1
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Altstidl JM, Achenbach S, Feyrer J, Nazli JB, Marwan M, Gaede L, Möllmann H, Giesler T, Rittger H, Pauschinger M, Rudolph TK, Moshage W, Brück M, Tröbs M. Use of coronary physiology to guide revascularization in clinical practice: results of the F(FR) 2 registry. Clin Res Cardiol 2024:10.1007/s00392-024-02463-w. [PMID: 38832995 DOI: 10.1007/s00392-024-02463-w] [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: 02/22/2024] [Accepted: 05/15/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Despite the recommendation of coronary physiology to guide revascularization in angiographically intermediate stenoses without established correlation to ischemia, its uptake in clinical practice is slow. AIMS This study aimed to analyze the use of coronary physiology in clinical practice. METHODS Based on a multicenter registry (Fractional Flow Reserve Fax Registry, F(FR)2, ClinicalTrials.gov identifier NCT03055910), clinical use, consequences, and complications of coronary physiology were systematically analyzed. RESULTS F(FR)2 enrolled 2,000 patients with 3,378 intracoronary pressure measurements. Most measurements (96.8%) were performed in angiographically intermediate stenoses. Out of 3,238 lesions in which coronary physiology was used to guide revascularization, revascularization was deferred in 2,643 (78.2%) cases. Fractional flow reserve (FFR) was the most common pressure index used (87.6%), with hyperemia induced by an intracoronary bolus of adenosine in 2,556 lesions (86.4%) and intravenous adenosine used for 384 measurements (13.0%). The route of adenosine administration did not influence FFR results (change-in-estimate -3.1% for regression model predicting FFR from diameter stenosis). Agreement with the subsequent revascularization decision was 93.4% for intravenous and 95.0% for intracoronary adenosine (p = 0.261). Coronary artery occlusion caused by the pressure wire was reported in two cases (0.1%) and dissection in three cases (0.2%), which was fatal once (0.1%). CONCLUSIONS In clinical practice, intracoronary pressure measurements are mostly used to guide revascularization decisions in angiographically intermediate stenoses. Intracoronary and intravenous administration of adenosine seem equally suited. While the rate of serious complications of wire-based intracoronary pressure measurements in clinical practice seems to be low, it is not negligible.
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Affiliation(s)
- J Michael Altstidl
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Stephan Achenbach
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Johannes Feyrer
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - J Benedikt Nazli
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Mohamed Marwan
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Luise Gaede
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Helge Möllmann
- Department of Medicine 1 - Cardiology, Nephrology, Intensive Care and Rhythmology, St. Johannes Hospital Dortmund, Dortmund, Germany
| | - Tom Giesler
- Department of Cardiology, Helios Klinik Jerichower Land, Burg, Germany
| | - Harald Rittger
- Department of Cardiology and Pulmonology, Hospital Fürth, Fürth, Germany
| | - Matthias Pauschinger
- Department of Medicine 8 - Cardiology, Nuremberg Hospital South, Nuremberg, Germany
| | - Tanja K Rudolph
- Department of General and Interventional Cardiology, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
| | - Werner Moshage
- Department of Cardiology, Hospital Traunstein, Traunstein, Germany
| | - Martin Brück
- Department of Medicine 1, Hospital Wetzlar, Wetzlar, Germany
| | - Monique Tröbs
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany.
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2
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Fezzi S, Ding D, Mahfoud F, Huang J, Lansky AJ, Tu S, Wijns W. Illusion of revascularization: does anyone achieve optimal revascularization during percutaneous coronary intervention? Nat Rev Cardiol 2024:10.1038/s41569-024-01014-0. [PMID: 38710772 DOI: 10.1038/s41569-024-01014-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 05/08/2024]
Abstract
This Perspective article is a form of 'pastiche', inspired by the 1993 review by Lincoff and Topol entitled 'Illusion of reperfusion', and explores how their concept continues to apply to percutaneous revascularization in patients with coronary artery disease and ischaemia. Just as Lincoff and Topol argued that reperfusion of acute myocardial infarction was facing unresolved obstacles that hampered clinical success in 1993, we propose that challenging issues are similarly jeopardizing the potential benefits of stent-based angioplasty today. By analysing the appropriateness and efficacy of percutaneous coronary intervention (PCI), we emphasize the limitations of relying solely on visual angiographic guidance, which frequently leads to inappropriate stenting and overtreatment in up to one-third of patients and the associated increased risk of periprocedural myocardial infarction. The lack of optimal revascularization observed in half of patients undergoing PCI confers risks such as suboptimal physiology after PCI, residual angina and long-term stent-related events, leaving an estimated 76% of patients with an 'illusion of revascularization'. These outcomes highlight the need to refine our diagnostic tools by integrating physiological assessments with targeted intracoronary imaging and emerging strategies, such as co-registration systems and angiography-based computational methods enhanced by artificial intelligence, to achieve optimal revascularization outcomes.
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Affiliation(s)
- Simone Fezzi
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Daixin Ding
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland
- Department of Cardiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Felix Mahfoud
- Saarland University Hospital, Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Homburg/Saar, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- University Heart Center Basel, Department of Cardiology, University Basel, Basel, Switzerland
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Alexandra J Lansky
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Shengxian Tu
- Department of Cardiology, Ren Ji Hospital, School of Medicine, and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.
| | - William Wijns
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland.
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3
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Wu X, Wang K, Li G, Wu J, Jiang J, Gao F, Zhu L, Xu Q, Wang X, Xu M, Chen H, Ma L, Han X, Luo N, Tu S, Wang J, Hu X. Diagnostic Performance of Angiography-Derived Quantitative Flow Ratio in Complex Coronary Lesions. Circ Cardiovasc Imaging 2024; 17:e016046. [PMID: 38502735 DOI: 10.1161/circimaging.123.016046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/23/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Quantitative flow ratio derived from computed tomography angiography (CT-QFR) and invasive coronary angiography (Murray law-based quantitative flow ratio [μQFR]) are novel approaches enabling rapid computation of fractional flow reserve without the use of pressure guidewires and vasodilators. However, the feasibility and diagnostic performance of both CT-QFR and μQFR in evaluating complex coronary lesions remain unclear. METHODS Between September 2014 and September 2021, 240 patients with 30% to 90% coronary diameter stenosis who underwent both coronary computed tomography angiography and invasive coronary angiography with fractional flow reserve within 60 days were retrospectively enrolled. The diagnostic performance of CT-QFR and μQFR in detecting functional ischemia among all lesions, especially complex coronary lesions, was analyzed using fractional flow reserve as the reference standard. RESULTS CT-QFR and μQFR analyses were performed on 309 and 289 vessels, respectively. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for CT-QFR in all lesions at the per-vessel level were 91% (with a 95% CI of 84%-96%), 92% (95% CI, 88%-95%), 83% (95% CI, 75%-90%), 96% (95% CI, 93%-98%), and 92% (95% CI, 88%-95%), with values for μQFR of 90% (95% CI, 81%-95%), 97% (95% CI, 93%-99%), 92% (95% CI, 84%-97%), 96% (95% CI, 92%-98%), and 94% (95% CI, 91%-97%), respectively. Among bifurcation, tandem, and moderate-to-severe calcified lesions, the diagnostic values of CT-QFR and μQFR showed great correlation and agreement with those of invasive fractional flow reserve, achieving an area under the receiver operating characteristic curve exceeding 0.9 for each complex lesion at the vessel level. Furthermore, the accuracies of CT-QFR and μQFR in the gray zone were 85% and 84%, respectively. CONCLUSIONS Angiography-derived quantitative flow ratio (CT-QFR and μQFR) demonstrated remarkable diagnostic performance in complex coronary lesions, indicating its pivotal role in the management of patients with coronary artery disease.
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Affiliation(s)
- Xianpeng Wu
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Kan Wang
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Guohua Li
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Jie Wu
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Cardiology, Jinhua People's Hospital, Jinhua, China (J. Wu)
| | - Jun Jiang
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Feng Gao
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Lingjun Zhu
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Qiyuan Xu
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Xinhong Wang
- Department of Radiology (X. Wang, M.X.), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mengxi Xu
- Department of Radiology (X. Wang, M.X.), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hui Chen
- Department of Cardiology (H.C., L.M.), Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Longhui Ma
- Department of Cardiology (H.C., L.M.), Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xianjun Han
- Department of Radiology (X. Han, N.L.), Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Nan Luo
- Department of Radiology (X. Han, N.L.), Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (S.T.)
| | - Jian'an Wang
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Xinyang Hu
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
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4
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Shabbir A, Travieso A, Mejía-Rentería H, Espejo-Paeres C, Gonzalo N, Banning AP, Serruys PW, Escaned J. Coronary Physiology as Part of a State-of-the-Art Percutaneous Coronary Intervention Strategy: Lessons from SYNTAX II and Beyond. Cardiol Clin 2024; 42:147-158. [PMID: 37949536 DOI: 10.1016/j.ccl.2023.07.001] [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
The use of coronary physiology allows for rational decision making at the time of PCI, contributing to better patient outcomes. Yet, coronary physiology is only one aspect of optimal revascularization. State-of-the-art PCI must also consider other important aspects such as intracoronary imaging guidance and specific procedural expertise, as tested in the SYNTAX II study. In this review, we highlight the technical aspects pertaining to the use of physiology as used in that trial and offer a glimpse into the future with emerging physiologic metrics, including functional coronary angiography, which have already established themselves as useful indices to guide decision making.
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Affiliation(s)
- Asad Shabbir
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Alejandro Travieso
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Hernán Mejía-Rentería
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Carolina Espejo-Paeres
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Nieves Gonzalo
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Adrian P Banning
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway, Ireland; National Heart and Lung Institute, Imperial College London, London, UK
| | - Javier Escaned
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain.
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5
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Elbadawi A, Sedhom R, Ghoweba M, Etewa AM, Kayani W, Rahman F. Contemporary Use of Coronary Physiology in Cardiology. Cardiol Ther 2023; 12:589-614. [PMID: 37668939 DOI: 10.1007/s40119-023-00329-2] [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: 04/21/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023] Open
Abstract
Coronary angiography has a limited ability to predict the functional significance of intermediate coronary lesions. Hence, physiological assessment of coronary lesions, via fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR), has been introduced to determine their functional significance. An accumulating body of evidence has consolidated the role of physiology-guided revascularization, particularly among patients with stable ischemic heart disease. The use of FFR or iFR to guide decision-making in patients with stable ischemic heart disease and intermediate coronary lesions received a class I recommendation from major societal guidelines. Nevertheless, the role of coronary physiology testing is less clear among certain patients' groups, including patients with serial coronary lesions, acute coronary syndromes, aortic stenosis, heart failure, as well as post-percutaneous coronary interventions. In this review, we aimed to discuss the utility and clinical evidence of coronary physiology (mainly FFR and iFR), with emphasis on those specific patient groups.
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Affiliation(s)
- Ayman Elbadawi
- Division of Cardiology, Christus Good Shepherd, 707 East Marshall Avenue, Longview, TX, 75604, USA.
| | - Ramy Sedhom
- Department of Internal Medicine, Einstein Medical Centre, Philadelphia, PA, USA
| | - Mohamed Ghoweba
- Department of Internal Medicine, Christus Good Shepherd, Longview, TX, 75601, USA
| | | | - Waleed Kayani
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Faisal Rahman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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6
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Koo BK, Hwang D, Park S, Kuramitsu S, Yonetsu T, Kim CH, Zhang J, Yang S, Doh JH, Jeong YH, Choi KH, Lee JM, Ahn JM, Matsuo H, Shin ES, Hu X, 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 2. JACC. ASIA 2023; 3:825-842. [PMID: 38155788 PMCID: PMC10751650 DOI: 10.1016/j.jacasi.2023.07.004] [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: 06/15/2023] [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 clinical data that has led to major recommendations in all 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 includes both wire- and image-based physiologic assessment. This is Part 2 of the whole consensus document, which provides theoretical and practical information on physiologic indexes for specific clinical conditions and patient statuses.
