/00015385.2023.2250944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/17/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND The resting full-cycle ratio (RFR), a new non-congestive resting index, is commonly used for physiological evaluations of coronary arteries. AIMS This study aims to evaluate the accuracy of RFR in detecting coronary artery stenosis with hemodynamic significance using fractional flow reserve (FFR) as the reference standard. METHODS Using 'RFR, resting full-cycle ratio' as the search term, we searched PubMed, Embase, Cochrane Library, and Web of Science databases, screening the literature according to the inclusion and exclusion criteria. By applying FFR ≤ 0.80 and RFR ≤ 0.89 as the diagnostic criteria for ischaemia, we analysed the synthetic sensitivity, specificity, and corresponding 95% confidence intervals, then synthesised the summary receiver operating characteristic curve (SROC). RESULTS Three studies were included in this meta-analysis, comprising 1,084 patients with 1,312 lesions. When we used FFR ≤ 0.80 as the reference standard, the synthesised sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) of RFR in the diagnosis of coronary ischaemia were 73%, 81%, 67%, 85%, 3.95, and 0.33, respectively. Besides, the area under the curve (AUC) was 0.8276. CONCLUSION Using FFR as the reference standard, RFR has good diagnostic accuracy in detecting coronary ischaemic lesions and may be an effective alternative to FFR in the future, to some extent.
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Affiliation(s)
- Yue Luo
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Min Mao
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fan Wu
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kanghua Ma
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Chang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Xiang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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13
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Kubota M, Oguri A. Diagnostic accuracy of diastolic pressure ratio using a pressure microcatheter for intracoronary physiological assessment. Heart Vessels 2023; 38:1395-1403. [PMID: 37626238 DOI: 10.1007/s00380-023-02301-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/02/2023] [Indexed: 08/27/2023]
Abstract
Recently, instantaneous wave-free ratio (iFR) has emerged as an alternative to the fractional flow reserve (FFR) for intracoronary physiological assessment. Although all diastolic resting indices are reportedly identical to the iFR, limited data exist on diastolic pressure ratio (dPR) measured using a microcatheter (dPRmicro). This study aimed to evaluate the diagnostic accuracy of dPRmicro compared to FFR measured using a microcatheter (FFRmicro) in real-world practice for intracoronary physiological assessment. This was a single-center, retrospective, observational study. We identified 103 consecutive suspected angina pectoris patients (107 lesions) who underwent dPRmicro and FFRmicro measurement using the Navvus® catheter at Takasaki Heart Hospital from March 2019 to June 2019. A total of 103 lesions in 103 patients were finally included in the study. The mean FFRmicro and dPRmicro values were 0.80 and 0.88, respectively. With an FFRmicro ≤ 0.80, the dPRmicro showed a diagnostic accuracy of 79.6%, sensitivity of 74.6%, specificity of 87.5%, positive predictive value of 90.4%, and negative predictive value of 68.6%. The area under the receiver operating characteristic (ROC) curve was 0.894 (95% confidence interval, 0.833-0.956), and the optimal cut-off value for dPRmicro derived from the ROC analysis was 0.90. dPRmicro and FFRmicro values were discordant in 21/103 cases (20.4%). As a multivariable logistic regression analysis was performed, the male sex (vs. female) had a statistically significant association with a dPRmicro-FFRmicro discordance (OR 4.91; 95% CI, 1.04-23.0; P = 0.044). No other factors were found to be significantly associated with the discordance. In conclusion, dPRmicro measured using a microcatheter had good diagnostic accuracy and correlation with FFRmicro, hence, it can be useful for making revascularization decisions. However, re-studies in larger populations will be needed to better understand the properties of diastolic resting index measured using a microcatheter in clinical settings.
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Affiliation(s)
- Masayuki Kubota
- Department of Cardiology, Takasaki Heart Hospital, Gumma, Japan
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsushi Oguri
- Department of Cardiology, Takasaki Heart Hospital, Gumma, Japan.
- Department of Cardiovascular Medicine, Don-Don Mamorou Clinic, Tochigi, Japan.
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14
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Eftekhari A, Holck EN, Westra J, Olsen NT, Bruun NH, Jensen LO, Engstrøm T, Christiansen EH. Instantaneous wave free ratio vs. fractional flow reserve and 5-year mortality: iFR SWEDEHEART and DEFINE FLAIR. Eur Heart J 2023; 44:4376-4384. [PMID: 37634144 DOI: 10.1093/eurheartj/ehad582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS Guidelines recommend revascularization of intermediate epicardial artery stenosis to be guided by evidence of ischaemia. Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are equally recommended. Individual 5-year results of two major randomized trials comparing FFR with iFR-guided revascularization suggested increased all-cause mortality following iFR-guided revascularization. The aim of this study was a study-level meta-analysis of the 5-year outcome data in iFR-SWEDEHEART (NCT02166736) and DEFINE-FLAIR (NCT02053038). METHODS Composite of major adverse cardiovascular events (MACE) and its individual components [all-cause death, myocardial infarction (MI), and unplanned revascularisation] were analysed. Raw Kaplan-Meier estimates, numbers at risk, and number of events were extracted at 5-year follow-up and analysed using the ipdfc package (Stata version 18, StataCorp, College Station, TX, USA). RESULTS In total, iFR and FFR-guided revascularization was performed in 2254 and 2257 patients, respectively. Revascularization was more often deferred in the iFR group [n = 1128 (50.0%)] vs. the FFR group [n = 1021 (45.2%); P = .001]. In the iFR-guided group, the number of deaths, MACE, unplanned revascularization, and MI was 188 (8.3%), 484 (21.5%), 235 (10.4%), and 123 (5.5%) vs. 143 (6.3%), 420 (18.6%), 241 (10.7%), and 123 (5.4%) in the FFR group. Hazard ratio [95% confidence interval (CI)] estimates for MACE were 1.18 [1.04; 1.34], all-cause mortality 1.34 [1.08; 1.67], unplanned revascularization 0.99 [0.83; 1.19], and MI 1.02 [0.80; 1.32]. CONCLUSIONS Five-year all-cause mortality and MACE rates were increased with revascularization guided by iFR compared to FFR. Rates of unplanned revascularization and MI were equal in the two groups.
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Affiliation(s)
- Ashkan Eftekhari
- Department Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Emil Nielsen Holck
- Department Cardiology, Aarhus University Hospital, Denmark
- Department Clinical Medicine, Health, Aarhus University, Denmark
| | - Jelmer Westra
- Department Cardiology, Aarhus University Hospital, Denmark
- Department Cardiology, Linköping University Hospital, Sweden
| | | | | | | | | | - Evald Høj Christiansen
- Department Cardiology, Aarhus University Hospital, Denmark
- Department Clinical Medicine, Health, Aarhus University, Denmark
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15
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Alasnag M. Instantaneous wave-free ratio compared with fractional flow reserve: time for rethinking current recommendations. Eur Heart J 2023; 44:4385-4387. [PMID: 37634167 DOI: 10.1093/eurheartj/ehad574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023] Open
Affiliation(s)
- Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, PO Box 126418, Jeddah 21372, Saudi Arabia
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16
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Boutaleb AM, Scalia A, Ghafari C, Carlier S. Microcatheter-versus wire-based measurement of the fractional flow reserve. Acta Cardiol 2023; 78:1024-1032. [PMID: 37581347 DOI: 10.1080/00015385.2023.2246009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/29/2023] [Accepted: 08/03/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR) guided-percutaneous interventions is nowadays the gold standard for optimal coronary artery revascularization. While multiple pressure guidewires have been validated, the use of microcatheter for FFR measurements is still a matter of debate. OBJECTIVE The aim of this study was to investigate the crossing profile characteristics of the NAVVUS® microcatheter as compared with the COMETTM pressure wire. At the same time, we compared non-hyperaemic pressure ratio (NHPR) and FFR measurements of both systems. METHOD/MATERIALS In this retrospective study, all angiographically intermediate coronary artery stenoses each month were assessed, using either the NAVVUS® or the COMETTM pressure system, to receive coronary artery physiology assessment with NHPR and FFR measurements. The crossing profile of both systems was compared regarding objective coronary artery lesion characteristics using quantitative coronary analysis evaluation. RESULTS Over a period of 4.5 years, we evaluated 213 coronary artery stenoses using one of the two coronary tools. We found a 9.2% crossing profile failure rate using the microcatheter, compared to 0.7% in the pressure wire group (p < .001). The crossing failure was significantly correlated with the presence of coronary artery calcifications and angulation (p = .042, p = .049, respectively). FFR values were comparable be- tween the two groups and were significantly lower in the presence of coronary calcifications and proportional to the degree of stenosis (p = .036, p = .010). Pressure drift was comparable. CONCLUSION Our observations are in line with other studies reporting the poor crossing profile of the NAVVUS® microcatheter. NHPR and FFR measures of both systems were well correlated.
