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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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Asano T, Tanigaki T, Ikeda K, Ono M, Yokoi H, Kobayashi Y, Kozuma K, Tanaka N, Kawase Y, Matsuo H. Consensus document on the clinical application of invasive functional coronary angiography from the Japanese Association of Cardiovascular Intervention and Therapeutics. Cardiovasc Interv Ther 2024; 39:109-125. [PMID: 38367157 PMCID: PMC10940478 DOI: 10.1007/s12928-024-00988-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/09/2024] [Indexed: 02/19/2024]
Abstract
Invasive functional coronary angiography (FCA), an angiography-derived physiological index of the functional significance of coronary obstruction, is a novel physiological assessment tool for coronary obstruction that does not require the utilization of a pressure wire. This technology enables operators to rapidly evaluate the functional relevance of coronary stenoses during and even after angiography while reducing the burden of cost and complication risks related to the pressure wire. FCA can be used for treatment decision-making for revascularization, strategy planning for percutaneous coronary intervention, and procedure optimization. Currently, various software-computing FCAs are available worldwide, with unique features in their computation algorithms and functions. With the emerging application of this novel technology in various clinical scenarios, the Japanese Association of Cardiovascular Intervention and Therapeutics task force was created to outline expert consensus on the clinical use of FCA. This consensus document advocates optimal clinical applications of FCA according to currently available evidence while summarizing the concept, history, limitations, and future perspectives of FCA along with globally available software.
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Affiliation(s)
- Taku Asano
- Department of Cardiovascular Medicine, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, P.O. Box 104-8560, Tokyo, Japan.
| | - Toru Tanigaki
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Kazumasa Ikeda
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Masafumi Ono
- Department of Cardiovascular Medicine, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, P.O. Box 104-8560, Tokyo, Japan
| | - Hiroyoshi Yokoi
- Department of Cardiovascular Medicine, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University, Chiba, Japan
| | - Ken Kozuma
- Department of Cardiology, Teikyo University, Tokyo, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Yoshiaki Kawase
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
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3
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Munhoz D, Collet C, Mizukami T, Yong A, Leone AM, Eftekhari A, Ko B, da Costa BR, Berry C, Collison D, Perera D, Christiansen EH, Rivero F, Zimmermann FM, Ando H, Matsuo H, Nakayama M, Escaned J, Sonck J, Sakai K, Adjedj J, Desta L, van Nunen LX, West NEJ, Fournier S, Storozhenko T, Amano T, Engstrøm T, Johnson T, Shinke T, Biscaglia S, Fearon WF, Ali Z, De Bruyne B, Johnson NP. Rationale and design of the pullback pressure gradient (PPG) global registry. Am Heart J 2023; 265:170-179. [PMID: 37611857 DOI: 10.1016/j.ahj.2023.07.016] [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] [Received: 04/06/2023] [Revised: 06/20/2023] [Accepted: 07/08/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Diffuse disease has been identified as one of the main reasons leading to low post-PCI fractional flow reserve (FFR) and residual angina after PCI. Coronary pressure pullbacks allow for the evaluation of hemodynamic coronary artery disease (CAD) patterns. The pullback pressure gradient (PPG) is a novel metric that quantifies the distribution and magnitude of pressure losses along the coronary artery in a focal-to-diffuse continuum. AIM The primary objective is to determine the predictive capacity of the PPG for post-PCI FFR. METHODS This prospective, large-scale, controlled, investigator-initiated, multicenter study is enrolling patients with at least 1 lesion in a major epicardial vessel with a distal FFR ≤ 0.80 intended to be treated by PCI. The study will include 982 subjects. A standardized physiological assessment will be performed pre-PCI, including the online calculation of PPG from FFR pullbacks performed manually. PPG quantifies the CAD pattern by combining several parameters from the FFR pullback curve. Post-PCI physiology will be recorded using a standardized protocol with FFR pullbacks. We hypothesize that PPG will predict optimal PCI results (post-PCI FFR ≥ 0.88) with an area under the ROC curve (AUC) ≥ 0.80. Secondary objectives include patient-reported and clinical outcomes in patients with focal vs. diffuse CAD defined by the PPG. Clinical follow-up will be collected for up to 36 months, and an independent clinical event committee will adjudicate events. RESULTS Recruitment is ongoing and is expected to be completed in the second half of 2023. CONCLUSION This international, large-scale, prospective study with pre-specified powered hypotheses will determine the ability of the preprocedural PPG index to predict optimal revascularization assessed by post-PCI FFR. In addition, it will evaluate the impact of PPG on treatment decisions and the predictive performance of PPG for angina relief and clinical outcomes.