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Affiliation(s)
- Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 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
| | - Shoichi Kuramitsu
- Department of Cardiovascular Medicine, Sapporo Heart Center, Sapporo Cardio Vascular Clinic, Sapporo, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Chee Hae Kim
- Department of Internal Medicine and Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jinlong Zhang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea and Department of Internal Medicine, Chung-Ang University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 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
| | - 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, 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
| | - 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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7
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Ding Y, Li Q, Chen Q, Tang Y, Zhang H, He Y, Fu G, Yang Q, Shou X, Ye Y, Zhao X, Zhang Y, Li Y, Zhang X, Wu C, Wang R, Xu L, Zhang R, Yeung A, Zeng Y, Qian X. Diagnostic performance of a novel automated CT-derived FFR technology in detecting hemodynamically significant coronary artery stenoses: A multicenter trial in China. Am Heart J 2023; 265:180-190. [PMID: 37611856 DOI: 10.1016/j.ahj.2023.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/17/2023] [Accepted: 08/12/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND AND AIMS Computed tomography-derived fractional flow reserve (CT-derived FFR) algorithms have emerged as promising noninvasive methods for identifying hemodynamically significant coronary artery disease (CAD). However, its broad adaption is limited by the complex workflow, slow processing, and supercomputer requirement. Therefore, CT-derived FFR solutions capable of producing fast and accurate results could help deliver time-sensitive results rapidly and potentially alter patient management. The current study aimed to determine the diagnostic performance of a novel CT-derived FFR algorithm, esFFR, on patients with CAD was evaluated. METHODS 329 patients from 6 medical centers in China were included in this prospective study. CT-derived FFR calculations were performed on 350 vessels using the esFFR algorithm using patients' presenting coronary computed tomography angiography (CCTA) images, and results and processing speed were recorded. Using invasive FFR measurements from direct coronary angiography as the reference standard, the diagnostic performance of esFFR and CCTA in detecting hemodynamically significant lesions were compared. Post-hoc analyses were performed for patients with calcified lesions or stenoses within the CT-derived FFR diagnostic "gray zone." RESULTS The esFFR values correlated well with invasive FFR. The sensitivity, specificity, accuracy, positive and negative predictive value for esFFR were all above 90%. The overall performance of esFFR was superior to CCTA. Coronary calcification had minimal effects on esFFR's diagnostic performance. It also maintained 85% of diagnostic accuracy for "gray zone" lesions, which historically was <50%. The average esFFR processing speed was 4.6 ± 1.3 minutes. CONCLUSIONS The current study demonstrated esFFR had high diagnostic efficacy and fast processing speed in identifying hemodynamically significant CAD.
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Affiliation(s)
- Yaodong Ding
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Quan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - QiLiang Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - Yida Tang
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Haitao Zhang
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yong He
- Department of Cardiology, West China Hospital, Sichuan University, Sichuan, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Qing Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiling Shou
- Department of Cardiology, Shanxi Provincial People's Hospital, Shanxi, China
| | - Yicong Ye
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiliang Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yu Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Changyan Wu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Rui Wang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lei Xu
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ren Zhang
- Department of Cardiology, Hendrick Medical Center, Abilene, TX
| | - Alan Yeung
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA
| | - Yong Zeng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Xiang Qian
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA.
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8
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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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9
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Escaned J, Berry C, De Bruyne B, Shabbir A, Collet C, Lee JM, Appelman Y, Barbato E, Biscaglia S, Buszman PP, Campo G, Chieffo A, Colleran R, Collison D, Davies J, Giacoppo D, Holm NR, Jeremias A, Paradies V, Piróth Z, Raposo L, Roguin A, Rudolph T, Sarno G, Sen S, Toth GG, Van Belle E, Zimmermann FM, Dudek D, Stefanini G, Tarantini G. Applied coronary physiology for planning and guidance of percutaneous coronary interventions. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the European Society of Cardiology. EUROINTERVENTION 2023; 19:464-481. [PMID: 37171503 PMCID: PMC10436072 DOI: 10.4244/eij-d-23-00194] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/23/2023] [Indexed: 05/13/2023]
Abstract
The clinical value of fractional flow reserve and non-hyperaemic pressure ratios are well established in determining an indication for percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD). In addition, over the last 5 years we have witnessed a shift towards the use of physiology to enhance procedural planning, assess post-PCI functional results, and guide PCI optimisation. In this regard, clinical studies have reported compelling data supporting the use of longitudinal vessel analysis, obtained with pressure guidewire pullbacks, to better understand how obstructive CAD contributes to myocardial ischaemia, to establish the likelihood of functionally successful PCI, to identify the presence and location of residual flow-limiting stenoses and to predict long-term outcomes. The introduction of new functional coronary angiography tools, which merge angiographic information with fluid dynamic equations to deliver information equivalent to intracoronary pressure measurements, are now available and potentially also applicable to these endeavours. Furthermore, the ability of longitudinal vessel analysis to predict the functional results of stenting has played an integral role in the evolving field of simulated PCI. Nevertheless, it is important to have an awareness of the value and challenges of physiology-guided PCI in specific clinical and anatomical contexts. The main aim of this European Association of Percutaneous Cardiovascular Interventions clinical consensus statement is to offer up-to-date evidence and expert opinion on the use of applied coronary physiology for procedural PCI planning, disease pattern recognition and post-PCI optimisation.
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Affiliation(s)
- Javier Escaned
- Hospital Clínico San Carlos IdISCC, Complutense University of Madrid, Madrid, Spain
| | - Colin Berry
- Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Center Hospital, Lausanne, Switzerland
| | - Asad Shabbir
- Hospital Clínico San Carlos IdISCC, Complutense University of Madrid, Madrid, Spain
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yolande Appelman
- Amsterdam UMC, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Cona, Italy
| | - Piotr P Buszman
- Andrzej Frycz Modrzewski Kraków University, Kraków, Poland
- American Heart of Poland, Ustroń, Poland
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Cona, Italy
| | - Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Róisín Colleran
- Cardiovascular Research Institute Dublin and Department of Cardiology, Mater Private Network, Dublin, Ireland
- School of Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Damien Collison
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Justin Davies
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Daniele Giacoppo
- Cardiovascular Research Institute Dublin and Department of Cardiology, Mater Private Network, Dublin, Ireland
- Department of Cardiology, Alto Vicentino Hospital, Santorso, Italy
- ISAResearch, German Heart Centre Munich, Munich, Germany
| | - Niels R. Holm
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Zsolt Piróth
- Gottsegen National Cardiovascular Center, Budapest, Hungary
| | - Luís Raposo
- Unidade de Intervenção Cardiovascular, Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Ariel Roguin
- Hillel Yaffe Medical Center, Hadera, Israel
- Faculty of Medicine, Technion, Haifa, Israel
| | - Tanja Rudolph
- Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen, Germany
| | - Giovanna Sarno
- Cardiology, Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Sayan Sen
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Gabor G Toth
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Eric Van Belle
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Institut Coeur Poumon, Lille, France
- Department of Cardiology, Institut Pasteur de Lille, Lille, France
| | | | - Dariusz Dudek
- Interventional Cardiology Unit, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Giuseppe Tarantini
- Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
- University of Padua Medical School, Padua, Italy
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10
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Showkathali R, Yalamanchi RP. Contemporary Left Main Percutaneous Coronary Intervention: A State-of-the-art Review. Interv Cardiol 2023; 18:e20. [PMID: 37435600 PMCID: PMC10331562 DOI: 10.15420/icr.2023.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/13/2023] [Indexed: 07/13/2023] Open
Abstract
The majority of the left ventricular myocardium is supplied by the left main coronary artery. Atherosclerotic obstruction of the left main coronary artery therefore leads to significant myocardial jeopardy. Coronary artery bypass surgery (CABG) has been the gold standard for left main coronary artery disease in the past. However, advancements in technology have established percutaneous coronary intervention (PCI) as a standard, safe and reasonable alternative to CABG, with comparable outcomes. Contemporary PCI of left main coronary artery disease comprises careful patient selection, accurate technique guided by either intravascular ultrasound or optical coherence tomography and - if necessary - physiological assessment using fractional flow reserve. This review focuses on current evidence from registries and randomised trials comparing PCI with CABG, procedural tips and tricks, adjuvant technologies and the triumph of PCI.
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11
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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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12
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Shabbir A, Travieso A, Mejía-Rentería H, Espejo-Paeres C, Gonzalo N, Banning AP, Serruys PW, Escaned J. Coronary Physiology as Part of a State-of-the-Art Percutaneous Coronary Intervention Strategy: Lessons from SYNTAX II and Beyond. Interv Cardiol Clin 2023; 12:141-153. [PMID: 36372458 DOI: 10.1016/j.iccl.2022.09.012] [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
The use of coronary physiology allows for rational decision making at the time of PCI, contributing to better patient outcomes. Yet, coronary physiology is only one aspect of optimal revascularization. State-of-the-art PCI must also consider other important aspects such as intracoronary imaging guidance and specific procedural expertise, as tested in the SYNTAX II study. In this review, we highlight the technical aspects pertaining to the use of physiology as used in that trial and offer a glimpse into the future with emerging physiologic metrics, including functional coronary angiography, which have already established themselves as useful indices to guide decision making.
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Affiliation(s)
- Asad Shabbir
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Alejandro Travieso
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Hernán Mejía-Rentería
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Carolina Espejo-Paeres
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Nieves Gonzalo
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Adrian P Banning
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway, Ireland; National Heart and Lung Institute, Imperial College London, London, UK
| | - Javier Escaned
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain.
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13
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Functional Patterns of Coronary Disease. JACC Cardiovasc Interv 2022; 15:2174-2191. [DOI: 10.1016/j.jcin.2022.07.015] [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: 03/31/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 11/09/2022]
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14
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Fezzi S, Huang J, Lunardi M, Ding D, Ribichini FL, Tu S, Wijns W. Coronary physiology in the catheterisation laboratory: an A to Z practical guide. ASIAINTERVENTION 2022; 8:86-109. [PMID: 36798834 PMCID: PMC9890586 DOI: 10.4244/aij-d-22-00022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/21/2022] [Indexed: 11/16/2022]
Abstract
Coronary revascularisation, either percutaneous or surgical, aims to improve coronary flow and relieve myocardial ischaemia. The decision-making process in patients with coronary artery disease (CAD) remains largely based on invasive coronary angiography (ICA), even though until recently ICA could not assess the functional significance of coronary artery stenoses. Invasive wire-based approaches for physiological evaluations were developed to properly assess the ischaemic relevance of epicardial CAD. Fractional flow reserve (FFR) and later, instantaneous wave-free ratio (iFR), were shown to improve clinical outcomes in several patient subsets when used for coronary revascularisation guidance or deferral and for procedural optimisation of percutaneous coronary intervention (PCI) results. Despite accumulating evidence and positive guideline recommendations, the adoption of invasive physiology has remained quite low, mainly due to technical and economic issues as well as to operator-resistance to change. Coronary image-based computational physiology has been recently developed, with promising results in terms of accuracy and a reduction in computational time, costs, radiation exposure and risks for the patient. Lastly, the integration of intracoronary imaging and physiology allows for individualised PCI treatment, aiming at complete relief of ischaemia through optimised morpho-functional immediate procedural results. Instead of a conventional state-of-the-art review, this A to Z dictionary attempts to provide a practical guide for the application of coronary physiology in the catheterisation laboratory, exploring several methods, their pitfalls, and useful tips and tricks.