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Affiliation(s)
| | | | - Chadi Ghafari
- Department of Cardiology, University of Mons, UMONS, Mons, Belgium
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17
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Faurie B, Acheampong A, Abdellaoui M, Dessus I, Monsegu J, Wintzer-Wehekind J. Direct wire pacing during measurement of fractional flow reserve: A randomized proof-of-concept noninferiority crossover trial. Front Cardiovasc Med 2023; 10:1137309. [PMID: 37937287 PMCID: PMC10625906 DOI: 10.3389/fcvm.2023.1137309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/30/2023] [Indexed: 11/09/2023] Open
Abstract
Background Adenosine administration for fractional flow reserve (FFR) measurement may induce heart pauses. Aims To assess the accuracy and tolerability of direct wire pacing (DWP) during measurement of FFR. Methods Adults with at least one intermediate coronary artery stenosis (40%-80%) were consecutively enrolled between June 2021 and February 2022 in this randomized, noninferiority, crossover trial (NCT04970082) carried out in France. DWP was applied (DWP) or not (standard method) through the pressure guidewire used for FFR measurement during adenosine-induced maximal hyperaemia. Subjects were randomly assigned to the allocation sequence (DWP first or standard first). A 2-minute washout period was observed between the two FFR measurements performed for each stenosis. The primary endpoint was the reproducibility of FFR measurements between methods. Results A total of 150 focal lesions, presented by 94 subjects, were randomized (ratio: 1:1). The FFR values obtained with each method were nearly identical (R = 0.98, p = 0.005). The mean FFR difference of 0.00054 (95% confidence interval: 0.004 to 0.003) showed the noninferiority of FFR measurement with DWP vs. that with the standard method. Higher levels of chest discomfort were reported with DWP than with the standard method (0.61 ± 0.84 vs. 1.05 ± 0.89, p < 0.001), and a correlation was observed between the electrical sensations reported with DWP and chest discomfort (p < 0.001). Pauses (n = 20/148 lesions) were observed with the standard method, but did not correlate with chest discomfort (p = 0.21). No pauses were observed with DWP. Conclusions DWP during FFR measurement resulted in accurate and reproducible FFR values, and eliminated the pauses induced by adenosine.
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Affiliation(s)
| | - Angela Acheampong
- Institut Cardiovasculaire de Grenoble, Grenoble, France
- Université Libre de Bruxelles, Bruxelles, Belgium
| | | | - Ilona Dessus
- Institut Cardiovasculaire de Grenoble, Grenoble, France
- Université Grenoble-Alpes, CHU Grenoble-Alpes, Grenoble, France
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18
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Koo BK, Lee JM, Hwang D, Park S, Shiono Y, Yonetsu T, Lee SH, Kawase Y, Ahn JM, Matsuo H, Shin ES, Hu X, Ding D, Fezzi S, Tu S, Low AF, Kubo T, Nam CW, Yong AS, Harding SA, Xu B, Hur SH, Choo GH, Tan HC, Mullasari A, Hsieh IC, Kakuta T, Akasaka T, Wang J, Tahk SJ, Fearon WF, Escaned J, Park SJ. Practical Application of Coronary Physiologic Assessment: Asia-Pacific Expert Consensus Document: Part 1. JACC. ASIA 2023; 3:689-706. [PMID: 38095005 PMCID: PMC10715899 DOI: 10.1016/j.jacasi.2023.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/13/2023] [Accepted: 07/08/2023] [Indexed: 12/30/2023]
Abstract
Coronary physiologic assessment is performed to measure coronary pressure, flow, and resistance or their surrogates to enable the selection of appropriate management strategy and its optimization for patients with coronary artery disease. The value of physiologic assessment is supported by a large body of evidence that has led to major recommendations in clinical practice guidelines. This expert consensus document aims to convey practical and balanced recommendations and future perspectives for coronary physiologic assessment for physicians and patients in the Asia-Pacific region based on updated information in the field that including both wire- and image-based physiologic assessment. This is Part 1 of the whole consensus document, which describes the general concept of coronary physiology, as well as practical information on the clinical application of physiologic indices and novel image-based physiologic assessment.
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Affiliation(s)
- Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sungjoon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Seung Hun Lee
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yoshiaki Kawase
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Daixin Ding
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
| | - Simone Fezzi
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Adrian F. Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Takashi Kubo
- Department of Cardiology, Tokyo Medical University, Hachioji Medical Center, Tokyo, Japan
| | - Chang-Wook Nam
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Andy S.C. Yong
- Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia
| | - Scott A. Harding
- Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Bo Xu
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Seung-Ho Hur
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Gim Hooi Choo
- Department of Cardiology, Cardiac Vascular Sentral KL (CVSKL), Kuala Lumpur, Malaysia
| | - Huay Cheem Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Ajit Mullasari
- Department of Cardiology, Madras Medical Mission, Chennai, India
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Seung-Jea Tahk
- Department of Cardiology, Ajou University Medical Center, Suwon, Korea
| | - William F. Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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19
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Giannopoulos AA, Keller L, Sepulcri D, Boehm R, Garefa C, Venugopal P, Mitra J, Ghose S, Deak P, Pack JD, Davis CL, Stähli BE, Stehli J, Pazhenkottil AP, Kaufmann PA, Buechel RR. High-Speed On-Site Deep Learning-Based FFR-CT Algorithm: Evaluation Using Invasive Angiography as the Reference Standard. AJR Am J Roentgenol 2023; 221:460-470. [PMID: 37132550 DOI: 10.2214/ajr.23.29156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND. Estimation of fractional flow reserve from coronary CTA (FFR-CT) is an established method of assessing the hemodynamic significance of coronary lesions. However, clinical implementation has progressed slowly, partly because of off-site data transfer with long turnaround times for results. OBJECTIVE. The purpose of this study was to evaluate the diagnostic performance of FFR-CT computed on-site with a high-speed deep learning-based algorithm with invasive hemodynamic indexes as the reference standard. METHODS. This retrospective study included 59 patients (46 men, 13 women; mean age, 66.5 ± 10.2 years) who underwent coronary CTA (including calcium scoring) followed within 90 days by invasive angiography with invasive fractional flow reserve (FFR) and/or instantaneous wave-free ratio measurements from December 2014 to October 2021. Coronary artery lesions were considered to have hemodynamically significant stenosis in the presence of invasive FFR of 0.80 or less and/or instantaneous wave-free ratio of 0.89 or less. A single cardiologist evaluated the CTA images using an on-site deep learning-based semiautomated algorithm entailing a 3D computational flow dynamics model to determine FFR-CT for coronary artery lesions detected with invasive angiography. Time for FFR-CT analysis was recorded. FFR-CT analysis was repeated by the same cardiologist in 26 randomly selected examinations and by a different cardiologist in 45 randomly selected examinations. Diagnostic performance and agreement were assessed. RESULTS. A total of 74 lesions were identified with invasive angiography. FFR-CT and invasive FFR had strong correlation (r = 0.81) and, in Bland-Altman analysis, bias of 0.01 and 95% limits of agreement of -0.13 to 0.15. FFR-CT had AUC for hemodynamically significant stenosis of 0.975. At a cutoff of 0.80 or less, FFR-CT had 95.9% accuracy, 93.5% sensitivity, and 97.7% specificity. In 39 lesions with severe calcifications (≥ 400 Agatston units), FFR-CT had AUC of 0.991 and at a cutoff of 0.80, 94.7% sensitivity, 95.0% specificity, and 94.9% accuracy. Mean analysis time per patient was 7 minutes 54 seconds. Intraobserver agreement (intraclass correlation coefficient, 0.85; bias, -0.01; 95% limits of agreement, -0.12 and 0.10) and interobserver agreement (intraclass correlation coefficient, 0.94; bias, -0.01; 95% limits of agreement, -0.08 and 0.07) were good to excellent. CONCLUSION. A high-speed on-site deep learning-based FFR-CT algorithm had excellent diagnostic performance for hemodynamically significant stenosis with high reproducibility. CLINICAL IMPACT. The algorithm should facilitate implementation of FFR-CT technology into routine clinical practice.
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Affiliation(s)
- Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Lukas Keller
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Daniel Sepulcri
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Reto Boehm
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Chrysoula Garefa
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | | | | | | | | | | | | | - Barbara E Stähli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Julia Stehli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
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20
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Lee OH, Roh JW, Kim Y, Heo SJ, Im E, Cho DK. Invasive physiologic assessment of coronary artery stenosis by resting full-cycle ratio and fractional flow reserve: a prospective observational study. Sci Rep 2023; 13:15783. [PMID: 37737284 PMCID: PMC10516888 DOI: 10.1038/s41598-023-43082-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/19/2023] [Indexed: 09/23/2023] Open
Abstract
Resting full-cycle ratio (RFR), an alternative to fractional flow reserve (FFR) for evaluating intermediate coronary artery stenosis, helps reduce patients' time, cost, and discomfort. However, the validation data for RFR and FFR are lacking. We aimed to assess the diagnostic accuracy of RFR and FFR and evaluate effective decision-making for revascularization using their values. Patients subjected to an invasive physiological study for intermediate coronary artery stenosis in Yongin Severance hospital between October 2020 and April 2022 were prospectively and consecutively recruited. We evaluated the correlation between RFR and FFR measurements and the diagnostic performance of RFR (≤ 0.89) versus FFR (≤ 0.80). In all, 474 intermediate coronary stenosis lesions from 400 patients were evaluated using RFR and FFR values. There was a strong linear relationship between RFR and FFR (r = 0.75, 95% CI 0.70-0.78, p < 0.01). Comparing diagnostic performance between RFR and FFR, RFR demonstrated diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 85.0%, 80.0%, 86.7%, 67.1%, and 92.7%, respectively. We analyzed the RFR value in the hyperemia zone (0.86-0.93) according to positive (RFR: 0.86-0.89) and negative (RFR: 0.90-0.93) areas. PPV in positive area is 47.8% (95% Confidence Interval [CI]: 33.8% to 62.0%) and NPV in negative area is 87.7% (95% CI: 80.3% to 93.1%). Excellent correlation exists between RFR and FFR and the diagnostic value of RFR without hyperemia compared with FFR in establishing the accurate functional significance of coronary artery stenosis was shown. RFR alone could evaluate the functional significance of coronary artery stenosis without unnecessary hyperemia, except in the positive area.Trial registration: URL: http://trialsearch.who.int ; Unique identifier: KCT0005255.
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Affiliation(s)
- Oh-Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, South Korea
| | - Ji Woong Roh
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, South Korea
| | - Yongcheol Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, South Korea.
| | - Seok-Jae Heo
- Division of Biostatistics, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Eui Im
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, South Korea
| | - Deok-Kyu Cho
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, South Korea.