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Affiliation(s)
- Daniel Munhoz
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Takuya Mizukami
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Division of Clinical Pharmacology, Department of Pharmacology, Showa University, Tokyo, Japan
| | - Andy Yong
- Concord Repatriation General Hospital, University of Sydney, New South Wales, Australia
| | - Antonio Maria Leone
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University School of Medicine, Rome, Italy; Center of Excellence in Cardiovascular Diagnostics and Therapeutic, Ospedale Fabenefratelli Isola Tiberina Gemelli Isola, Rome, Italy
| | - Ashkan Eftekhari
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Brian Ko
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Clayton, Victoria, Australia
| | - Bruno R da Costa
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, England; Clinical Epidemiology and Health Care Research, Institute of Health Policy and Management Evaluation (IHPME), University of Toronto, Toronto, Ontorio, Canada
| | - Colin Berry
- School Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Damien Collison
- School Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, St Thomas' Hospital Campus, King's College London, London, UK
| | | | - Fernando Rivero
- Cardiac Department, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Hirohiko Ando
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | | | - Javier Escaned
- Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Madrid, Spain
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Koshiro Sakai
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Medicine, Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Julien Adjedj
- Department of Cardiology, Arnault Tzanck Institute Saint Laurent du Var, France
| | - Liyew Desta
- Department of Cardiology, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Lokien X van Nunen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Stephane Fournier
- Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Tatyana Storozhenko
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Prevention and Treatment of Emergency Conditions, L.T. Malaya Therapy National Institute NAMSU, Kharkiv, Ukraine
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Thomas Engstrøm
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Johnson
- University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Toshiro Shinke
- Department of Medicine, Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Ferrara, Italy
| | - William F Fearon
- Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, CA
| | - Ziad Ali
- St Francis Hospital and Heart Center, Roslyn, NY
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nils P Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX.
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Scarsini R, Campo G, DI Serafino L, Zanon S, Rubino F, Monizzi G, Biscaglia S, Ancona M, Polimeni A, Niccoli G, Fineschi M, Porto I, Leone AM. #FullPhysiology: a systematic step-by-step guide to implement intracoronary physiology in daily practice. Minerva Cardiol Angiol 2023; 71:504-514. [PMID: 37712217 DOI: 10.23736/s2724-5683.23.06414-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
#FullPhysiology is a comprehensive and systematic approach to evaluate patients with suspected coronary disease using PressureWire technology (Abbott Vascular, Santa Clara, CA, USA). This advancement in technology enables the investigation of each component of the coronary circulation, including epicardial, microvascular, and vasomotor function, without significantly increasing procedural time or technical complexity. By identifying the predominant physiopathology responsible for myocardial ischemia, #FullPhysiology enhances precision medicine by providing accurate diagnosis and facilitating tailored interventional or medical treatments. This overview aims to provide insights into modern coronary physiology and describe a systematic approach to assess epicardial flow-limiting disease, longitudinal physiological vessel analysis, microvascular and vasomotor dysfunction, as well as post- percutaneous coronary intervention (PCI) physiological results.