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Affiliation(s)
- 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
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland,Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Mattia Lunardi
- 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
| | - Daixin Ding
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland,Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Flavio L. Ribichini
- 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,Department of Cardiology, Fujian Medical University Union Hospital, Fujian, China
| | - William Wijns
- The Lambe Institute for Translational Research, Galway National University of Ireland Galway (NUIG), Costello Road, Shantalla, Galway, H91 V4AY, Ireland
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15
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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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16
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Ahn JM, Nakayoshi T, Hashikata T, Kashiyama K, Arashi H, Kweon J, Van't Veer M, Lyons J, Fearon WF. Impact of Serial Coronary Stenoses on Various Coronary Physiologic Indices. Circ Cardiovasc Interv 2022; 15:e012134. [PMID: 36126133 DOI: 10.1161/circinterventions.122.012134] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Determining the functional significance of each individual coronary lesion in patients with serial coronary stenoses is challenging. It has been proposed that nonhyperemic pressure ratios, such as the instantaneous wave free ratio (iFR) and the ratio of resting distal to proximal coronary pressure (Pd/Pa) are more accurate than fractional flow reserve (FFR) because autoregulation should maintain stable resting coronary flow and avoid hemodynamic interdependence (cross-talk) that occurs during hyperemia. This study aimed to measure the degree of hemodynamic interdependence of iFR, resting Pd/Pa, and FFR in a porcine model of serial coronary stenosis. METHODS In 6 anesthetized female swine, 381 serial coronary stenoses were created in the left anterior descending artery using 2 balloon catheters. The degree of hemodynamic interdependence was calculated by measuring the absolute changes in iFR, resting Pd/Pa, and FFR across the fixed stenosis as the severity of the other stenosis varied. RESULTS The hemodynamic interdependence of iFR, resting Pd/Pa, and FFR was 0.039±0.048, 0.021±0.026, and 0.034±0.034, respectively (all P<0.001). When the functional significance of serial stenoses was less severe (0.70-0.90 for each index), the hemodynamic interdependence was 0.009±0.020, 0.007±0.013, and 0.017±0.022 for iFR, resting Pd/Pa, and FFR, respectively (all P<0.001). However, in more severe serial coronary stenoses (<0.60 for each index), hemodynamic interdependence was 0.060±0.050, 0.037±0.030, and 0.051±0.037 for iFR, resting Pd/Pa, and FFR, respectively (all P<0.001). CONCLUSIONS When assessing serial coronary stenoses, nonhyperemic pressure ratios are affected by hemodynamic interdependence. When the functional significance of serial coronary stenoses is severe, the effect is similar to that which is seen with FFR.
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Affiliation(s)
- Jung-Min Ahn
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine (J.-M.A., T.N., T.H., K.K., H.A., J.L., W.F.F.).,Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (J.-M.A., J.K.)
| | - Takaharu Nakayoshi
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine (J.-M.A., T.N., T.H., K.K., H.A., J.L., W.F.F.)
| | - Takehiro Hashikata
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine (J.-M.A., T.N., T.H., K.K., H.A., J.L., W.F.F.)
| | - Kuninobu Kashiyama
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine (J.-M.A., T.N., T.H., K.K., H.A., J.L., W.F.F.)
| | - Hiroyuki Arashi
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine (J.-M.A., T.N., T.H., K.K., H.A., J.L., W.F.F.)
| | - Jihoon Kweon
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine (J.-M.A., T.N., T.H., K.K., H.A., J.L., W.F.F.).,Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (J.-M.A., J.K.)
| | - Marcel Van't Veer
- Department of Cardiology, Catharina Hospital Eindhoven, the Netherlands (M.v.V.).,Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (M.v.V.)
| | - Jennifer Lyons
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine (J.-M.A., T.N., T.H., K.K., H.A., J.L., W.F.F.)
| | - William F Fearon
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine (J.-M.A., T.N., T.H., K.K., H.A., J.L., W.F.F.).,VA Palo Alto Health Care System, CA (W.F.F.)
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17
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Dai N, Zhang R, Yuan S, Hu N, Guan C, Zou T, Qiao Z, He J, Duan S, Xie L, Dou K, Zhang Y, Xu B, Ge J. Prognostic Implications of Quantitative Flow Ratio-Derived Physiological 2-Dimensional Residual Disease Patterns After Stenting. JACC Cardiovasc Interv 2022; 15:1624-1634. [PMID: 35981836 DOI: 10.1016/j.jcin.2022.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/27/2022] [Accepted: 06/14/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Post-percutaneous coronary intervention (PCI) residual disease is associated with clinical outcomes. Nevertheless, the prognostic value of residual disease patterns remains unknown. OBJECTIVES This study aimed to evaluate clinical implications of 2-dimensional residual disease patterns after PCI. METHODS One thousand six hundred seven vessels that underwent successful PCI were included. Two-dimensional residual disease patterns were determined by visual assessment or the quantitative flow ratio (QFR)-derived pull back pressure gradient index (with a cutoff value of 0.78 to define predominant focal versus diffuse disease) and instantaneous QFR gradient per unit length (with a cutoff value of ≥0.005/mm to define a major gradient). The clinical outcome was the 2-year vessel-oriented composite outcome (VOCO). RESULTS Residual disease patterns were classified into 4 groups: predominant focal without and with a major gradient (group 1 [n = 1,058] and group 2 [n = 63], respectively) and predominant diffuse without and with a major gradient (group 3 [n = 318] and group 4 [n = 168], respectively). At 2 years, VOCO was lowest in group 1 (1.4% vs 5.4% in group 2 vs 4.8% in group 3 vs 8.5% in group 4, all P < 0.05), whereas there was no prognostic value for classifications by visual assessment. Physiological residual disease patterns were independently associated with VOCO and showed increased prognostic value when introduced to a model with clinical risk factors only (C index: 0.77 vs. 0.68, P = 0.008; net reclassification improvement: 0.65, P < 0.001; integrated discrimination improvement: 0.020, P < 0.001). CONCLUSIONS Objective analysis of post-PCI QFR pull backs using the concept of 2-dimensional residual disease patterns is feasible and superior to visual assessments. The residual disease patterns were independently associated with VOCO at 2 years.
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Affiliation(s)
- Neng Dai
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Rui Zhang
- State Key Laboratory of Cardiovascular Disease, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sheng Yuan
- State Key Laboratory of Cardiovascular Disease, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Nan Hu
- School of Electronics and Information Engineering, Soochow University, Suzhou, China
| | - Changdong Guan
- Catheterization Laboratories, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tongqiang Zou
- Catheterization Laboratories, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zheng Qiao
- State Key Laboratory of Cardiovascular Disease, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jining He
- State Key Laboratory of Cardiovascular Disease, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | - Lihua Xie
- Catheterization Laboratories, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kefei Dou
- State Key Laboratory of Cardiovascular Disease, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yingmei Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Bo Xu
- Catheterization Laboratories, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China.
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18
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Jeremias A, Nijjer S, Davies J, DiMario C. Physiologic Assessment and Guidance in the Cardiac Catheterization Laboratory. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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19
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Aleem S, Parikh P, Bhasin V, Pyo RT. Interventional Approach in Small Vessel, Diffuse, and Tortuous Coronary Artery Disease. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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20
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Nammour A, Aboul-Enein HM, Hamouda M, Elhelaly A. Pre-angioplasty instantaneous wave-free ratio pullback predicts hemodynamic outcome in diffuse coronary artery disease. CARDIOMETRY 2022. [DOI: 10.18137/cardiometry.2022.21.95101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Serial stenoses or diffuse vessel narrowing hamper pressure wire–guided management of coronary stenoses. Characterization of functional relevance of individual stenoses or narrowed segments constitutes an unmet need in ischemia-driven percutaneous revascularization. Aim of the Study: To perform hemodynamic mapping of the entire vessel using pullback technique of a pressure guidewire with continuous instantaneous wave-free ratio (iFR) measurement compared coronary angiography aiming to minimize the procedure, decrease number and length of stents used. Materials and Methods: This study was conducted on 40 patients presented with diffuse coronary artery disease and undergoing elective PCI. Diagnostic coronary angiography using the routine angiographic projections was done with assessment of non-obstructive coronary lesions by 2D quantitative coronary angiography and iFR pullback measurement Results: Percentage of difference between probable sig lesions via pullback technique and No of actual sig lesions for studied group, was (59.5%). The difference was statistically highly significant p=0.0001. Conclusion: Compared with angiography alone, availability of iFR pullback data significantly decreased the number and length of hemodynamically significant lesions identified for revascularization.
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21
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Zhang R, Xu B, Dou K, Guan C, Zhao Y, Wang X, Zou T, Qiao Z, Xie L, Wang H, Yuan S, Song L, Tu S, Wang Y, Wijns W. Post-PCI outcomes predicted by pre-intervention simulation of residual quantitative flow ratio using augmented reality. Int J Cardiol 2022; 352:33-39. [PMID: 35101540 DOI: 10.1016/j.ijcard.2022.01.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/10/2022] [Accepted: 01/25/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND The simulated residual quantitative flow ratio (QFR) computed from pre-intervention three-dimensional (3-D) coronary angiograms, which could theoretically predict actual post-percutaneous coronary intervention (PCI) QFR value, can be used for enhanced PCI via augmented reality. The study sought to investigate the concordance between simulated residual QFR and actual post-PCI QFR, and the prognostic value of simulated residual QFR. METHODS QFR assessment was retrospectively performed in treated vessels from the all-comers PANDA III trial. Three-step analysis was performed: 1) concordance between simulated residual QFR and post-PCI QFR; 2) prognostic value of simulated residual QFR; and 3) forecast of outcomes by virtual randomized controlled trials (RCTs) between residual QFR and angiographic guidance. RESULTS Of 2989 treated vessels, 2146 (71.8%) with paired analyzable simulated residual QFR and post-PCI QFR were included. The simulated residual QFR and post-PCI QFR were strongly correlated (r = 0.976). Low simulated residual QFR (≤0.92) was independently associated with higher risk of 2-year vessel-oriented composite endpoint (adjusted hazard ratio: 5.50; 95% confidence interval: 3.03 to 10.0). Based upon 5000 iterations of virtual RCTs, simulated residual QFR-guided strategy was anticipated to have a 2.6% absolute reduction of 2-year incidence of target vessel failure compared with the angiography-guided strategy. CONCLUSIONS With high consistency to actual post-PCI QFR, the simulated residual QFR computed from pre-PCI 3-D coronary angiograms and augmented reality could predict functional outcome of the procedure and 2-year prognosis. Using data from PANDA III trial, the present study forecasted superiority of residual QFR-guided PCI strategy over angiographic guidance. Clinical Trial Registration Information URL: https://www.clinicaltrials.gov; Unique identifier: NCT02017275.