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21
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Halbach M, Ameskamp C, Mauri V, Ernst A, Lake P, Nienaber S, Baldus S, Adam M, Wienemann H. Prognostic impact of resting full-cycle ratio and diastolic non-hyperemic pressure ratios in patients with deferred revascularization. Clin Res Cardiol 2023; 112:1220-1230. [PMID: 36602599 PMCID: PMC10449998 DOI: 10.1007/s00392-022-02149-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Non-hyperemic pressure ratios (NHPRs) like resting full-cycle ratio (RFR), diastolic pressure ratio during entire diastole (dPR[entire]) and diastolic pressure ratio during wave-free period (dPR[WFP]) are increasingly used to guide revascularization. The effect of NHPRs on mid-term prognosis has not been well established. OBJECTIVE We investigated the prognostic implications of NHRPs in patients whose revascularization was deferred based on fractional flow reserve (FFR) in a single-centre population. METHODS NHPRs and FFR were calculated offline from pressure tracings by an independent core laboratory. Follow-up data were acquired through records of hospital visits or telephone interviews. The primary outcome was a vessel-oriented composite outcome (VOCO) (a composite of cardiac death, vessel-related myocardial infarction, and ischemia-driven revascularization) in deferred vessels at 2 years. RESULTS 316 patients with 377 deferred lesions were analysed. Discordance of NHPRs and FFR was found in 13.0-18.3% of lesions. The correlation coefficient between NHPRs was 0.99 (95% confidence interval 0.99-1.00). At 2 years, VOCO occurred in 19 lesions (5.0%). Estimated glomerular filtration rate < 30 mL/min/1.73 m2 [hazard ratio (HR) 5.7, p = 0.002], previous myocardial infarction (HR 3.3, p = 0.018), diabetes (HR 2.7, p = 0.042), RFR ≤ 0.89 (HR 2.7, p = 0.041) and dPR[WFP] ≤ 0.89 (HR 2.7, p = 0.049) were associated with higher incidence of VOCO at 2 years in the univariable analysis. A non-significant trend was found for dPR[entire] (HR 1.9, p = 0.26). CONCLUSION A positive RFR or dPR[WFP] were associated with a worse prognosis in deferred lesions, suggesting that the use of NHPRs in addition to FFR may improve risk estimation.
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Affiliation(s)
- Marcel Halbach
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany.
| | - Christopher Ameskamp
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Victor Mauri
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Angela Ernst
- Institute of Medical Statistics and Computational Biology, University of Cologne, Robert-Koch-Str. 10, 50931, Cologne, Germany
| | - Philipp Lake
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Stephan Nienaber
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Stephan Baldus
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Matti Adam
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Hendrik Wienemann
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
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22
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Trøan J, Hansen KN, Noori M, Ellert-Gregersen J, Junker A, Veien KT, Hougaard M, Fallesen CO, Hansen HS, Jensen LO. The Influence of Microcirculatory Dysfunction on the Resting Full Cycle Ratio Compared to Fractional Flow Reserve. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 54:41-46. [PMID: 37045636 DOI: 10.1016/j.carrev.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/16/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND The relation between the resting full cycle ratio (RFR) and fractional flow reserve (FFR) is not fully understood. This study aims to investigate the influence of coronary microvascular dysfunction, assessed by the index of microvascular resistance (IMR), on RFR compared to FFR in patients undergoing functional assessment for coronary stenosis. MATERIALS AND METHODS Two-hundred patients with borderline stenosis underwent functional assessment of RFR, FFR, coronary flow reserve (CFR) and IMR. Retriever operator curve analysis was performed to assess the diagnostic value of RFR in patients with (IMR ≥ 24) and (IMR < 24). RESULTS Median RFR did not differ significantly in patients with IMR ≥ 24 compared to patients with IMR < 24: 0.89 (interquartile range (IQR) 0.84, 0.95) vs. 0.90 (IQR 0.84, 0.92), p = 0.29). FFR was significantly higher in patients with IMR ≥ 24 compared to patients with IMR < 24: median FFR 0.85 (IQR (0.76, 0.92)) vs. 0.82 (IQR 0.73, 0.86), p = 0.009, and median CFR was significantly lower 1.80 (IQR 1.40, 2.55) vs. 2.70 (IQR 1.80, 3.95), p < 0.001. The diagnostic value of RFR was high (Area under the curve (AUC) 0.89 95 % Confidence Interval: [0.85, 0.93]) and AUC did not differ between patients with IMR ≥ 24 compared to patients with IMR < 24: 0.89 vs. 0.90, p = 0.89. An overall optimal cut off of 0.88 was identified. The cut off did not differ significantly between patients with IMR ≥ 24 compared to patients with IMR < 24: 0.88 vs. 0.90, p = 0.397. CONCLUSION In patients with coronary borderline stenosis, the coronary microvascular function did not influence on the cut off values or AUC of RFR compared to FFR.
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Affiliation(s)
- Jens Trøan
- Department of Cardiology Odense University Hospital, Odense, Denmark.
| | | | - Manijeh Noori
- Department of Cardiology Odense University Hospital, Odense, Denmark
| | | | - Anders Junker
- Department of Cardiology Odense University Hospital, Odense, Denmark
| | | | - Mikkel Hougaard
- Department of Cardiology Odense University Hospital, Odense, Denmark
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23
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Ordiene R, Unikas R, Aldujeli A, Benetis R, Jakuska P, Ceponiene I, Jankauskas A, Plisiene J, Lenkutis T, Rudokaite G, Braukyliene R, Stonis M, Davies J, Punjabi PP. Instantaneous wave free ratio value impact on left internal mammary artery graft patency. Perfusion 2023; 38:1230-1239. [PMID: 35521921 PMCID: PMC10466988 DOI: 10.1177/02676591221099808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To assess whether instantaneous wave - free ratio (iFR) value is associated with left internal mammary artery (LIMA) graft failure at 12 months follow-up post coronary artery bypass graft (CABG). BACKGROUND Data suggests bypass to a non-significant left anterior descending artery (LAD) lesion due to visual over-estimation may lead to LIMA graft failure. Implementing iFR may result in better arterial graft patency. METHODS In iCABG (iFR guided CABG) study patients planned to undergo an isolated CABG procedure was prospectively enrolled and iFR was performed for LAD. Coronary computed tomography angiography was performed at 2 and 12 months follow-up. The primary endpoint of this study was to determine the rate of LIMA graft occlusion or hypoperfusion at 2 and 12-months follow-up. We considered a composite secondary endpoint of Major adverse cardiovascular and cerebrovascular event (MACCE) as a secondary outcome. RESULTS In total 69 patients were included with no differences regarding age, sex and risk factors. At 2 months, 50 of LIMAs with pre-CABG iFR median 0.855 (0.785 - 0.892) were patent. Hypoperfusion was found in 8 LIMAs (median iFR 0.88 (0.842 - 0.90)). While, 7 LIMAs (median iFR 0.91 (0.88 - 0.96)) were occluded (p = 0.04). At 12 months, when iFR of LAD was >0.85: just 12 (31.6% out of all patent LIMAS) grafts were patent and 24 (100.0% out of all hypoperfused/occluded) grafts were hypoperfused or occluded (p < 0.001). In terms of MACCE, no difference (p = 1.0) was found between all 3 groups divided according to iFR value. CONCLUSIONS Instantaneous wave - free ratio value above 0.85 in LAD is a powerful tool predicting LIMA graft failure at 1-year follow up period.
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Affiliation(s)
- Rasa Ordiene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ramunas Unikas
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ali Aldujeli
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantas Benetis
- Department of Cardiac, Thoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Povilas Jakuska
- Department of Cardiac, Thoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Indre Ceponiene
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Antanas Jankauskas
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jurgita Plisiene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Tadas Lenkutis
- Department of Cardiac, Thoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Gabriele Rudokaite
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rima Braukyliene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Mindaugas Stonis
- Department of Anaesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Justin Davies
- Department of Cardiology, Imperial College London, Hammersmith Hospital, London, UK
| | - Prakash P Punjabi
- Division of Cardiothoracic Surgery, Imperial College London, Hammersmith Hospital, London, UK
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24
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Fujii Y, Kitagawa T, Ikenaga H, Tatsugami F, Awai K, Nakano Y. The reliability and utility of on-site CT-derived fractional flow reserve (FFR) based on fluid structure interactions: comparison with FFR CT based on computational fluid dynamics, invasive FFR, and resting full-cycle ratio. Heart Vessels 2023; 38:1095-1107. [PMID: 37004540 DOI: 10.1007/s00380-023-02265-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/23/2023] [Indexed: 04/04/2023]
Abstract
Fractional flow reserve (FFR) derived off-site by coronary computed tomography angiography (CCTA) (FFRCT) is obtained by applying the principles of computational fluid dynamics. This study aimed to validate the overall reliability of on-site CCTA-derived FFR based on fluid structure interactions (CT-FFR) and assess its clinical utility compared with FFRCT, invasive FFR, and resting full-cycle ratio (RFR). We calculated the CT-FFR for 924 coronary vessels in 308 patients who underwent CCTA for clinically suspected coronary artery disease. Of these patients, 35 patients with at least one obstructive stenosis (> 50%) detected on CCTA underwent both CT-FFR and FFRCT for further investigation. Furthermore, 24 and 20 patients underwent invasive FFR and RFR in addition to CT-FFR, respectively. The inter-observer correlation (r) of CT-FFR was 0.93 (95% confidence interval [CI] 0.85-0.97, P < 0.0001) with a mean absolute difference of - 0.0042 (limits of agreement - 0.073, 0.064); 97.3% of coronary arteries without obstructive lesions on CCTA had negative results for ischemia on CT-FFR (> 0.80). The correlation coefficient between CT-FFR and FFRCT for 105 coronary vessels was 0.87 (95% CI 0.82-0.91, P < 0.0001) with a mean absolute difference of - 0.012 (limits of agreement - 0.12, 0.10). CT-FFR correlated well with both invasive FFR (r = 0.66, 95% CI 0.36-0.84, P = 0.0003) and RFR (r = 0.78, 95% CI 0.51-0.91, P < 0.0001). These data suggest that CT-FFR can potentially substitute for FFRCT and correlates closely with invasive FFR and RFR with high reproducibility. Our findings should be proven by further clinical investigation in a larger cohort.
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Affiliation(s)
- Yuto Fujii
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Toshiro Kitagawa
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan.
| | - Hiroki Ikenaga
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Fuminari Tatsugami
- Department of Diagnostic Radiology, Hiroshima University Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Kazuo Awai
- Department of Diagnostic Radiology, Hiroshima University Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Yukiko Nakano
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
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25
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Weferling M, Kim WK. Invasive Functional Assessment of Coronary Artery Disease in Patients with Severe Aortic Stenosis in the TAVI Era. J Clin Med 2023; 12:5414. [PMID: 37629456 PMCID: PMC10455333 DOI: 10.3390/jcm12165414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/14/2023] [Accepted: 08/19/2023] [Indexed: 08/27/2023] Open
Abstract
Coronary artery disease (CAD) is a common finding in patients suffering from aortic valve stenosis (AS), with a prevalence of over 50% in patients 70 years of age or older. Transcatheter aortic valve intervention (TAVI) is the standard treatment option for patients with severe AS and at least 75 years of age. Current guidelines recommend percutaneous coronary intervention (PCI) in patients planned for TAVI with stenoses of >70% in the proximal segments of non-left main coronary arteries and in >50% of left main stenoses. While the guidelines on myocardial revascularization clearly recommend functional assessment of coronary artery stenoses of less than 90% in the absence of non-invasive ischemia testing, a statement regarding invasive functional testing in AS patients with concomitant CAD is lacking in the recently published guideline on the management of valvular heart disease. This review aims to provide an overview of the hemodynamic background in AS patients, discusses and summarizes the current evidence of invasive functional testing in patients with severe AS, and gives a future perspective on the ongoing trials on that topic.
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Affiliation(s)
- Maren Weferling
- Department of Cardiology, Kerckhoff Heart and Thorax Center, 61231 Bad Nauheim, Germany;
- German Center for Cardiovascular Research (DZHK), Partnersite Rhein-Main, 10785 Berlin, Germany
| | - Won-Keun Kim
- Department of Cardiology, Kerckhoff Heart and Thorax Center, 61231 Bad Nauheim, Germany;
- German Center for Cardiovascular Research (DZHK), Partnersite Rhein-Main, 10785 Berlin, Germany
- Department of Cardio-Thoracic Surgery, Kerckhoff Heart and Thorax Center, 61231 Bad Nauheim, Germany
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26
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Tavoosi A, Kadoya Y, Chong AY, Small GR, Chow BJW. Utility of FFRCT in Patients with Chest Pain. Curr Atheroscler Rep 2023; 25:427-434. [PMID: 37358803 DOI: 10.1007/s11883-023-01117-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 06/27/2023]
Abstract
PURPOSE OF REVIEW The goal of this article is to review the data supporting the use of fractional flow reserve derived from coronary computed tomography angiography (FFRCT) in patients with chest pain. REVIEW FINDINGS Numerous clinical trials have demonstrated that the diagnostic accuracy of coronary computed tomography angiography (CCTA) can be improved with the use of FFRCT, primarily due to its superior specificity when compared to CCTA alone. This promising development may help reduce the need for invasive angiography in patients presenting with chest pain. Furthermore, some studies have indicated that incorporating FFRCT into decision-making is safe, with an FFRCT value of ≥ 0.8 being associated with favorable outcomes. While FFRCT has been shown to be feasible in patients with acute chest pain, further large-scale studies are warranted to confirm its utility. The emergence of FFRCT as a tool for the management of patients with chest pain is promising. However, potential limitations require the interpretation of FFRCT in conjunction with clinical context.
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Affiliation(s)
- Anahita Tavoosi
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Yoshito Kadoya
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Aun Yeong Chong
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Gary R Small
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Benjamin J W Chow
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
- Department of Radiology, University of Ottawa, Ottawa, Canada.
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27
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Seligman H, Patel SB, Alloula A, Howard JP, Cook CM, Ahmad Y, de Waard GA, Pinto ME, van de Hoef TP, Rahman H, Kelshiker MA, Rajkumar CA, Foley M, Nowbar AN, Mehta S, Toulemonde M, Tang MX, Al-Lamee R, Sen S, Cole G, Nijjer S, Escaned J, Van Royen N, Francis DP, Shun-Shin MJ, Petraco R. Development of artificial intelligence tools for invasive Doppler-based coronary microvascular assessment. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2023; 4:291-301. [PMID: 37538145 PMCID: PMC10393887 DOI: 10.1093/ehjdh/ztad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/16/2023] [Indexed: 08/05/2023]
Abstract
Aims Coronary flow reserve (CFR) assessment has proven clinical utility, but Doppler-based methods are sensitive to noise and operator bias, limiting their clinical applicability. The objective of the study is to expand the adoption of invasive Doppler CFR, through the development of artificial intelligence (AI) algorithms to automatically quantify coronary Doppler quality and track flow velocity. Methods and results A neural network was trained on images extracted from coronary Doppler flow recordings to score signal quality and derive values for coronary flow velocity and CFR. The outputs were independently validated against expert consensus. Artificial intelligence successfully quantified Doppler signal quality, with high agreement with expert consensus (Spearman's rho: 0.94), and within individual experts. Artificial intelligence automatically tracked flow velocity with superior numerical agreement against experts, when compared with the current console algorithm [AI flow vs. expert flow bias -1.68 cm/s, 95% confidence interval (CI) -2.13 to -1.23 cm/s, P < 0.001 with limits of agreement (LOA) -4.03 to 0.68 cm/s; console flow vs. expert flow bias -2.63 cm/s, 95% CI -3.74 to -1.52, P < 0.001, 95% LOA -8.45 to -3.19 cm/s]. Artificial intelligence yielded more precise CFR values [median absolute difference (MAD) against expert CFR: 4.0% for AI and 7.4% for console]. Artificial intelligence tracked lower-quality Doppler signals with lower variability (MAD against expert CFR 8.3% for AI and 16.7% for console). Conclusion An AI-based system, trained by experts and independently validated, could assign a quality score to Doppler traces and derive coronary flow velocity and CFR. By making Doppler CFR more automated, precise, and operator-independent, AI could expand the clinical applicability of coronary microvascular assessment.
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Affiliation(s)
- Henry Seligman
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sapna B Patel
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
| | - Anissa Alloula
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Christopher M Cook
- Essex Cardiothoracic Centre, Basildon, Essex, UK
- Anglia Ruskin University, Chelmsford, UK
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Guus A de Waard
- Heart Centre, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Mauro Echavarría Pinto
- Hospital General ISSSTE Queretaro, Faculty of Medicine, Autonomous University of Queretaro, Querétaro, Mexico
| | - Tim P van de Hoef
- Heart Centre, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Haseeb Rahman
- The British Heart Foundation Centre of Excellence and the National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, Kings College Medical School, St Thomas Hospital, London, UK
| | - Mihir A Kelshiker
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Alexandra N Nowbar
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
| | - Samay Mehta
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
| | | | - Meng-Xing Tang
- Department of Engineering, Imperial College London, London, UK
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Graham Cole
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Sukhjinder Nijjer
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Javier Escaned
- Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Niels Van Royen
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Ricardo Petraco
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, London W12 0HS, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
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Starczyński M, Dudek S, Baruś P, Niedzieska E, Wawrzeńczyk M, Ochijewicz D, Piasecki A, Gumiężna K, Milewski K, Grabowski M, Kochman J, Tomaniak M. Intravascular Imaging versus Physiological Assessment versus Biomechanics-Which Is a Better Guide for Coronary Revascularization. Diagnostics (Basel) 2023; 13:2117. [PMID: 37371012 DOI: 10.3390/diagnostics13122117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 10/23/2022] [Accepted: 10/26/2022] [Indexed: 06/29/2023] Open
Abstract
Today, coronary artery disease (CAD) continues to be a prominent cause of death worldwide. A reliable assessment of coronary stenosis represents a prerequisite for the appropriate management of CAD. Nevertheless, there are still major challenges pertaining to some limitations of current imaging and functional diagnostic modalities. The present review summarizes the current data on invasive functional and intracoronary imaging assessment using optical coherence tomography (OCT), and intravascular ultrasound (IVUS). Amongst the functional parameters-on top of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR)-we point to novel angiography-based measures such as quantitative flow ratio (QFR), vessel fractional flow reserve (vFFR), angiography-derived fractional flow reserve (FFRangio), and computed tomography-derived flow fractional reserve (FFR-CT), as well as hybrid approaches focusing on optical flow ratio (OFR), computational fluid dynamics and attempts to quantify the forces exaggerated by blood on the coronary plaque and vessel wall.