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Affiliation(s)
- Rui Zhang
- State Key Laboratory of Cardiovascular Disease, Beijing, China; Cardiometabolic Medicine Center, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Catheterization Laboratories, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Cardiovascular Diseases, Beijing, China.
| | - Kefei Dou
- State Key Laboratory of Cardiovascular Disease, Beijing, China; Cardiometabolic Medicine Center, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Changdong Guan
- Catheterization Laboratories, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanyan Zhao
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Xuxia Wang
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Tongqiang Zou
- Catheterization Laboratories, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zheng Qiao
- State Key Laboratory of Cardiovascular Disease, Beijing, China; Cardiometabolic Medicine Center, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihua Xie
- Catheterization Laboratories, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haoyu Wang
- State Key Laboratory of Cardiovascular Disease, Beijing, China; Cardiometabolic Medicine Center, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sheng Yuan
- State Key Laboratory of Cardiovascular Disease, Beijing, China; Cardiometabolic Medicine Center, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Song
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Yang Wang
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland Galway, Ireland
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22
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Zhang J, Hwang D, Yang S, Kim CH, Lee JM, Nam CW, Shin ES, Doh JH, Hoshino M, Hamaya R, Kanaji Y, Murai T, Zhang JJ, Ye F, Li X, Ge Z, Chen SL, Kakuta T, Koo BK. Differential Prognostic Implications of Pre- and Post-Stent Fractional Flow Reserve in Patients Undergoing Percutaneous Coronary Intervention. Korean Circ J 2021; 52:47-59. [PMID: 34877828 PMCID: PMC8738713 DOI: 10.4070/kcj.2021.0128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/10/2021] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
The current study showed that pre-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) was associated with target vessel failure (TVF) after PCI. When the prognostic value of post-PCI FFR was evaluated according to pre-PCI FFR value, the risk of TVF significantly decreased along with the increase of post-PCI FFR in the low pre-PCI FFR group, but not in the high pre-PCI FFR group. Our study results suggest that patient prognosis can be varied according to the level of physiologic indices, both before and after PCI, and the integration of both information can provide better risk stratification after PCI. Background and Objectives The influence of pre-intervention coronary physiologic status on outcomes post percutaneous coronary intervention (PCI) is not well known. We sought to investigate the prognostic implications of pre-PCI fractional flow reserve (FFR) combined with post-PCI FFR. Methods A total of 1,479 PCI patients with pre-and post-PCI FFR data were analyzed. The patients were classified according to the median values of pre-PCI FFR (0.71) and post-PCI FFR (0.88). The primary outcome was target vessel failure (TVF) at 2 years. Results The risk of TVF was higher in the low pre-PCI FFR group than in the high pre-PCI FFR group (hazard ratio, 1.82; 95% confidence interval, 1.15–2.87; p=0.011). In 4 group comparisons, the cumulative incidences of TVF at 2 years were 3.8%, 4.1%, 4.8%, and 10.2% in the high pre-/high post-, low pre-/high post-, high pre-/low post-, and low pre-/low post-PCI FFR groups, respectively. The risk of TVF was the highest in the low pre-/low post-PCI FFR group among the groups (p values for comparisons <0.05). In addition, the high pre-/low post-PCI FFR group presented a comparable risk of TVF with the high post-PCI FFR groups (p values for comparison >0.05). When the prognostic value of the post-PCI FFR was evaluated according to the pre-PCI FFR, the risk of TVF significantly decreased with an increase in post-PCI FFR in the low pre-PCI FFR group, but not in the high pre-PCI FFR group. Conclusions Pre-PCI FFR was associated with clinical outcomes after PCI, and the prognostic value of post-PCI FFR differed according to the pre-PCI FFR. Trial Registration ClinicalTrials.gov Identifier: NCT04012281
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Affiliation(s)
- Jinlong Zhang
- Department of Cardiology, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Chee Hae Kim
- Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, 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
| | - Chang-Wook Nam
- Department of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan Hospital, Ulsan, Korea
| | - Joon-Hyung Doh
- Department of Cardiology, Inje University Ilsan Paik Hospital, Goyang, Korea.
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Rikuta Hamaya
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Yoshihisa Kanaji
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tadashi Murai
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Jun-Jie Zhang
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Fei Ye
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaobo Li
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhen Ge
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shao-Liang Chen
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
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23
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Zimbardo G, Cialdella P, DI Giusto F, Migliaro S, Anastasia G, Petrolati E, Galante D, D'Amario D, Leone AM. Physiological assessment after percutaneous coronary intervention: the hard truth. Panminerva Med 2021; 63:519-528. [PMID: 34486363 DOI: 10.23736/s0031-0808.21.04363-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Physiologically guided revascularization, using Fractional Flow Reserve (FFR) or instantaneous wave free ratio (iFR) has been demonstrated to be associated with better long-term outcomes compared to an angiographically-guided strategy, mainly avoiding inappropriate coronary stenting and its associated adverse events. On the contrary, the role of invasive physiological assessment after percutaneous coronary intervention (PCI) is much less well established. However, a large body of evidence suggests that a relevant proportion of patients undergoing PCI with a satisfying angiographic result show instead a suboptimal functional product with a potentially negative prognostic impact. For this reason, many efforts have been focused to identify interventional strategies to physiologically optimize PCI. Measuring the functional result after as PCI, especially when performed after a physiological assessment, implies that the operator is ready to accept the hard truth of an unsatisfactory physiological result despite angiographically optimal and, consequently, to optimize the product with some additional effort. The aim of this review is to bridge this gap in knowledge by better defining the paradigm shift of invasive physiological assessment from a simple tool for deciding whether an epicardial stenosis has to be treated to a thoroughly physiological approach to PCI with the suggestion of a practical flow chart.
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Affiliation(s)
| | | | - Federico DI Giusto
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Migliaro
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gianluca Anastasia
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Edoardo Petrolati
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico Galante
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D'Amario
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio M Leone
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy -
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24
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Invasive Coronary Physiology After Stent Implantation: Another Step Toward Precision Medicine. JACC Cardiovasc Interv 2021; 14:237-246. [PMID: 33541534 DOI: 10.1016/j.jcin.2020.10.055] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/15/2020] [Accepted: 10/13/2020] [Indexed: 01/10/2023]
Abstract
Intracoronary physiology is routinely used in setting the indication for percutaneous coronary intervention (PCI) but seldom in assessing procedural results. This attitude is increasingly challenged by accumulated evidence demonstrating the value of post-PCI functional assessment in predicting long-term patient outcomes. Besides fractional flow reserve, a number of new indexes recently incorporated to clinical practice, including nonhyperemic pressure and functional angiographic indexes, provide new opportunities for the physiological assessment of PCI results. Largely, the benefit of these tools is derived from longitudinal analysis of the treated vessel, which allows precise identification of the vessel segment accounting for a suboptimal functional result and enabling operators to perform accurate PCI optimization. In this document the authors review available evidence supporting why physiological assessment should be extended to immediate post-PCI with the aim of improving patient outcomes. A step-by-step guide on how available physiological tools can be used for such purpose is provided.
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25
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Ding D, Huang J, Westra J, Cohen DJ, Chen Y, Andersen BK, Holm NR, Xu B, Tu S, Wijns W. Immediate post-procedural functional assessment of percutaneous coronary intervention: current evidence and future directions. Eur Heart J 2021; 42:2695-2707. [PMID: 33822922 DOI: 10.1093/eurheartj/ehab186] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/17/2021] [Accepted: 03/11/2021] [Indexed: 01/10/2023] Open
Abstract
Percutaneous coronary intervention (PCI) guided by coronary physiology provides symptomatic benefit and improves patient outcomes. Nevertheless, over one-fourth of patients still experience recurrent angina or major adverse cardiac events following the index procedure. Coronary angiography, the current workhorse for evaluating PCI efficacy, has limited ability to identify suboptimal PCI results. Accumulating evidence supports the usefulness of immediate post-procedural functional assessment. This review discusses the incidence and possible mechanisms behind a suboptimal physiology immediately after PCI. Furthermore, we summarize the current evidence base supporting the usefulness of immediate post-PCI functional assessment for evaluating PCI effectiveness, guiding PCI optimization, and predicting clinical outcomes. Multiple observational studies and post hoc analyses of datasets from randomized trials demonstrated that higher post-PCI functional results are associated with better clinical outcomes as well as a reduced rate of residual angina and repeat revascularization. As such, post-PCI functional assessment is anticipated to impact patient management, secondary prevention, and resource utilization. Pre-PCI physiological guidance has been shown to improve clinical outcomes and reduce health care costs. Whether similar benefits can be achieved using post-PCI physiological assessment requires evaluation in randomized clinical outcome trials.
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Affiliation(s)
- Daixin Ding
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, University Road, Galway H91 TK3, Ireland.,Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, No. 1954 Hua Shan Road, Xuhui District, Shanghai 200030, China
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, University Road, Galway H91 TK3, Ireland.,Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, No. 1954 Hua Shan Road, Xuhui District, Shanghai 200030, China
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - David Joel Cohen
- St. Francis Hospital, Roslyn NY and Cardiovascular Research Foundation, 100 Port Washington Blvd (Middle Neck Road), New York, NY 11576, USA
| | - Yundai Chen
- Department of Cardiology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing 100853, China
| | | | - Niels Ramsing Holm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Bo Xu
- Catheterization Laboratories, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, A 167, Beilishi Road, Xicheng District, Beijing 100037, China
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, No. 1954 Hua Shan Road, Xuhui District, Shanghai 200030, China.,Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou, Fujian 350001, China
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, University Road, Galway H91 TK3, Ireland
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26
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Rajkumar CA, Shun-Shin M, Seligman H, Ahmad Y, Warisawa T, Cook CM, Howard JP, Ganesananthan S, Amarin L, Khan C, Ahmed A, Nowbar A, Foley M, Assomull R, Keenan NG, Sehmi J, Keeble TR, Davies JR, Tang KH, Gerber R, Cole G, O’Kane P, Sharp AS, Khamis R, Kanaganayagam G, Petraco R, Ruparelia N, Malik IS, Nijjer S, Sen S, Francis DP, Al-Lamee R. Placebo-Controlled Efficacy of Percutaneous Coronary Intervention for Focal and Diffuse Patterns of Stable Coronary Artery Disease. Circ Cardiovasc Interv 2021; 14:e009891. [PMID: 34340523 PMCID: PMC8366766 DOI: 10.1161/circinterventions.120.009891] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/25/2021] [Indexed: 01/22/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Christopher A. Rajkumar
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Matthew Shun-Shin
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Yousif Ahmad
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Columbia University Medical Centre, New York–Presbyterian Hospital (Y.A.)
| | - Takayuki Warisawa
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- St. Marianna University School of Medicine, Yokohama, Japan (T.W.)
| | - Christopher M. Cook
- Essex Cardiothoracic Centre, Basildon, United Kingdom (C.M.C., T.R.K., J.R.D., K.H.T.)
| | - James P. Howard
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Sashiananthan Ganesananthan
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
| | - Laura Amarin
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
| | - Caitlin Khan
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
| | | | - Alexandra Nowbar
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Ravi Assomull
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Niall G. Keenan
- West Hertfordshire Hospitals NHS Trust, Watford, United Kingdom (N.G.K., J.S.)
| | - Joban Sehmi
- West Hertfordshire Hospitals NHS Trust, Watford, United Kingdom (N.G.K., J.S.)
| | - Thomas R. Keeble
- Essex Cardiothoracic Centre, Basildon, United Kingdom (C.M.C., T.R.K., J.R.D., K.H.T.)
- Anglia Ruskin School of Medicine, Chelmsford, Essex, United Kingdom (T.R.K., J.R.D.)
| | - John R. Davies
- Essex Cardiothoracic Centre, Basildon, United Kingdom (C.M.C., T.R.K., J.R.D., K.H.T.)
- Anglia Ruskin School of Medicine, Chelmsford, Essex, United Kingdom (T.R.K., J.R.D.)
| | - Kare H. Tang
- Essex Cardiothoracic Centre, Basildon, United Kingdom (C.M.C., T.R.K., J.R.D., K.H.T.)
| | - Robert Gerber
- East Sussex Healthcare NHS Trust, Hastings, United Kingdom (R.G.)
| | - Graham Cole
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Peter O’Kane
- Royal Bournemouth and Christchurch NHS Trust, Bournemouth, United Kingdom (P.O.)
| | - Andrew S.P. Sharp
- University Hospital of Wales, Cardiff, United Kingdom (A.S.P.S.)