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Affiliation(s)
- Miłosz Starczyński
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Stanisław Dudek
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Piotr Baruś
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Emilia Niedzieska
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Mateusz Wawrzeńczyk
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Dorota Ochijewicz
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Adam Piasecki
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Karolina Gumiężna
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Krzysztof Milewski
- Center for Cardiovascular Research and Development, American Heart of Poland, 43-316 Bielsko-Biała, Poland
| | - Marcin Grabowski
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Janusz Kochman
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Mariusz Tomaniak
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
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Liu J, Li B, Zhang Y, Zhang L, Huang S, Sun H, Liu J, Zhao X, Zhang M, Wang W, Liu Y. A high-fidelity geometric multiscale hemodynamic model for predicting myocardial ischemia. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 233:107476. [PMID: 36933317 DOI: 10.1016/j.cmpb.2023.107476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Coronary computed tomography angiography (CCTA) derived fractional flow reserve (CT-FFR) requires a maximal hyperemic state to be modeled by assuming the total coronary resistance decreased to a constant 0.24 of that under the resting state. However, this assumption neglects the vasodilator capacity of individual patients. Herein, we proposed a high-fidelity geometric multiscale model (HFMM) to characterize coronary pressure and flow under the resting state, seeking to better predict myocardial ischemia by using CCTA-derived instantaneous wave-free ratio (CT-iFR). METHODS Fifty-seven patients (62 lesions) who had undergone CCTA and were then referred to invasive FFR were prospectively enrolled. The coronary microcirculation resistance hemodynamic model (RHM) under the resting condition was established on a patient-specific basis. Coupled with a closed-loop geometric multiscale model (CGM) of their individual coronary circulations, the HFMM model was established to non-invasively derive the CT-iFR from CCTA images. RESULTS With the invasive FFR being the reference standard, accuracy of the obtained CT-iFR in identifying myocardial ischemia was greater than those of the CCTA and non-invasively derived CT-FFR (90.32% vs. 79.03% vs. 84.3%). The overall computational time of CT-iFR was 61 ± 6 min, faster than that of the CT-FFR (8 h). The sensitivity, specificity, positive predictive value, and negative predictive value of the CT-iFR in discriminating an invasive FFR > 0.8 were 78% (95% CI: 40-97%), 92% (95% CI: 82-98%), 64% (95% CI: 39-83%), and 96% (95% CI:88-99%), respectively. CONCLUSIONS A high-fidelity geometric multiscale hemodynamic model was developed for rapid and accurate estimation of CT-iFR. Compared with CT-FFR, CT-iFR is of less computational cost and enables assessment of tandem lesions.
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Affiliation(s)
- Jincheng Liu
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Bao Li
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Yanping Zhang
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Liyuan Zhang
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Suqin Huang
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Hao Sun
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Jian Liu
- Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Xi Zhao
- Central Research Institute, United Imaging Healthcare, Shanghai, China
| | - Mingzi Zhang
- Macquarie Medical School, Faculty of Medicine, Health, and Human Sciences, Macquarie University, Sydney, Australia
| | | | - Youjun Liu
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China.
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Comparison of vessel fractional flow reserve with invasive resting full-cycle ratio in patients with intermediate coronary lesions. Int J Cardiol 2023; 377:1-8. [PMID: 36693476 DOI: 10.1016/j.ijcard.2023.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Vessel fractional flow reserve (vFFR) is a novel angiography-derived index for the assessment of myocardial ischemia without the need for pressure wires and hyperemic agents. vFFR has demonstrated very good diagnostic performance compared with the hyperemic index fractional flow reserve (FFR). The aim of this study was to compare vFFR to the non-hyperemic pressure ratio resting full-cycle ratio (RFR). METHODS This was a retrospective, observational, single-center study of an all-comer cohort undergoing RFR assessment. Invasive coronary angiography was obtained without a dedicated vFFR acquisition protocol, and vFFR calculation was attempted in all vessels interrogated by RFR (1483 lesions of 1030 patients). RESULTS vFFR could be analyzed in 986 lesions from 705 patients. Median diameter stenosis was 37% (interquartile range (IQR): 30.0-44.0%), vFFR 0.86 (IQR: 0.81-0.91) and RFR 0.94 (IQR: (0.90-0.97). The correlation between vFFR and RFR was strong (r = 0.70, 95% confidence interval (CI): 0.66-0.74, p < 0.001). Using RFR ≤0.89 as reference, the sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy for vFFR were 77%, 93%, 77%, and 92% and 89%. vFFR yielded a high area under the curve (AUC) of 0.92 (95% CI: 0.90-0.94). The good diagnostic performance of vFFR was confirmed among subgroups of patients with diabetes, severe aortic stenosis, female gender and lesions located in the left anterior descending artery. CONCLUSION vFFR has a high diagnostic performance taking RFR as the reference standard for evaluating the functional significance of coronary stenoses.
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31
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Boutaleb AM, Ghafari C, Ungureanu C, Carlier S. Fractional flow reserve and non-hyperemic indices: Essential tools for percutaneous coronary interventions. World J Clin Cases 2023; 11:2123-2139. [PMID: 37122527 PMCID: PMC10131021 DOI: 10.12998/wjcc.v11.i10.2123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/22/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Hemodynamical evaluation of a coronary artery lesion is an important diagnostic step to assess its functional impact. Fractional flow reserve (FFR) received a class IA recommendation from the European Society of Cardiology for the assessment of angiographically moderate stenosis. FFR evaluation of coronary artery disease offers improvement of the therapeutic strategy, deferring unnecessary procedures for lesions with a FFR > 0.8, improving patients' management and clinical outcome. Post intervention, an optimal FFR > 0.9 post stenting should be reached and > 0.8 post drug eluting balloons. Non-hyperemic pressure ratio measurements have been validated in previous studies with a common threshold of 0.89. They might overestimate the hemodynamic significance of some lesions but remain useful whenever hyperemic agents are contraindicated. FFR remains the gold standard reference for invasive assessment of ischemia. We illustrate this review with two cases introducing the possibility to estimate also non-invasively FFR from reconstructed 3-D angiograms by quantitative flow ratio. We conclude introducing a hybrid approach to intermediate lesions (DFR 0.85-0.95) potentially maximizing clinical decision from all measurements.
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Affiliation(s)
- Amine Mamoun Boutaleb
- Department of Cardiology, Ibn Rochd University Hospital, Casablanca 20230, Casablanca, Morocco
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
| | - Chadi Ghafari
- Department of Cardiology, University of Mons, Mons 7000, Belgium
| | - Claudiu Ungureanu
- Department of Cardiology, University of Mons, Mons 7000, Belgium
- Catheterization Unit, Jolimont Hospital, La Louvière 7100, Belgium, Belgium
| | - Stéphane Carlier
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
- Department of Cardiology, University of Mons, Mons 7000, Belgium
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de Oliveira Laterza Ribeiro M, Correia VM, Herling de Oliveira LL, Soares PR, Scudeler TL. Evolving Diagnostic and Management Advances in Coronary Heart Disease. Life (Basel) 2023; 13:951. [PMID: 37109480 PMCID: PMC10143565 DOI: 10.3390/life13040951] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Despite considerable improvement in diagnostic modalities and therapeutic options over the last few decades, the global burden of ischemic heart disease is steadily rising, remaining a major cause of death worldwide. Thus, new strategies are needed to lessen cardiovascular events. Researchers in different areas such as biotechnology and tissue engineering have developed novel therapeutic strategies such as stem cells, nanotechnology, and robotic surgery, among others (3D printing and drugs). In addition, advances in bioengineering have led to the emergence of new diagnostic and prognostic techniques, such as quantitative flow ratio (QFR), and biomarkers for atherosclerosis. In this review, we explore novel diagnostic invasive and noninvasive modalities that allow a more detailed characterization of coronary disease. We delve into new technological revascularization procedures and pharmacological agents that target several residual cardiovascular risks, including inflammatory, thrombotic, and metabolic pathways.
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Affiliation(s)
| | | | | | | | - Thiago Luis Scudeler
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
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Verdoia M, Rognoni A. Coronary Physiology: Modern Concepts for the Guidance of Percutaneous Coronary Interventions and Medical Therapy. J Clin Med 2023; 12:2274. [PMID: 36983275 PMCID: PMC10057250 DOI: 10.3390/jcm12062274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
Recent evidence on ischemia, rather than coronary artery disease (CAD), representing a major determinant of outcomes, has led to a progressive shift in the management of patients with ischemic heart disease. According to most recent guidelines, myocardial revascularization strategies based on anatomical findings should be progressively abandoned in favor of functional criteria for the guidance of PCI. Thus, emerging importance has been assigned to the assessment of coronary physiology in order to determine the ischemic significance of coronary stenoses. However, despite several indexes and tools that have been developed so far, the existence of technical and clinical conditions potentially biasing the functional evaluation of the coronary tree still cause debates regarding the strategy of choice. The present review provides an overview of the available methods and the most recent acquirements for the invasive assessment of ischemia, focusing on the most widely available indexes, fractional flow reserve (FFR) and instant-wave free ratio (iFR), in addition to emerging examples, as new approaches to coronary flow reserve (CFR) and microvascular resistance, aiming at promoting the knowledge and application of those "full physiology" principles, which are generally advocated to allow a tailored treatment and the achievement of the largest prognostic benefits.
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Affiliation(s)
- Monica Verdoia
- Nuovo Ospedale Degli Infermi, Azienda Sanitaria Locale Biella, 13900 Biella, Italy
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34
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Fawaz S, Khan S, Simpson R, Clesham G, Cook CM, Davies JR, Karamasis GV, Keeble TR. Invasive Detection of Coronary Microvascular Dysfunction: How It Began, and Where We Are Now. Interv Cardiol 2023; 18:e07. [PMID: 37601734 PMCID: PMC10433108 DOI: 10.15420/icr.2022.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/02/2022] [Indexed: 03/17/2023] Open
Abstract
The landscape of interventional cardiology is ever evolving. Contemporary practice has shifted from a stenosis-centred approach to the total characterisation of both the epicardial and microcirculatory vessels. Microcirculatory dysfunction plays an important role in the pathophysiology of acute and chronic coronary syndromes, and characterisation of the microcirculation has important clinical consequences. Accordingly, the invasive diagnosis of microcirculatory dysfunction is becoming a key feature of the interventional cardiologist's toolkit. This review focuses on the methodology underpinning the invasive diagnosis of microvascular dysfunction and highlights the indices that have arisen from these methodologies.
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Affiliation(s)
- Samer Fawaz
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - Sarosh Khan
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - Rupert Simpson
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - Gerald Clesham
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - Christopher M Cook
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - John R Davies
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - Grigoris V Karamasis
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School Athens, Greece
| | - Thomas R Keeble
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
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35
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Berntorp K, Rylance R, Yndigegn T, Koul S, Fröbert O, Christiansen EH, Erlinge D, Götberg M. Clinical Outcome of Revascularization Deferral With Instantaneous Wave-Free Ratio and Fractional Flow Reserve: A 5-Year Follow-Up Substudy From the iFR-SWEDEHEART Trial. J Am Heart Assoc 2023; 12:e028423. [PMID: 36734349 PMCID: PMC9973641 DOI: 10.1161/jaha.122.028423] [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: 02/04/2023]
Abstract
Background Although physiology-based assessment of coronary artery stenosis using instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) are established methods of guiding coronary revascularization, its clinical outcome in long-term deferral needs further evaluation, especially with acute coronary syndrome as a clinical presentation. The aim was to evaluate the long-term clinical outcome of deferral of revascularization based on iFR or FFR. Methods and Results This is a substudy of the iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trial, where patients deferred from revascularization from each study arm were selected. Nine hundred eight patients deferred from coronary revascularization with iFR (n=473) and FFR (n=435) were followed for 5 years. The national quality registry, SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies), was used for patient data collection and clinical follow-up. The end point was major adverse cardiac events and their individual components all-cause death, cardiovascular death, noncardiovascular death, nonfatal myocardial infarction, and unplanned revascularization. No significant difference was found in major adverse cardiac events (iFR 18.6% versus FFR 16.8%; adjusted hazard ratio, 1.08 [95% CI, 0.79-1.48]; P=0.63) or their individual components. Conclusions No differences in clinical outcomes after 5-year follow-up were noted when comparing iFR versus FFR as methods for deferral of coronary revascularization in patients presenting with stable angina pectoris and acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02166736.
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Affiliation(s)
- Karolina Berntorp
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Rebecca Rylance
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Troels Yndigegn
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Sasha Koul
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Ole Fröbert
- Faculty of Health, Department of CardiologyÖrebro University HospitalÖrebroSweden
| | | | - David Erlinge
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Matthias Götberg
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
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36
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Molossi S, Doan T, Sachdeva S. Anomalous Coronary Arteries. Cardiol Clin 2023; 41:51-69. [DOI: 10.1016/j.ccl.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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37
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Cameron JD. Non-hyperemic pressure-derived indices for guiding coronary intervention: Assessing comparative use and application. Int J Cardiol 2023; 372:46-47. [PMID: 36460207 DOI: 10.1016/j.ijcard.2022.11.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/27/2022] [Indexed: 12/05/2022]
Affiliation(s)
- James D Cameron
- Monash Cardiovascular Research Centre, MonashHEART, Monash Health, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia.
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38
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Yamanaka F, Shishido K, Yokota S, Moriyama N, Ochiai T, Yamada T, Hayashi T, Miyashita H, Yokoyama H, Yamanaga K, Tabata N, Yamaguchi M, Yamagishi T, Matsumoto T, Tobita K, Mizuno S, Tanaka Y, Murakami M, Takahashi S, Saito S, Tsujita K. Discordance between fractional flow reserve and instantaneous wave-free ratio in patients with severe aortic stenosis: A retrospective cohort study. J Cardiol 2023; 81:138-143. [PMID: 36057484 DOI: 10.1016/j.jjcc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/31/2022] [Accepted: 08/03/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Discordance between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) occurs in approximately 20 % of cases. However, no studies have reported the discordance in patients with severe aortic stenosis (AS). We aimed to evaluate the diagnostic discordance between FFR and iFR in patients with severe AS. METHODS We examined 140 consecutive patients with severe AS (164 intermediate coronary artery stenosis vessels). FFR and iFR were calculated in four quadrants based on threshold FFR and iFR values of ≤0.8 and ≤0.89, respectively (Group 1: iFR >0.89, FFR >0.80; Group 2: iFR ≤0.89, FFR >0.80; Group 3: iFR >0.89, FFR ≤0.80; and Group 4: iFR ≤0.89, FFR ≤0.80). Concordant groups were Groups 1 and 4, and discordant groups were Groups 2 and 3. Positive and negative discordant groups were Groups 3 and 2, respectively. RESULTS The median (Q1, Q3) FFR and iFR were 0.84 (0.76, 0.88) and 0.85 (0.76, 0.91), respectively. Discordance was observed in 48 vessels (29.3 %). In the discordant group, negative discordance (Group 2: iFR ≤0.89 and FFR >0.80) was predominant (45 cases, 93.6 %). Multivariate analysis showed that the left anterior descending artery [odds ratio (OR), 3.88; 95 % confidence interval (CI): 1.54-9.79, p = 0.004] and peak velocity ≥5.0 m/s (OR, 3.21; 95%CI: 1.36-7.57, p = 0.008) were independently associated with negative discordance (FFR >0.8 and iFR ≤0.89). CONCLUSIONS In patients with severe AS, discordance between FFR and iFR was predominantly negative and observed in 29.3 % of vessels. The left anterior descending artery and peak velocity ≥5.0 m/s were independently associated with negative discordance.
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Affiliation(s)
- Futoshi Yamanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan; Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Koki Shishido
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shohei Yokota
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Noriaki Moriyama
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Tomoki Ochiai
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takashi Yamada
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takahiro Hayashi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Hirokazu Miyashita
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Hiroaki Yokoyama
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kenshi Yamanaga
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Noriaki Tabata
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masashi Yamaguchi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Tamiharu Yamagishi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takashi Matsumoto
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kazuki Tobita
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shingo Mizuno
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yutaka Tanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Masato Murakami
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Saeko Takahashi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shigeru Saito
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Vasiljevs D, Kakurina N, Pontaga N, Kokina B, Osipovs V, Sorokins N, Pikta S, Trusinskis K, Lejnieks A. Culprit versus Complete Revascularization during the Initial Intervention in Patients with Acute Coronary Syndrome Using a Virtual Treatment Planning Tool: Results of a Single-Center Pilot Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020270. [PMID: 36837471 PMCID: PMC9967361 DOI: 10.3390/medicina59020270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/12/2023] [Accepted: 01/27/2023] [Indexed: 02/01/2023]
Abstract
Background and Objectives: The revascularization strategy for percutaneous coronary intervention (PCI) in patients with multivessel (MV) acute coronary syndrome (ACS) remains controversial. Certain gaps in the evidence are related to the optimal timing of non-culprit lesion revascularization and the utility of instantaneous wave-free ratio (iFR) in the management of MV ACS intervention. The major benefits of iFR utilization in MV ACS patients in one-stage complete revascularization are: (1) the possibility to virtually plan the PCI, both the location and the extension of the necessary stenting to achieve the prespecified final hemodynamic result; (2) the opportunity to validate the final hemodynamic result of the PCI, both in culprit artery and all non-culprit arteries and (3) the value of obliviating the uncomfortable, costly, time consuming and sometimes deleterious effects from Adenosine, as there is no requirement for administration. Thus, iFR use fosters the achievement of physiologically appropriate complete revascularization in MV ACS patients during acute hospitalization. Materials and Methods: This pilot study was aimed to test the feasibility of a randomized trial research protocol as well as to assess patient safety signals of co-registration iFR-guided one-stage complete revascularization compared with that of standard staged angiography-guided PCI in de novo patients with MV ACS. This was a single-center, prospective, randomized, open-label clinical trial consecutively screening patients with ACS for MV disease. The intervention strategy of interest was iFR-guided physiologically complete one-stage revascularization, in which the virtual PCI planning of non-culprit lesions and the intervention itself were performed in one stage directly following treatment of the culprit lesion and other critical stenosis of more than ninety percent. Seventeen patients were recruited and completed the 3-month follow-up. Results: Index PCI duration was significantly longer while the volume of contrast media delivered in index PCI was significantly greater in the iFR-guided group than in the angiography-guided group (119.4 ± 40.7 vs. 47 ± 15.5 min, p = 0.004; and 360 ± 97.9 vs. 192.5 ± 52.8 mL, p = 0.003). There were no significant differences in PCI-related major adverse cardiovascular events (MACE) between the groups during acute hospitalization and at 3-months follow-up. One-stage iFR-guided PCI requires fewer PCI attempts until complete revascularization than does angiography-guided staged PCI. Conclusions: Complete revascularization with the routine use of the virtual planning tool in one-stage iFR-guided PCI is a feasible practical strategy in an everyday Cath lab environment following the protocol designed for the study. No statistically significant safety signals were documented in the number of PCI related MACE during the 3-month follow-up.
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Affiliation(s)
- Deniss Vasiljevs
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
- Correspondence: ; Tel.: +371-6544-0858
| | - Natalja Kakurina
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Natalja Pontaga
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Baiba Kokina
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
| | - Vladimirs Osipovs
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Nikolajs Sorokins
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Sergejs Pikta
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Karlis Trusinskis
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Str., LV-1002 Riga, Latvia
| | - Aivars Lejnieks
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
- Riga East Clinical University Hospital, 2 Hipokrata Str., LV-1038 Riga, Latvia
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Joseph T, Foley M, Al-Lamee R. Physiology and Intravascular Imaging Coregistration-Best of all Worlds? Interv Cardiol Clin 2023; 12:71-82. [PMID: 36372463 DOI: 10.1016/j.iccl.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Percutaneous coronary intervention is increasingly guided by coronary physiology and optimized using intravascular imaging. Pressure-based measurements determine the significance of a stenosis using hyperemic or nonhyperemic pressure ratios (eg, the instantaneous wave-free ratio). Intravascular ultrasound and optical coherence tomography provide cross-sectional and longitudinal detail regarding plaque composition and vessel characteristics. These facilitate lesion preparation and optimization of stent sizing and positioning. This review explores the evidence-base and practical aspects of coregistering pressure gradient assessment and intravascular imaging with angiography. We then discuss gaps in the evidence and what is needed to help integrate these techniques into clinical practice.
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Affiliation(s)
- Tobin Joseph
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W120HS, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London, W120HS, UK
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W120HS, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London, W120HS, UK.