- University of Exeter, United Kingdom (A.S.P.S.)
| | - Ramzi Khamis
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Gajen Kanaganayagam
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Ricardo Petraco
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Neil Ruparelia
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Iqbal S. Malik
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Sukhjinder Nijjer
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Darrel P. Francis
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.S.-S., H.S., Y.A., T.W., J.P.H., S.G., L.A., C.K., A.N., M.F., R.A., G.C., R.K., R.P., N.R., S.N., S.S., D.P.F., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.S.-S., H.S., J.P.H., A.N., M.F., R.A., G.C., R.K., G.K., R.P., N.R., I.S.M., S.N., S.S., D.P.F., R.A.-L.)
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27
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Chang H, Kim HK, Shin D, Lim KS, Kim SU, Jeon CY, Lee HY, Lee Y, Won J, Lee SH, Kakuta T, Lee JM. Coronary Circulatory Indexes Before and After Percutaneous Coronary Intervention in a Porcine Tandem Stenoses Model. J Am Heart Assoc 2021; 10:e021824. [PMID: 34275325 PMCID: PMC8475665 DOI: 10.1161/jaha.121.021824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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 In tandem stenoses, nonhyperemic pressure ratio pullback is the preferred method to fractional flow reserve (FFR), based on the assumption of stable resting coronary flow. This study aimed to evaluate temporal changes of coronary circulatory indexes in tandem stenoses before and after angioplasty for proximal stenosis. Methods and Results Coronary tandem stenoses were created by porcine restenosis model with 2 bare metal stents in the left anterior descending artery. Four weeks later, changes in distal coronary pressure (Pd), averaged peak velocity, microvascular resistance, transstenotic pressure gradient across distal stenosis, resting Pd/aortic pressure, and FFR were measured before and 1, 5, 10, 15, and 20 minutes after balloon angioplasty for proximal stenosis. After angioplasty, there were significant changes in both resting and hyperemic Pd, averaged peak velocity, microvascular resistance, and transstenotic pressure gradient across distal stenosis (all P values <0.01). After initial acute changes, hyperemic averaged peak velocity and microvascular resistance did not show significant difference from the baseline values (P=0.712 and 0.972, respectively). Conversely, resting averaged peak velocity remained increased (10.1±0.7 to 17.8±0.7; P<0.001) and resting microvascular resistance decreased (6.0±0.1 to 2.2±0.7; P<0.001). Transstenotic pressure gradient across distal stenosis was significantly increased in both resting (13.1±7.6 to 25.3±4.2; P=0.040) and hyperemic conditions (11.0±3.0 to 27.4±3.3 mm Hg; P<0.001). Actual post–percutaneous coronary intervention Pd/aortic pressure and FFR were significantly lower than predicted values (Pd/aortic pressure, 0.68±0.22 versus 0.85±0.14; P<0.001; FFR, 0.63±0.08 versus 0.81±0.08; P<0.001). Conclusions After angioplasty for proximal stenosis, transstenotic pressure gradient across distal stenosis showed similar changes between resting and hyperemic conditions. Both actual post–percutaneous coronary intervention resting Pd/aortic pressure and FFR were significantly lower than predicted values.
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Affiliation(s)
- Haseong Chang
- Division of Cardiology Department of Medicine Konkuk University Medical CenterSchool of MedicineKonkuk University Seoul Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center Chosun University HospitalUniversity of Chosun College of Medicine Gwangju Korea
| | - Doosup Shin
- Division of Cardiovascular Medicine Department of Internal Medicine University of Iowa Carver College of Medicine IA
| | - Kyung Seob Lim
- Futuristic Animal Resource and Research Center & National Primate Research Center Korea Research Institute of Bioscience and Biotechnology Chungbuk Korea
| | - Sun-Uk Kim
- Futuristic Animal Resource and Research Center & National Primate Research Center Korea Research Institute of Bioscience and Biotechnology Chungbuk Korea
| | - Chang-Yeop Jeon
- Futuristic Animal Resource and Research Center & National Primate Research Center Korea Research Institute of Bioscience and Biotechnology Chungbuk Korea
| | - Hwal-Yong Lee
- Futuristic Animal Resource and Research Center & National Primate Research Center Korea Research Institute of Bioscience and Biotechnology Chungbuk Korea
| | - Youngjeon Lee
- Futuristic Animal Resource and Research Center & National Primate Research Center Korea Research Institute of Bioscience and Biotechnology Chungbuk Korea
| | - Jinyoung Won
- Futuristic Animal Resource and Research Center & National Primate Research Center Korea Research Institute of Bioscience and Biotechnology Chungbuk Korea
| | - Seung Hun Lee
- Department of Internal Medicine and Cardiovascular Center Chonnam National University Hospital Gwangju Korea
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan
| | - Joo Myung Lee
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
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28
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Lee JM, Lee SH, Shin D, Choi KH, van de Hoef TP, Kim HK, Samady H, Kakuta T, Matsuo H, Koo BK, Fearon WF, Escaned J. Physiology-Based Revascularization: A New Approach to Plan and Optimize Percutaneous Coronary Intervention. JACC. ASIA 2021; 1:14-36. [PMID: 36338358 PMCID: PMC9627934 DOI: 10.1016/j.jacasi.2021.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/17/2021] [Accepted: 03/20/2021] [Indexed: 06/12/2023]
Abstract
Coronary physiological assessment using fractional flow reserve or nonhyperemic pressure ratios has become a standard of care for patients with coronary atherosclerotic disease. However, most evidence has focused on the pre-interventional use of physiological assessment to aid revascularization decision-making, whereas post-interventional physiological assessment has not been well established. Although evidence for supporting the role of post-interventional physiological assessment to optimize immediate revascularization results and long-term prognosis has been reported, a more thorough understanding of these data is crucial in incorporating post-interventional physiological assessment into daily practice. Recent scientific efforts have also focused on the potential role of pre-interventional fractional flow reserve or nonhyperemic pressure ratio pullback tracings to characterize patterns of coronary atherosclerotic disease to better predict post-interventional physiological outcomes, and thereby identify the appropriate revascularization target. Pre-interventional pullback tracings with dedicated post-processing methods can provide characterization of focal versus diffuse disease or major gradient versus minor gradient stenosis, which would result in different post-interventional physiological results. This review provides a comprehensive look at the current evidence regarding the evolving role of physiological assessment as a functional optimization tool for the entire process of revascularization, and not merely as a pre-interventional tool for revascularization decision-making.
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Key Words
- CI, confidence interval
- DES, drug-eluting stent(s)
- FFR, fractional flow reserve
- HR, hazard ratio
- MACE, major adverse cardiac event(s)
- NHPR, nonhyperemic pressure ratio
- PCI, percutaneous coronary intervention
- TVF, target vessel failure
- VOCE, vessel-related composite event
- fractional flow reserve
- iFR, instantaneous wave-free ratio
- instantaneous wave-free ratio
- nonhyperemic pressure ratios
- percutaneous coronary intervention
- prognosis
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doosup Shin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tim P. van de Hoef
- Department of Clinical and Experimental Cardiology, Amsterdam UMC–University of Amsterdam, Amsterdam, the Netherlands
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Republic of Korea
| | - Habib Samady
- Andreas Gruentzig Cardiovascular Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Javier Escaned
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
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29
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Yang S, Koo BK, Hwang D, Zhang J, Hoshino M, Lee JM, Murai T, Park J, Shin ES, Doh JH, Nam CW, Wang J, Chen S, Tanaka N, Matsuo H, Akasaka T, Chang HJ, Kakuta T, Narula J. High-Risk Morphological and Physiological Coronary Disease Attributes as Outcome Markers After Medical Treatment and Revascularization. JACC Cardiovasc Imaging 2021; 14:1977-1989. [PMID: 34023270 DOI: 10.1016/j.jcmg.2021.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/06/2021] [Accepted: 04/09/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study sought to evaluate the prognostic impact of plaque morphology and coronary physiology on outcomes after medical treatment or percutaneous coronary intervention (PCI). BACKGROUND Although fractional flow reserve (FFR) is currently best practice, morphological characteristics of coronary artery disease also contribute to outcomes. METHODS A total of 872 vessels in 538 patients were evaluated by invasive FFR and coronary computed tomography angiography. High-risk attributes (HRA) were defined as high-risk physiological attribute (invasive FFR ≤0.8) and high-risk morphological attributes including: 1) local plaque burden (minimum lumen area <4 mm2 and plaque burden ≥70%); 2) adverse plaque characteristics ≥2; and 3) global plaque burden (total plaque volume ≥306.5 mm3 and percent atheroma volume ≥32.2%). The primary outcome was the composite of revascularization, myocardial infarction, or cardiac death at 5 years. RESULTS The mean FFR was 0.88 ± 0.08, and PCI was performed in 239 vessels. The primary outcome occurred in 54 vessels (6.2%). All high-risk morphological attributes were associated with the increased risk of adverse outcomes after adjustment for FFR ≤0.8 and demonstrated direct prognostic effect not mediated by FFR ≤0.8. The 5-year event risk proportionally increased as the number of HRA increased (p for trend <0.001) with lower risk in the PCI group than the medical treatment group in vessels with 1 or 2 HRA (9.7% vs. 14.7%), but not in vessels with either 0 or ≥3 HRA. Of the vessels with pre-procedural FFR ≤0.8, ischemia relief by PCI (pre-PCI FFR ≤0.8 and post-PCI FFR >0.8) significantly reduced vessel-oriented composite outcome risk compared with medical treatment alone in vessels with 0 or 1 high-risk morphological attributes (hazard ratio: 0.33; 95% confidence interval: 0.12 to 0.93; p = 0.035), but the risk reduction was attenuated in vessels with ≥2 high-risk morphological attributes. CONCLUSIONS High-risk morphological attributes offered additive prognostic value to coronary physiology and may optimize selection of treatment strategies by adding to FFR-based risk predictions (CCTA-FFR Registry for Development of Comprehensive Risk Prediction Model; NCT04037163).
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Affiliation(s)
- Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea; Institute on Aging, Seoul National University, Seoul, Korea.
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jinlong Zhang
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tadashi Murai
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Jiesuck Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea; Division of Cardiology, Ulsan Hospital, Ulsan, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jianan Wang
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shaoliang Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Hitoshi Matsuo
- Department of Cardiology, Gifu Heart Center, Gifu, Japan
| | | | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei-Cedars-Sinai Integrative Cardiovascular Imaging Research Center, Yonsei University College of Medicine, Seoul, Korea
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Shahinian JH, Chong AY, Glineur D. Cutting-Edge Coronary Imaging Guiding CABG. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:218-222. [PMID: 33877923 PMCID: PMC8609503 DOI: 10.1177/15569845211008162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Jasmin H Shahinian
- 27339 Department of Cardiac Surgery, University of Ottawa Heart Institute, Canada.,Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Aun Yeong Chong
- Department of Cardiology, University of Ottawa Heart Institute, Canada
| | - David Glineur
- 27339 Department of Cardiac Surgery, University of Ottawa Heart Institute, Canada
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Al-Lamee R, Rajkumar CA, Ganesananthan S, Jeremias A. Optimising physiological endpoints of percutaneous coronary intervention. EUROINTERVENTION 2021; 16:e1470-e1483. [PMID: 33792544 PMCID: PMC9753914 DOI: 10.4244/eij-d-20-00988] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Invasive coronary physiology to select patients for coronary revascularisation has become established in contemporary guidelines for the management of stable coronary artery disease. Compared to revascularisation based on angiography alone, the use of coronary physiology has been shown to improve clinical outcomes and cost efficiency. However, recent data from randomised controlled trials have cast doubt upon the value of ischaemia testing to select patients for revascularisation. Importantly, 20-40% of patients have persistence or recurrence of angina after angiographically successful percutaneous coronary intervention (PCI). This state-of-the-art review is focused on the transitioning role of invasive coronary physiology from its use as a dichotomous test for ischaemia with fixed cut-points, towards its utility for real-time guidance of PCI to optimise physiological results. We summarise the contemporary evidence base for ischaemia testing in stable coronary artery disease, examine emerging indices which allow advanced physiological guidance of PCI, and discuss the rationale and evidence base for post-PCI physiological assessments to assess the success of revascularisation.
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Affiliation(s)
- Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, 2nd Floor, B Block, Hammersmith Hospital, Du Cane Road, London, W12 0HS, United Kingdom
| | - Christopher A. Rajkumar
- National Heart and Lung Institute, Imperial College London, London, United Kingdom,Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Allen Jeremias
- Department of Cardiology, St. Francis Hospital, The Heart Center, Roslyn, NY, USA
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32
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Gong Y, Zheng B, Yi T, Yang F, Hong T, Liu Z, Huo Y, Li J, Huo Y. Coronary angiography-derived contrast fractional flow reserve. Catheter Cardiovasc Interv 2021; 99:763-771. [PMID: 33590679 DOI: 10.1002/ccd.29558] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/09/2021] [Accepted: 02/02/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Based on coronary angiography and mean aortic pressure, a specially designed computational flow dynamics (CFD) method is proposed to determine contrast fractional flow reserve (cFFR) without using invasive pressure wire. This substudy assessed diagnostic performance of coronary angiography-derived cFFR in catheterization laboratory, based on a previous multicenter trial for online assessment of coronary angiography-derived FFR (caFFR). METHODS Patients with diagnosis of stable angina pectoris or unstable angina pectoris were enrolled in six centers. Wire-based FFR was measured in coronary arteries with 30-90% diameter stenosis. Offline angiography-derived cFFR was computed in blinded fashion against the wire-based FFR and caFFR at an independent core laboratory. RESULTS A total of 330 patients were enrolled to fulfill inclusion/exclusion criteria from June 26 to December 18, 2018. Offline angiography-derived cFFR and wire-based FFR results were compared in 328 interrogated vessels. The statistical analysis showed the highest diagnostic accuracy of 89.0 and 86.6% for angiography-derived cFFR with a cutoff value of 0.94 and 0.93 against the wire-based FFR with a cutoff value of 0.80 and 0.75, respectively. The corresponding sensitivity and specificity were 92.2 and 87.3% for the cutoff value of 0.94 and 80.0 and 88.4% for the cutoff value of 0.93, which are similar to those against the caFFR. The receiver-operating curve has area under the curve of 0.951 and 0.972 for the wire-based FFR with the cutoff value of 0.80 and 0.75, respectively. CONCLUSIONS Coronary angiography-derived cFFR showed higher accuracy, sensitivity, and specificity against wired-based FFR and caFFR. Hence, angiography-derived cFFR could enhance the hemodynamic assessment of coronary lesions.
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Affiliation(s)
- Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Tieci Yi
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Fan Yang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Tao Hong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Zhaoping Liu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yunlong Huo
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, Guangdong, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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33
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Kayaert P, Coeman M, Gevaert S, De Pauw M, Haine S. Physiology-Based Revascularization of Left Main Coronary Artery Disease. J Interv Cardiol 2021; 2021:4218769. [PMID: 33628144 PMCID: PMC7892248 DOI: 10.1155/2021/4218769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/12/2021] [Accepted: 01/22/2021] [Indexed: 01/10/2023] Open
Abstract
It is of critical importance to correctly assess the significance of a left main lesion. Underestimation of significance beholds the risk of inappropriate deferral of revascularization, whereas overestimation may trigger major but unnecessary interventions. This article addresses the invasive physiological assessment of left main disease and its role in deciding upon revascularization. It mainly focuses on the available evidence for fractional flow reserve and instantaneous wave-free ratio, their interpretation, and limitations. We also discuss alternative invasive physiological indices and imaging, as well as the link between physiology, ischemia, and prognosis.
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Affiliation(s)
- Peter Kayaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Mathieu Coeman
- Department of Cardiology, Jan Yperman Ziekenhuis, Ypres, Belgium
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Steven Haine
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
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34
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Omori H, Kawase Y, Mizukami T, Tanigaki T, Hirata T, Kikuchi J, Ota H, Sobue Y, Miyake T, Kawamura I, Okubo M, Kamiya H, Hirakawa A, Kawasaki M, Nakagawa M, Tsuchiya K, Suzuki Y, Ito T, Terashima M, Kondo T, Suzuki T, Escaned J, Matsuo H. Comparisons of Nonhyperemic Pressure Ratios. JACC Cardiovasc Interv 2020; 13:2688-2698. [DOI: 10.1016/j.jcin.2020.06.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/22/2020] [Accepted: 06/30/2020] [Indexed: 01/10/2023]
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35
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Gong Y, Feng Y, Yi T, Yang F, Li Y, Zhang L, Zheng B, Hong T, Liu Z, Huo Y, Li J, Huo Y. Coronary Angiography-Derived Diastolic Pressure Ratio. Front Bioeng Biotechnol 2020; 8:596401. [PMID: 33195166 PMCID: PMC7641609 DOI: 10.3389/fbioe.2020.596401] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 09/30/2020] [Indexed: 01/10/2023] Open
Abstract
Aims Based on the aortic pressure waveform, a specially designed computational fluid dynamic (CFD) method was proposed to determine coronary angiography-derived diastolic pressure ratio (caDPR) without using invasive pressure wire. The aim of the study is to retrospectively assess diagnostic performance of the caDPR in the catheterization laboratory, based on a previous multicenter trial for online assessment of coronary angiography-derived FFR (caFFR). Methods and Results Patients with diagnosis of stable or unstable angina pectoris were enrolled in six centers. Wire-derived FFR was measured in coronary arteries with 30–90% diameter stenosis. Offline caDPR was assessed in blinded fashion against wire-derived FFR at an independent core laboratory. A total of 330 patients who met the inclusion/exclusion criteria were enrolled from June 26 to December 18, 2018. Offline computed caDPR and wire-derived FFR were compared in 328 interrogated vessels. The caDPR with a cutoff value of 0.89 shows diagnostic accuracy of 87.7%, sensitivity of 89.5%, specificity of 86.8%, and AUC of 0.940 against the wire-derived FFR with a cutoff value of 0.80. Conclusions Using wired-based FFR as the standard reference, there is good diagnostic performance of the novel-CFD-design caDPR. Hence, caDPR could enhance the hemodynamic assessment of coronary lesions.
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Affiliation(s)
- Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yundi Feng
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, China
| | - Tieci Yi
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Fan Yang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yuxi Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Long Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Tao Hong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Zhaoping Liu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yunlong Huo
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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36
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Michail M, Thakur U, Mehta O, Ramzy JM, Comella A, Ihdayhid AR, Cameron JD, Nicholls SJ, Hoole SP, Brown AJ. Non-hyperaemic pressure ratios to guide percutaneous coronary intervention. Open Heart 2020; 7:openhrt-2020-001308. [PMID: 33004619 PMCID: PMC7534727 DOI: 10.1136/openhrt-2020-001308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/03/2020] [Accepted: 08/07/2020] [Indexed: 01/10/2023] Open
Abstract
The use of fractional flow reserve (FFR) in guiding revascularisation improves patient outcomes and has been well-established in clinical guidelines. Despite this, the uptake of FFR has been limited, likely attributable to the perceived increase in procedural time and use of hyperaemic agents that can cause patient discomfort. This has led to the development of instantaneous wave-free ratio (iFR), an alternative non-hyperaemic pressure ratio (NHPR). Since its inception, the use of iFR has been supported by an increasing body of evidence and is now guideline recommended. More recently, other commercially available NHPRs including diastolic hyperaemia-free ratio and resting full-cycle ratio have emerged. Studies have demonstrated that these indices, in addition to mean distal coronary artery pressure to mean aortic pressure ratio, are mathematically analogous (with specific nuances) to iFR. Additionally, there is increasing data demonstrating the equivalent diagnostic performance of alternative NHPRs in comparison with iFR and FFR. These NHPRs are now integral within most current pressure wire systems and are commonly available in the catheter laboratory. It is therefore key to understand the fundamental differences and evidence for NHPRs to guide appropriate clinical decision-making.
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Affiliation(s)
- Michael Michail
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia .,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Udit Thakur
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Ojas Mehta
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - John M Ramzy
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Andrea Comella
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Abdul Rahman Ihdayhid
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - James D Cameron
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Stephen P Hoole
- Department of Interventional Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Adam J Brown
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
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Modi BN, Rahman H, Ryan M, Ellis H, Pavlidis A, Redwood S, Clapp B, Chowienczyk P, Perera D. Comparison of fractional flow reserve, instantaneous wave-free ratio and a novel technique for assessing coronary arteries with serial lesions. EUROINTERVENTION 2020; 16:577-583. [PMID: 31543499 DOI: 10.4244/eij-d-19-00635] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
AIMS Physiological indices such as fractional flow reserve (FFR), instantaneous wave-free ratio (iFR) and resting distal coronary to aortic pressure (Pd/Pa) are increasingly used to guide revascularisation. However, reliable assessment of individual stenoses in serial coronary disease remains an unmet need. This study aimed to compare conventional pressure-based indices, a reference Doppler-based resistance index (hyperaemic stenosis resistance [hSR]) and a recently described mathematical correction model to predict the contribution of individual stenoses in serial disease. METHODS AND RESULTS Resting and hyperaemic pressure wire pullbacks were performed in 54 patients with serial disease. For each stenosis, FFR, iFR, and Pd/Pa were measured by the translesional gradient in each index and the predicted FFR (FFRpred) derived mathematically from hyperaemic pullback data. "True" stenosis significance by each index was assessed following PCI of the accompanying stenosis or measurements made in a large disease-free branch. In 27 patients, Doppler average peak flow velocity (APV) was also measured to calculate hSR (hSR=∆P/APV, where ∆P=translesional pressure gradient). FFR underestimated individual stenosis severity, inversely proportional to cumulative FFR (r=0.5, p<0.001). Mean errors for FFR, iFR and Pd/Pa were 33%, 20% and 24%, respectively, and 14% for FFRpred (p<0.001). Stenosis misclassification rates based on FFR 0.80, iFR 0.89 and Pd/Pa 0.91 thresholds were not significantly different (17%, 24% and 20%, respectively) but were higher than FFRpred (11%, p<0.001). Apparent and true hSR correlated strongly (r=0.87, p<0.001, mean error 0.19±0.3), with only 7% of stenoses misclassified. CONCLUSIONS Individual stenosis severity is significantly underestimated in the presence of serial disease, using both hyperaemic and resting pressure-based indices. hSR is less prone to error but challenges in optimising Doppler signals limit clinical utility. A mathematical correction model, using data from hyperaemic pressure wire pullback, produces similar accuracy to hSR and is superior to conventional pressure-based indices.