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W120HS, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London, W120HS, UK; Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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Nijjer SS. Using Physiology Pullback for Percutaneous Coronary Intervention Guidance: Is this the Future? Interv Cardiol Clin 2023; 12:41-53. [PMID: 36372461 DOI: 10.1016/j.iccl.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Modern coronary intervention requires integration of angiographic, physiologic, and intravascular imaging. This article describes the use and techniques needed to understand coronary physiology pullback data and how use it to make revascularization decisions. The article describes instantaneous wave-free ratio, fractional flow reserve, and the data that support their use and how they differ when used in tandem disease. Common practical mistakes and errors are discussed together with a brief review of the limited published research data.
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Affiliation(s)
- Sukhjinder Singh Nijjer
- Department of Cardiology, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, United Kingdom. https://twitter.com/SukhNijjer
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Fawaz S, Cook CM. Understanding the Basis for Hyperemic and Nonhyperemic Coronary Pressure Assessment. Interv Cardiol Clin 2023; 12:1-12. [PMID: 36372454 DOI: 10.1016/j.iccl.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Despite the now routine integration of invasive physiologic systems into coronary catheter laboratories worldwide, it remains critical that all operators maintain a sound understanding of the fundamental physiologic basis for coronary pressure assessment. More specifically, performing operators should be well informed regarding the basis for hyperemic (ie, fractional flow reserve) and nonhyperemic (ie, instantaneous wave-free ratio and other nonhyperemic pressure ratio) coronary pressure assessment. In this article, we provide readers a comprehensive history charting the inception, development, and validation of hyperemic and nonhyperemic coronary pressure assessment.
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Affiliation(s)
- Samer Fawaz
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom
| | - Christopher M Cook
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom.
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Di Serafino L, Barbato E, Serino F, Svanerud J, Scalamogna M, Cirillo P, Petitto M, Esposito M, Silvestri T, Franzone A, Piccolo R, Esposito G. Myocardial mass affects diagnostic performance of non-hyperemic pressure-derived indexes in the assessment of coronary stenosis. Int J Cardiol 2023; 370:84-89. [PMID: 36265648 DOI: 10.1016/j.ijcard.2022.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/09/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022]
Abstract
Background Several non-hyperemic pressure-derived Indexes (NHPI) have been introduced for the assessment of coronary stenosis, showing a good correlation with fractional flow reserve (FFR). Notably, either the assessment of NHPI during adenosine administration (NHPIADO) or the Hybrid Approach (NHPIHA), combining NHPI with FFR, have been showed to increase the accuracy of such indexes. It remains unclear whether diagnostic performance might be affected by the extent of the subtended myocardial mass. METHODS We enrolled consecutive patients with an intermediate coronary stenosis assessed with NHPI and FFR. NHPI were also measured during adenosine (ADO) administration (NHPIADO). The amount of jeopardized myocardium was assessed using the Duke Jeopardy Score (DJS). With FFR as reference, we assessed the accuracy of NHPI, NHPIADO and NHPIHA according to the extent of the subtended myocardium. RESULTS One-hundred-seventy stenoses from 151 patients were grouped according to the DJS as follows: A) Small Extent (SE, n = 82); B) Moderate Extent (ME, n = 53); C) Large Extent (LE, n = 35). As compared with FFR, NHPI showed a significantly different accuracy, as assessed by the Youden's index, according to the extent of the jeopardized myocardium (SE: 0.39 ± 0.05, ME: 0.68 ± 0.06, LE: 0.28 ± 0.06, p < 0.001). Conversely, both the NHPIADO (SE: 0.76 ± 0.02, ME: 0.88 ± 0.02, LE: 0.82 ± 0.02, p = 0.72) and NHPIHA (SE: 0.82 ± 0.07, ME: 0.84 ± 0.02, LE: 0.88 ± 0.02, p = 0.70) allowed for a better diagnostic accuracy regardless of the amount of myocardium subtended. CONCLUSIONS Diagnostic performance of NHPI might be affected by the extent of myocardial territory subtended by the coronary stenosis. A hybrid approach might be useful to overcome this limitation.
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Affiliation(s)
- Luigi Di Serafino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy; Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Federica Serino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Maria Scalamogna
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Marta Petitto
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Mafalda Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Tania Silvestri
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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Sehatbakhsh S, Li W, Takahashi T, Takahashi K, Parikh MA, Kobayashi Y. Nonhyperemic Pressure Ratios-All the Same or Nuanced Differences? Interv Cardiol Clin 2023; 12:13-19. [PMID: 36372456 DOI: 10.1016/j.iccl.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Fractional flow reserve (FFR) has become the gold standard for invasively assessing the functional significance of coronary artery disease (CAD) to guide revascularization. The amount of evidence supporting the role of FFR in the cardiac catheterization laboratory is large and still growing. However, FFR uptake in the daily practice is limited by a variety of factors such as invasive instrumentation of the coronary artery that requires extra time and need for vasodilator medications for hyperemia. In this review, we describe the details of wire-based alternatives to FFR, providing insights as to their development, clinical evidence, and limitations.
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Affiliation(s)
- Samineh Sehatbakhsh
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 210th Street, Bronx, NY 10467, USA
| | - Weijia Li
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, The Bronx, NY 10461, USA
| | - Tatsunori Takahashi
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, The Bronx, NY 10461, USA
| | - Kayo Takahashi
- Department of Cardiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Manish A Parikh
- Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, 506 6th Street, Brooklyn, NY 11215, USA
| | - Yuhei Kobayashi
- Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, 506 6th Street, Brooklyn, NY 11215, USA.
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Johnson DT, Svanerud J, Ahn JM, Bezerra HG, Collison D, van 't Veer M, Hennigan B, De Bruyne B, Kirkeeide RL, Gould KL, Johnson NP. Use of a Pressure Wire for Automatically Correcting Artifacts in Phasic Pressure Tracings From a Fluid-Filled Catheter. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 46:98-105. [PMID: 35918253 DOI: 10.1016/j.carrev.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 07/16/2022] [Accepted: 07/25/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND/PURPOSE Matching phasic pressure tracings between a fluid-filled catheter and high-fidelity pressure wire has received limited attention, although each part contributes half of the information to clinical decisions. We aimed to study the impact of a novel and automated method for improving the phasic calibration of a fluid-filled catheter by accounting for its oscillatory behavior. METHODS/MATERIALS Retrospective analysis of drift check tracings was performed using our algorithm that corrects for mean difference (offset), temporal delays (timing), differential sensitivity of the manifold transducer and pressure wire sensor (gain), and the oscillatory behavior of the fluid-filled catheter described by its resonant frequency and damping factor (how quickly oscillations disappear after a change in pressure). RESULTS Among 2886 cases, correcting for oscillations showed a large improvement in 28 % and a medium improvement in 41 % (decrease in root mean square error >0.5 mmHg to <1 or 1-2 mmHg, respectively). 96 % of oscillators were underdamped with median damping factor 0.27 and frequency 10.6 Hz. Fractional flow reserve or baseline Pd/Pa demonstrated no clinically important bias when ignoring oscillations. However, uncorrected subcycle non-hyperemic pressure ratios (NHPR) displayed both bias and scatter. CONCLUSIONS By automatically accounting for the oscillatory behavior of a fluid-filled catheter system, phasic matching against a high-fidelity pressure wire can be improved compared to standard equalization methods. The majority of tracings contain artifacts, mainly due to underdamped oscillations, and neglecting them leads to biased estimates of equalization parameters. No clinically important bias exists for whole-cycle metrics, in contrast to significant effects on subcycle NHPR.
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Affiliation(s)
- Daniel T Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, United States of America
| | | | | | | | | | - Marcel van 't Veer
- Catharina Hospital and Eindhoven University of Technology, Eindhoven, Netherlands
| | - Barry Hennigan
- Mater Private Hospital and University College, Cork, Ireland
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Richard L Kirkeeide
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, United States of America
| | - K Lance Gould
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, United States of America
| | - Nils P Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, United States of America.
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Kojima H, Ishii H, Tanaka A, Funakubo H, Kato T, Shimbo Y, Kawamiya T, Kuwatsuka Y, Ando M, Murohara T. Comparative study of fractional flow reserve and diastolic pressure ratio using a guidewire with a sensor for measuring intravascular pressure. Medicine (Baltimore) 2022; 101:e32578. [PMID: 36596027 PMCID: PMC9803508 DOI: 10.1097/md.0000000000032578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE This study aimed to evaluate the correlation and diagnostic agreement between diastolic pressure ratio (dPR) and fractional flow reserve (FFR) in a Japanese real-world setting. DESIGN Prospective multicenter observational study. METHODS This study included 100 patients with intermediate coronary artery stenosis at 4 Japanese hospitals. For these lesions, FFR and dPR were measured using a guidewire with a sensor and a monitor to measure intravascular pressure. The correlation and diagnostic agreement between FFR and dPR were assessed. When both FFR and dPR were negative or positive, the results were considered to be concordant. When one was positive and the other was negative, the result was regarded as discordant (positive discordance, FFR > 0.80 and dPR ≤ 0.89; negative discordance, FFR ≤ 0.80 and dPR > 0.89). RESULTS Overall, the FFR and dPR were well-correlated (R = 0.841). FFR and dPR were concordant in 89% of cases (concordant normal, 43%; concordant abnormal, 46%) and discordant in 11% (positive discordance, 7%; negative discordance, 4%). No significant difference was observed in the rate of concordant results between patients with and without diabetes mellitus. The diagnostic concordance rate was significantly different among the 3 coronary arteries (right coronary artery, 93.3%; left anterior descending artery, 93.2%; and left circumflex artery, 58.3%; P = .001). Additionally, the rate of concordant results tended to be higher when using intravenous administration of adenosine than when using intracoronary bolus injection of nicorandil (adenosine, 95.1%; nicorandil, 84.7%; P = .103). CONCLUSION We found that dPR was highly correlated with FFR, and diagnostic discordance was observed in 11% of the lesions. Several factors, including lesion location and medication for hyperemia, may cause the diagnostic discordance between dPR and FFR.