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Affiliation(s)
- Bhavik N Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, United Kingdom
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Difference in functional assessment of individual stenosis severity in serial coronary lesions between resting and hyperemic pressure-wire pullback: Insights from the GIFT registry. Int J Cardiol 2020; 312:10-15. [DOI: 10.1016/j.ijcard.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 04/19/2020] [Accepted: 05/01/2020] [Indexed: 01/10/2023]
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Matsuo A, Kasahara T, Ariyoshi M, Irie D, Isodono K, Tsubakimoto Y, Sakatani T, Inoue K, Fujita H. Utility of angiography-physiology coregistration maps during percutaneous coronary intervention in clinical practice. Cardiovasc Interv Ther 2020; 36:208-218. [PMID: 32507942 PMCID: PMC8019415 DOI: 10.1007/s12928-020-00668-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/16/2020] [Indexed: 01/22/2023]
Abstract
This study aimed to evaluate the utility and feasibility of physiological maps coregistered with angiograms using the pullback of a pressure guidewire with continuous instantaneous wave-free ratio (iFR) measurements. iFR pullback was obtained for 70 lesions from 70 patients with stable angina pectoris using SyncVision (Philips Corp.). Physiological maps were created, whereby the post-intervention iFR (post-iFR) was predicted as iFRpred. The iFR gap was defined if the difference between the iFRpred and post-iFR was ≥ 0.3. The lesion morphology changed from that during the physiological assessment to that during the angiographic assessment in 26 lesions (37.1%). In particular, 22.6% of angiographic tandem lesions changed to physiological focal lesions. The mean pre-intervention iFR, post-iFR, and iFRpred were 0.73 ± 0.17, 0.90 ± 0.06, and 0.93 ± 0.05, respectively. The mean difference between the iFRpred and post-iFR was 0.029 ± 0.099, with 95% limits of agreement of -0.070–0.128. iFR gaps occurred in 28 patients (40%). Notably, a new iFR gradient causing a ≥ 0.03 iFR drop after stenting occurred in 11 (15.7%) cases. The study patients were divided into two groups according to biases between post-iFR and iFRpred < 0.03 (good concordance group) or ≥ 0.03 (poor concordance group). The pre-intervention heart rate was the only independent predictor of poor concordance (odds ratio, 0.936; 95% confidence interval 0.883–0.992; p = 0.027). Physiological maps under resting conditions may contribute to a reduction in unnecessary stent placements without missing lesions requiring treatment. However, the predictive accuracy of post-iFR performance in the present study was slightly lower than that in the previous reports.
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Affiliation(s)
- Akiko Matsuo
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamanzadorimarutamachi, Kamigyo-ku, Kyoto, 602-8026, Japan.
| | - Takeru Kasahara
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamanzadorimarutamachi, Kamigyo-ku, Kyoto, 602-8026, Japan
| | - Makoto Ariyoshi
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamanzadorimarutamachi, Kamigyo-ku, Kyoto, 602-8026, Japan
| | - Daisuke Irie
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamanzadorimarutamachi, Kamigyo-ku, Kyoto, 602-8026, Japan
| | - Koji Isodono
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamanzadorimarutamachi, Kamigyo-ku, Kyoto, 602-8026, Japan
| | - Yoshinori Tsubakimoto
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamanzadorimarutamachi, Kamigyo-ku, Kyoto, 602-8026, Japan
| | - Tomohiko Sakatani
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamanzadorimarutamachi, Kamigyo-ku, Kyoto, 602-8026, Japan
| | - Keiji Inoue
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamanzadorimarutamachi, Kamigyo-ku, Kyoto, 602-8026, Japan
| | - Hiroshi Fujita
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamanzadorimarutamachi, Kamigyo-ku, Kyoto, 602-8026, Japan
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Non-hyperaemic coronary pressure measurements to guide coronary interventions. Nat Rev Cardiol 2020; 17:629-640. [DOI: 10.1038/s41569-020-0374-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2020] [Indexed: 01/11/2023]
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Higashioka D, Shiono Y, Kubo T, Kitabata H, Nishi T, Terada K, Emori H, Takahata M, Wada T, Shimamura K, Matsuo Y, Ino Y, Tanaka A, Hozumi T, Akasaka T. The inter-study reproducibility of instantaneous wave-free ratio and angiography coregistration. J Cardiol 2020; 75:507-512. [DOI: 10.1016/j.jjcc.2019.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 01/10/2023]
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[Coronary physiology in the catheter laboratory]. Herz 2020; 46:15-23. [PMID: 31938804 DOI: 10.1007/s00059-019-04878-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 11/21/2019] [Accepted: 12/06/2019] [Indexed: 01/10/2023]
Abstract
The regulation of coronary flow is mainly located in the resistance vessels of the microcirculation, so that the functional relevance of a coronary stenosis arises from the interaction between the epicardial stenosis and the downstream microcirculation. These complex interactions are precisely detectable by physiological measurements, such as the instantaneous wave-free ratio (iwFR) or the fractional flow reserve (FFR). In contrast, the purely visual assessment of the coronary anatomy could lead to misinterpretation and possibly to incorrect revascularization decisions. Consequently, in the current guidelines on myocardial revascularization of the European Society of Cardiology (ESC) the measurement of iwFR and FFR has a class IA indication in intermediate stenoses with unclear hemodynamic relevance. Despite this clear recommendation, physiological measurements are not yet regularly used in the clinical routine. Besides the purely hemodynamic assessment, novel methods such as co-registration and coronary mapping can be used for virtual planning of percutaneous coronary interventions, especially in vessels with diffuse lesions and serial stenoses. Furthermore, invasive flow measurements are also helpful for risk stratification between conservative and interventional treatment of patients with acute coronary syndrome, where additional factors of flow limitation, such as coronary spasm, thrombus and acute disturbance of the microcirculation play an important role.
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Warisawa T, Nour D, Seligman H, Doi S, Kuwata S, Howard JP, Rajkumar C, Cook CM, Nakayama Y, Kasahara M, Suzuki N, Matsuda H, Mizuno K, Akashi YJ. Interference Between Pressure-Wire and Deployed Coronary Stents: Insights from a Bench Test. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:765-770. [PMID: 31784356 DOI: 10.1016/j.carrev.2019.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/03/2019] [Accepted: 10/23/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND While several complications related to pressure-wire (PW) have been reported, mechanistic justification has not always been offered. Furthermore, interference between a PW and a protruding side-branch stent has not been previously reported. The purpose of this study was to evaluate interference between PW-pullback from a main-branch with a protruded ostial stent deployed in a side-branch. METHODS In a polyurethane bifurcation vessel model, PW-pullback was performed in a main-branch following protruded ostial stenting in a side-branch. Tested PWs included PressureWire X, Comet, OptoWire, and Verrata. For each PW, pullback was performed through the same proximal cell of the protruded stent 20 times. Interference during PW-pullback was objectively analyzed with a fiberscope placed at the distal main-branch and classified into 3 grades according to the interaction with stent strut. RESULTS There were significant differences in the rate of interference between the PWs. No-interference, interference without strut traction, and interference with strut traction (i.e. stent deformation) were observed as follows: 17/20, 3/20, and 0/20 in PressureWire X; 19/20, 1/20, and 0/20 in Comet; 8/20, 10/20, and 2/20 in OptoWire; and 13/20, 2/20, and 5/20 in Verrata, respectively (p for any differences: <0.001). Visually identifiable major stent deformation was observed once in OptoWire due to the deep concave sensor window and twice in Verrata due to the proximal gap between the sensor and coiled-wire. CONCLUSIONS PW-pullback in the main-branch after side-branch ostial stenting should be carefully performed to avoid stent deformation. Consideration on the specific mechanical features of the PW is also essential.
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Affiliation(s)
- Takayuki Warisawa
- National Heart and Lung Institute, Imperial College London, London, UK; Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.
| | - Daniel Nour
- National Heart and Lung Institute, Imperial College London, London, UK; James Cook University, Queensland, Australia
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Shunichi Doi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shingo Kuwata
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | - Yui Nakayama
- Department of Cardiovascular Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Mizuho Kasahara
- Department of Cardiovascular Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Norio Suzuki
- Department of Cardiovascular Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Hisao Matsuda
- Department of Cardiovascular Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Koichi Mizuno
- Department of Cardiovascular Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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Ahmad Y, Vendrik J, Eftekhari A, Howard JP, Cook C, Rajkumar C, Malik I, Mikhail G, Ruparelia N, Hadjiloizou N, Nijjer S, Al-Lamee R, Petraco R, Warisawa T, Wijntjens GWM, Koch KT, van de Hoef T, de Waard G, Echavarria-Pinto M, Frame A, Sutaria N, Kanaganayagam G, Ariff B, Anderson J, Chukwuemeka A, Fertleman M, Koul S, Iglesias JF, Francis D, Mayet J, Serruys P, Davies J, Escaned J, van Royen N, Götberg M, Juhl Terkelsen C, Høj Christiansen E, Piek JJ, Baan J, Sen S. Determining the Predominant Lesion in Patients With Severe Aortic Stenosis and Coronary Stenoses: A Multicenter Study Using Intracoronary Pressure and Flow. Circ Cardiovasc Interv 2019; 12:e008263. [PMID: 31752515 PMCID: PMC6924937 DOI: 10.1161/circinterventions.119.008263] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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
Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation.
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Affiliation(s)
- Yousif Ahmad
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Jeroen Vendrik
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, the Netherlands (J.V., K.T.K., T.v.d.H., J.J.P., J.B.)
| | - Ashkan Eftekhari
- Aarhus University Hospital Skejby, Denmark (A.E., C.J.T., E.H.C.)
| | - James P Howard
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Christopher Cook
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Christopher Rajkumar
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Iqbal Malik
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Ghada Mikhail
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Neil Ruparelia
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Nearchos Hadjiloizou
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Sukhjinder Nijjer
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Ricardo Petraco
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Takayuki Warisawa
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | | | - Karel T Koch
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, the Netherlands (J.V., K.T.K., T.v.d.H., J.J.P., J.B.)
| | - Tim van de Hoef
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, the Netherlands (J.V., K.T.K., T.v.d.H., J.J.P., J.B.)
| | - Guus de Waard
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands (G.d.W., N.v.R.)
| | | | - Angela Frame
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Nilesh Sutaria
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Gajen Kanaganayagam
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Ben Ariff
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Jon Anderson
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Andrew Chukwuemeka
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Michael Fertleman
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (S.K., M.G.)
| | - Juan F Iglesias
- Cardiology Department, Lausanne University Hospital, Switzerland (J.F.I.)
| | - Darrel Francis
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Jamil Mayet
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Patrick Serruys
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Justin Davies
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Javier Escaned
- Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.)
| | - Niels van Royen
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands (G.d.W., N.v.R.)
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (S.K., M.G.)
| | | | | | - Jan J Piek
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, the Netherlands (J.V., K.T.K., T.v.d.H., J.J.P., J.B.)
| | - Jan Baan
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, the Netherlands (J.V., K.T.K., T.v.d.H., J.J.P., J.B.)
| | - Sayan Sen
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
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Tarantini G, Barioli A, Nai Fovino L, Fraccaro C, Masiero G, Iliceto S, Napodano M. Unmasking Myocardial Bridge-Related Ischemia by Intracoronary Functional Evaluation. Circ Cardiovasc Interv 2019; 11:e006247. [PMID: 29903715 DOI: 10.1161/circinterventions.117.006247] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 05/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Invasive physiological assessment of myocardial bridges (MBs) is largely unsettled. Unlike fractional flow reserve (FFR), instantaneous wave-free ratio (iFR) is a diastole-specific index. As such, its value might not be hampered by systolic pressure overshooting and negative systolic pressure gradient caused by the compression of the tunneled coronary artery. METHODS AND RESULTS We prospectively enrolled 20 patients with angina and/or positive noninvasive stress test, absence of significant coronary artery stenosis, and angiographic suspicion/evidence of MB in the left anterior descending artery. According to a prespecified protocol, all patients underwent functional intracoronary evaluation with FFR at rest and after dobutamine (up to 20 μg kg-1 min-1) and atropine (1 mg) intravenous infusion. iFR at baseline and dobutamine-induced hyperemic wave-free period pressure ratio were also recorded. FFR values ≤0.80 and iFR values ≤0.89 were considered indicative of hemodynamic significance of MB. At baseline, no MB was hemodynamically significant according to FFR, whereas iFR was below the cutoff value in all but 7 patients. During inotropic challenge, median FFR did not change significantly (0.87-0.86, P=0.59). CONCLUSIONS Physiological evaluation of MBs with iFR seems to be more consistent with patients' symptoms and noninvasive test results compared with FFR.