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Affiliation(s)
- Hiroki Kojima
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
- *Correspondence: Hideki Ishii, MD, PhD, Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan. e-mail: ,
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Funakubo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshiaki Kato
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Yusaku Shimbo
- Department of Cardiology, Kariya Toyota General Hospital, Kariya, Japan
| | - Toshiki Kawamiya
- Department of Cardiology, Tsushima City Hospital, Tsushima, Japan
| | - Yachiyo Kuwatsuka
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Masahiko Ando
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Liang L, Zhu Y, Li F, Guo K, Chang S, Li Q, Zhang Y, Li D. Comparative analysis of instantaneous wave-free ratio and quantitative real-time myocardial contrast echocardiography for the assessment of myocardial perfusion. Front Cardiovasc Med 2022; 9:893647. [DOI: 10.3389/fcvm.2022.893647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 10/06/2022] [Indexed: 01/10/2023] Open
Abstract
Background and hypothesisThe field of coronary artery physiology is developing rapidly and changing the practice of interventional cardiology. A new functional evaluation technique using the instantaneous wave-free ratio (iFR) has become an alternative to fractional flow reserve. Future research studies need to determine whether physiological indicators play a role in evaluating myocardial perfusion in the catheter room.Materials and methodsThirty-eight patients scheduled for coronary angiography and iFR evaluation underwent a real-time myocardial contrast echocardiography (RT-MCE) examination at rest. The myocardial perfusion parameters (A, β, and A × β) on the myocardial perfusion curve were quantitatively analyzed using Q-Lab software. Coronary angiography and iFR assessment were completed within 1 week after the RT-MCE examination in all patients. Correlation analysis was used to identify iFR- and MCE-related indicators. The sensitivity and specificity of iFR in the quantitative detection of coronary microcirculation were obtained.ResultsThe correlation coefficients between iFR and A, β, and A × β were 0.81, 0.66, and 0.82, respectively. The cut-off value for iFR was 0.85 for microvascular ischemia detection, while the sensitivity and specificity for the diagnosis of myocardial perfusion were 90.7 and 89.9%, respectively. The receiver operating characteristic (ROC) curve area for iFR was 0.946 in the segments related to myocardial blood flow.ConclusionThe iFR is an effective tool for detecting myocardial microcirculation perfusion, with satisfactory diagnostic performance and a demonstrated role in physiological indices used for the perfusion assessment.
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Chuang MJ, Chang CC, Lee YH, Lu YW, Tsai YL, Chou RH, Wu CH, Lu TM, Huang PH. Clinical assessment of resting full-cycle ratio and fractional flow reserve for coronary artery disease in a real-world cohort. Front Cardiovasc Med 2022; 9:988820. [DOI: 10.3389/fcvm.2022.988820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/10/2022] [Indexed: 01/10/2023] Open
Abstract
BackgroundThere are few reports published on the comparison of the resting full-cycle ratio (RFR) and fractional flow reserve (FFR) on the assessment of the severity of coronary stenosis. We aimed to investigate the diagnostic accuracy of RFR for detection of functionally significant coronary lesions.MethodsThis was an observational, retrospective, single-center study. We evaluated both RFR and FFR for 277 coronary lesions of 235 patients who underwent coronary angiography. Patients presenting with chronic coronary syndrome, unstable angina, or non-ST-elevation myocardial infarction were included.ResultsThe mean FFR and RFR values were 0.84 ± 0.08 and 0.90 ± 0.08, respectively. RFR significantly correlated with FFR (r = 0.727, P < 0.001). The agreement rate between the FFR and RFR was 79.8% (221/277). The diagnostic performance of RFR vs. FFR was accuracy 79.8%, sensitivity 70.4%, specificity 83.7%, positive predictive value 64.0%, and negative predictive value 87.2%. The discriminative power of RFR to identify lesions with FFR ≤ 0.80 was acceptable when the RFR value was within the gray zone [0.86 ≤ RFR ≤ 0.93; AUC: 0.72 (95% CI:0.63–0.81)], while it was excellent when the RFR value was out of the gray zone [RFR > 0.93 or < 0.86; AUC: 0.94 (95% CI:0.88–0.99)].ConclusionRFR was significantly correlated with FFR in the assessment of intermediate coronary stenosis. An RFR-FFR hybrid approach increases the diagnostic accuracy of RFR in the detection of functionally significant lesions.
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Guan S, Gan Q, Han W, Zhai X, Wang M, Chen Y, Zhang L, Li T, Chang X, Liu H, Hong W, Li Z, Tu S, Qu X. Feasibility of Quantitative Flow Ratio Virtual Stenting for Guidance of Serial Coronary Lesions Intervention. J Am Heart Assoc 2022; 11:e025663. [PMID: 36129050 PMCID: PMC9673740 DOI: 10.1161/jaha.122.025663] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Coronary physiology measurement in serial coronary lesions with multiple stenoses is challenging. Therefore, we evaluated the feasibility of Murray fractal law‐based quantitative flow ratio (μQFR) virtual stenting for guidance of serial coronary lesions intervention. Methods and Results Patients who underwent elective coronary angiography and had 2 serial de novo coronary lesions of 30% to 90% diameter stenosis by visual estimation were prospectively enrolled. μQFR and fractional flow reserve (FFR) were assessed after coronary angiography. In vessels with an FFR ≤0.80, the lesion with the larger pressure gradient was considered to be the primary lesion and treated firstly, followed by FFR measurement. The second lesion was stented when FFR ≤0.80. All μQFR and predicted μQFR after stenting were calculated from diagnostic coronary angiography before interventions, with the analysts masked to the FFR data. A total of 54 patients with 61 target vessels were interrogated. Percutaneous coronary intervention was performed in 44 vessels with FFR ≤0.80. After stenting the primary lesions, 14 nonprimary lesions had FFR ≤0.80 and a second drug‐eluting stent was implanted. There was excellent correlation (r=0.97, P<0.001) and good agreement (mean difference: 0.00±0.03) between baseline μQFR and FFR in identifying flow‐limiting lesions. Per‐vessel diagnostic accuracy of μQFR on de novo lesions was 96.7% (95% CI, 88.7%–99.6%). μQFR and FFR are highly consistent (93.2%) in identifying the primary lesion requiring revascularization. After stenting the primary lesions, per‐vessel diagnostic accuracy of predicted μQFR for identifying the significance of the nonprimary lesion was 90.9%. Predicted residual μQFR with virtual stenting was higher than final FFR (mean difference: 0.05±0.06). Conclusions In vessels with serial coronary lesions, virtual stenting by μQFR can identify the primary flow‐limiting lesion for revascularization.
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Affiliation(s)
- Shaofeng Guan
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
| | - Qian Gan
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
| | - Wenzheng Han
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
| | - Xinrong Zhai
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
| | - Ming Wang
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
| | - Yang Chen
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
| | - Liang Zhang
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
| | - Tianqi Li
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
| | - Xifeng Chang
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
| | - Hongyuan Liu
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
| | - Weilin Hong
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
| | - Zehang Li
- Shanghai Jiao Tong University-Pulse Medical Imaging Joint Laboratory Shanghai China
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering Shanghai Jiao Tong University Shanghai China
| | - Xinkai Qu
- Department of Cardiology Huadong Hospital Affiliated to Fudan University Shanghai China.,Shanghai Key Laboratory of Clinical Geriatric Medicine Shanghai China
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Cameron JN, Comella A, Sutherland N, Brown AJ, Phan TG. Non-hyperaemic assessment of coronary ischaemia: application of machine learning techniques. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022; 3:505-515. [PMID: 36710902 PMCID: PMC9779890 DOI: 10.1093/ehjdh/ztac050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/24/2022] [Indexed: 02/01/2023]
Abstract
Aims Hyperaemic and non-hyperaemic pressure ratios (NHPR) are routinely used to identify significant coronary lesions. Machine learning (ML) techniques may help better understand these indices and guide future practice. This study assessed the ability of a purpose-built ML algorithm to classify coronary ischaemia during non-hyperaemia compared with the existing gold-standard technique (fractional flow reserve, FFR). Further, it investigated whether ML could identify components of coronary and aortic pressure cycles indicative of ischaemia. Methods and results Seventy-seven coronary vessel lesions (39 FFR defined ischaemia, 53 patients) with proximal and distal non-hyperaemic pressure waveforms and FFR values were assessed using supervised and unsupervised learning techniques in combination with principal component analysis (PCA). Fractional flow reserve measurements were obtained from the right coronary artery (13), left anterior descending (46), left circumflex (11), left main (1), obtuse marginal (2), and diagonal (4). The most accurate supervised learning classification utilized whole-cycle aortic with diastolic distal blood pressure waveforms, yielding a classification accuracy of 86.9% (sensitivity 86.8%, specificity 87.2%, positive predictive value 86.8%, negative predictive value 87.2%). Principal component analysis showed subtle variations in coronary pressures at the start of diastole have significant relation to ischaemia, and whole-cycle aortic pressure data are important for determining ischaemia. Conclusions Our ML algorithm classifies significant coronary lesions with accuracy similar to previous studies comparing time-domain NHPRs with FFR. Further, it has identified characteristics of pressure waveforms that relate to function. These results provide an application of ML to ischaemia requiring only standard data from non-hyperaemic pressure measurements.
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Affiliation(s)
| | | | - Nigel Sutherland
- Department of Cardiology, Northern Hospital Melbourne, 185 Cooper St, Epping, VIC 3076, Australia
| | - Adam J Brown
- Monash Cardiovascular Research Centre, MonashHeart, Monash Health, Melbourne 3168, Australia
| | - Thanh G Phan
- Department of Neurology, Monash Health and School of Clinical Sciences at Monash Health, Monash University, Melbourne 3168, Australia
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