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Affiliation(s)
- Giuseppe Tarantini
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy.
| | - Alberto Barioli
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
| | - Luca Nai Fovino
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
| | - Chiara Fraccaro
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
| | - Giulia Masiero
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
| | - Sabino Iliceto
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
| | - Massimo Napodano
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
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Modi BN, Rahman H, Arri S, Ellis H, Mills MT, Williams R, Asrress K, Clapp B, Redwood S, Perera D. Resting Coronary Flow Varies With Normal Cardiac Catheter Laboratory Stimuli. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:669-673. [PMID: 30415969 DOI: 10.1016/j.carrev.2018.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/28/2018] [Accepted: 10/08/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Growing evidence supports physiology-guided revascularization, with Fractional Flow Reserve (FFR) the most commonly used invasive measure of coronary blood flow impairment at the time of diagnostic angiography. Recently, there has been growing interest in stenosis severity indices measured at rest, such as Instantaneous Wave Free Ratio (iFR) and the ratio of distal coronary to aortic pressure at rest (resting Pd/Pa). Their reliability may, theoretically, be more susceptible to changes in microvascular tone and coronary flow. This study aimed to assess variability of resting coronary flow with normal catheter laboratory stimuli. METHODS Simultaneous intracoronary pressure (Pd) and Doppler Average Peak Flow Velocity (APV) recordings were made at rest and following the verbal warning preceding an intravenous adenosine infusion. RESULTS 72 patients undergoing elective angiography were recruited (mean age 62 years, 52.7% male) with a wide range of coronary artery disease severity (FFR 0.86 ± 0.09). Average peak flow velocity varied significantly between measurements at rest and just prior to commencement of adenosine, with a mean variation of 10.2% (17.82 ± 9.41 cm/s vs. 19.63 ± 10.44 cm/s, p < 0.001) with an accompanying significant drop in microvascular resistance (6.27 ± 2.73 mm Hg·cm-1·s-1 vs. 5.8 ± 2.92 mm Hg·cm-1·s-1, p < 0.001). These changes occurred without significant change in systemic hemodynamic measures. Whilst there was a trend for an associated change in the resting indices, Pd/Pa and iFR, this was statistically and clinically not significant (0.92 ± 0.08 vs. 0.92 ± 0.08, p = 0.110; and 0.90 ± 0.11 vs. 0.89 ± 0.12, p = 0.073). CONCLUSION Resting coronary flow and microvascular resistance vary significantly with normal catheter laboratory stimuli, such as simple warnings. The clinical impact of these observed changes on indices of stenosis severity, particularly those measured at rest, needs further assessment within larger cohorts.
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Affiliation(s)
- Bhavik N Modi
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Haseeb Rahman
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Satpal Arri
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Howard Ellis
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Mark T Mills
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Rupert Williams
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Kaleab Asrress
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Brian Clapp
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Simon Redwood
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Divaka Perera
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom.
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De Rosa S, Polimeni A, Petraco R, Davies JE, Indolfi C. Diagnostic Performance of the Instantaneous Wave-Free Ratio: Comparison With Fractional Flow Reserve. Circ Cardiovasc Interv 2019; 11:e004613. [PMID: 29326150 DOI: 10.1161/circinterventions.116.004613] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 11/16/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aim of the present study was to perform a meta-analysis of all available studies comparing the instantaneous wave-free ratio (iFR) with fractional flow reserve (FFR). METHODS AND RESULTS Published trials comparing the iFR with FFR were searched for in PubMed, Google Scholar, and Scopus electronic databases. A total of 23 studies were available for the analysis, including 6381 stenoses. First, a meta-analysis of all studies was performed exploring the correlation between FFR and iFR. Interestingly, we found good correlation (0.798 [0.78-0.82]) between the 2 indices (P<0.001). In addition, to evaluate the diagnostic performance of iFR to identify FFR-positive coronary stenoses, we performed an additional meta-analysis, summarizing the results of receiver operating characteristics analyses from individual studies reporting the area under the curve. Summing the results of these studies, we found that iFR has a good diagnostic performance for the identification of FFR-positive stenoses (area under the curve=0.88 [0.86-0.90]; P<0.001). Furthermore, our search results included 5 studies that compared iFR and FFR to a third independent reference standard. Interestingly, no significant differences between iFR and FFR were reported in those studies. CONCLUSIONS The present meta-analysis shows that iFR significantly correlates with standard FFR and shows a good diagnostic performance in identifying FFR-positive coronary stenoses. Finally, iFR and FFR have similar diagnostic efficiency for detection of ischemia-inducing stenoses when tested against a third comparator.
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Affiliation(s)
- Salvatore De Rosa
- From the Division of Cardiology, Department of Medical and Surgical Sciences (S.D.R., A.P., C.I.) and URT-CNR of IFC (C.I.), Magna Graecia University, Catanzaro, Italy; and National Heart and Lung Institute, Imperial College London, United Kingdom (R.P., J.E.D.)
| | - Alberto Polimeni
- From the Division of Cardiology, Department of Medical and Surgical Sciences (S.D.R., A.P., C.I.) and URT-CNR of IFC (C.I.), Magna Graecia University, Catanzaro, Italy; and National Heart and Lung Institute, Imperial College London, United Kingdom (R.P., J.E.D.)
| | - Ricardo Petraco
- From the Division of Cardiology, Department of Medical and Surgical Sciences (S.D.R., A.P., C.I.) and URT-CNR of IFC (C.I.), Magna Graecia University, Catanzaro, Italy; and National Heart and Lung Institute, Imperial College London, United Kingdom (R.P., J.E.D.)
| | - Justin E Davies
- From the Division of Cardiology, Department of Medical and Surgical Sciences (S.D.R., A.P., C.I.) and URT-CNR of IFC (C.I.), Magna Graecia University, Catanzaro, Italy; and National Heart and Lung Institute, Imperial College London, United Kingdom (R.P., J.E.D.)
| | - Ciro Indolfi
- From the Division of Cardiology, Department of Medical and Surgical Sciences (S.D.R., A.P., C.I.) and URT-CNR of IFC (C.I.), Magna Graecia University, Catanzaro, Italy; and National Heart and Lung Institute, Imperial College London, United Kingdom (R.P., J.E.D.).
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Gosling RC, Morris PD, Silva Soto DA, Lawford PV, Hose DR, Gunn JP. Virtual Coronary Intervention: A Treatment Planning Tool Based Upon the Angiogram. JACC Cardiovasc Imaging 2019; 12:865-872. [PMID: 29550308 PMCID: PMC6503181 DOI: 10.1016/j.jcmg.2018.01.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 12/19/2017] [Accepted: 01/04/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study sought to assess the ability of a novel virtual coronary intervention (VCI) tool based on invasive angiography to predict the patient's physiological response to stenting. BACKGROUND Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) is associated with improved clinical and economic outcomes compared with angiographic guidance alone. Virtual (v)FFR can be calculated based upon a 3-dimensional (3D) reconstruction of the coronary anatomy from the angiogram, using computational fluid dynamics (CFD) modeling. This technology can be used to perform virtual stenting, with a predicted post-PCI FFR, and the prospect of optimized treatment planning. METHODS Patients undergoing elective PCI had pressure-wire-based FFR measurements pre- and post-PCI. A 3D reconstruction of the diseased artery was generated from the angiogram and imported into the VIRTUheart workflow, without the need for any invasive physiological measurements. VCI was performed using a radius correction tool replicating the dimensions of the stent deployed during PCI. Virtual FFR (vFFR) was calculated pre- and post-VCI, using CFD analysis. vFFR pre- and post-VCI were compared with measured (m)FFR pre- and post-PCI, respectively. RESULTS Fifty-four patients and 59 vessels underwent PCI. The mFFR and vFFR pre-PCI were 0.66 ± 0.14 and 0.68 ± 0.13, respectively. Pre-PCI vFFR deviated from mFFR by ±0.05 (mean Δ = -0.02; SD = 0.07). The mean mFFR and vFFR post-PCI/VCI were 0.90 ± 0.05 and 0.92 ± 0.05, respectively. Post-VCI vFFR deviated from post-PCI mFFR by ±0.02 (mean Δ = -0.01; SD = 0.03). Mean CFD processing time was 95 s per case. CONCLUSIONS The authors have developed a novel VCI tool, based upon the angiogram, that predicts the physiological response to stenting with a high degree of accuracy.
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Affiliation(s)
- Rebecca C Gosling
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom; Department of Cardiology, Sheffield Teaching Hospitals, National Health Service Foundation Trust, Northern General Hospital, Sheffield, United Kingdom.
| | - Paul D Morris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom; Department of Cardiology, Sheffield Teaching Hospitals, National Health Service Foundation Trust, Northern General Hospital, Sheffield, United Kingdom; Insigneo Institute for In Silico Medicine, Sheffield, United Kingdom
| | - Daniel A Silva Soto
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Patricia V Lawford
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom; Insigneo Institute for In Silico Medicine, Sheffield, United Kingdom
| | - D Rodney Hose
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom; Insigneo Institute for In Silico Medicine, Sheffield, United Kingdom; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Julian P Gunn
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom; Department of Cardiology, Sheffield Teaching Hospitals, National Health Service Foundation Trust, Northern General Hospital, Sheffield, United Kingdom; Insigneo Institute for In Silico Medicine, Sheffield, United Kingdom
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Novel Method for Real-Time Coregistration of Coronary Physiology and Angiography by iFR. JACC Cardiovasc Interv 2019; 12:692-694. [DOI: 10.1016/j.jcin.2018.12.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 12/26/2018] [Indexed: 01/10/2023]
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Modi BN, Sankaran S, Kim HJ, Ellis H, Rogers C, Taylor CA, Rajani R, Perera D. Predicting the Physiological Effect of Revascularization in Serially Diseased Coronary Arteries. Circ Cardiovasc Interv 2019; 12:e007577. [PMID: 30722688 PMCID: PMC6794156 DOI: 10.1161/circinterventions.118.007577] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/19/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR) is commonly used to assess the functional significance of coronary artery disease but is theoretically limited in evaluating individual stenoses in serially diseased vessels. We sought to characterize the accuracy of assessing individual stenoses in serial disease using invasive FFR pullback and the noninvasive equivalent, fractional flow reserve by computed tomography (FFRCT). We subsequently describe and test the accuracy of a novel noninvasive FFRCT-derived percutaneous coronary intervention (PCI) planning tool (FFRCT-P) in predicting the true significance of individual stenoses. METHODS AND RESULTS Patients with angiographic serial coronary artery disease scheduled for PCI were enrolled and underwent prospective coronary CT angiography with conventional FFRCT-derived post hoc for each vessel and stenosis (FFRCT). Before PCI, the invasive hyperemic pressure-wire pullback was performed to derive the apparent FFR contribution of each stenosis (FFRpullback). The true FFR attributable to individual lesions (FFRtrue) was then measured following PCI of one of the lesions. The predictive accuracy of FFRpullback, FFRCT, and the novel technique (FFRCT-P) was then assessed against FFRtrue. From the 24 patients undergoing the protocol, 19 vessels had post hoc FFRCT and FFRCT-P calculation. When assessing the distal effect of all lesions, FFRCT correlated moderately well with invasive FFR ( R=0.71; P<0.001). For lesion-specific assessment, there was significant underestimation of FFRtrue using FFRpullback (mean discrepancy, 0.06±0.05; P<0.001, representing a 42% error) and conventional trans-lesional FFRCT (0.05±0.06; P<0.001, 37% error). Using FFRCT-P, stenosis underestimation was significantly reduced to a 7% error (0.01±0.05; P<0.001). CONCLUSIONS FFR pullback and conventional FFRCT significantly underestimate true stenosis contribution in serial coronary artery disease. A novel noninvasive FFRCT-based PCI planner tool more accurately predicts the true FFR contribution of each stenosis in serial coronary artery disease.
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Affiliation(s)
- Bhavik N. Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
| | | | - Hyun Jin Kim
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Howard Ellis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
| | - Campbell Rogers
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Charles A. Taylor
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Ronak Rajani
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
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