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Affiliation(s)
- Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy -
| | - Gianluca Campo
- Cardiology Unit, Ferrara University Hospital, Cona, Ferrara, Italy
| | - Luigi DI Serafino
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Sofia Zanon
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Francesca Rubino
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Monizzi
- Department of Cardiology, Galeazzi-Sant'Ambrogio Hospital, Milan, Italy
| | - Simone Biscaglia
- Cardiology Unit, Ferrara University Hospital, Cona, Ferrara, Italy
| | - Marco Ancona
- Cardiovascular Imaging Unit, Department of Cardiothoracic Surgery, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alberto Polimeni
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Cosenza, Italy
| | | | - Massimo Fineschi
- Department of Interventional Cardiology, Senese University Hospital, Le Scotte Polyclinic Hospital, Siena, Italy
| | - Italo Porto
- Cardiology Unit, Department of Cardiothoracic and Vascular Surgery (DICATOV), San Martino Polyclinic Hospital, Genoa, Italy
| | - Antonio M Leone
- Diagnostic and Interventional Unit, Ospedale Fatebenefratelli Gemelli Isola Tiberina, Rome, Italy
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5
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Budrys P, Peace A, Baranauskas A, Davidavicius G. Intravascular Ultrasound vs. Fractional Flow Reserve for Percutaneous Coronary Intervention Optimization in Long Coronary Artery Lesions. Diagnostics (Basel) 2023; 13:2921. [PMID: 37761287 PMCID: PMC10528528 DOI: 10.3390/diagnostics13182921] [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: 08/17/2023] [Revised: 08/29/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND intravascular ultrasound (IVUS) and fractional flow reserve (FFR) have both been shown to be superior to angiography in optimizing percutaneous coronary intervention (PCI). However, there is still a lack of comparative studies between PCI optimization using physiology and intravascular imaging head-to-head. The aim of this study was to compare the effectiveness of FFR and IVUS PCI optimization strategies on the functional PCI result (assessed with FFR) immediately post-PCI and at 9-12 months after the treatment of long coronary lesions. METHODS This was a single-center study comparing post-PCI FFR between two different PCI optimization strategies (FFR and IVUS). The study included 154 patients who had hemodynamically significant long lesions, necessitating a stent length of 30 mm or more. The procedural outcomes were functional PCI result immediately post-PCI and at 9-12 months after treatment. Clinical outcomes included target vessel failure (TVF) and functional target vessel restenosis rate during follow-up. RESULTS Baseline clinical characteristics and FFR (0.65 [0.55-0.71]) did not differ significantly between the two groups and the left anterior descending artery was treated in 82% of cases. The FFR optimization strategy resulted in a significantly shorter stented segment (49 mm vs. 63 mm, p = 0.001) compared to the IVUS optimization strategy. Although the rates of optimal functional PCI result (FFR > 0.9) did not significantly differ between the FFR and IVUS optimization strategies, a proportion of patients in the FFR group (12%) experienced poor post-PCI functional outcome with FFR values ≤ 0.8, which was not observed in the IVUS group. At the 9-12 month follow-up, 20% of patients in the FFR group had target-vessel-related myocardial ischemia, compared to 6% in the IVUS group. The rates of TVF and functional target vessel restenosis during follow-up were also numerically higher in the FFR optimization group. CONCLUSIONS The use of FFR PCI optimization strategy in the treatment of long coronary artery lesions is associated with a higher incidence of poor functional PCI result and larger myocardial ischemia burden at follow-up compared to the IVUS optimization strategy. However, this discrepancy did not translate into a statistically significant difference in clinical outcomes. This study highlights the importance of using IVUS to optimize long lesions functional PCI outcomes.
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Affiliation(s)
- Povilas Budrys
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Aaron Peace
- Department of Cardiology, Western Health and Social Care Trust, Derry BT47 6SB, UK
| | - Arvydas Baranauskas
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Giedrius Davidavicius
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
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Neleman T, Scoccia A, Groenland FTW, Ziedses des Plantes AC, van Zandvoort LJC, Ligthart JMR, Witberg KT, Lenzen MJ, Boersma E, Nuis RJ, den Dekker WK, Diletti R, Wilschut J, Zijlstra F, Van Mieghem NM, Daemen J. Validation of Segmental Post-PCI Physiological Gradients With IVUS-Detected Focal Lesions and Stent Underexpansion. JACC Cardiovasc Interv 2023:S1936-8798(23)00676-3. [PMID: 37354158 DOI: 10.1016/j.jcin.2023.03.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Segmental post-percutaneous coronary intervention (PCI) pressure gradients may detect residual disease and potential targets for optimization. However, universal definitions of relevant segmental gradients are lacking. OBJECTIVES The study sought to evaluate the diagnostic performance of post-PCI fractional flow reserve (FFR), distal coronary pressure-to-aortic pressure ratio (Pd/Pa), and diastolic pressure ratio (dPR) gradients to detect residual focal lesions and stent underexpansion as observed by intravascular ultrasound (IVUS). METHODS Patients from the IVUS-guided optimization arm of the FFR REACT (FFR-guided PCI Optimization Directed by High-Definition IVUS Versus Standard of Care) trial with complete IVUS and FFR pullback data were included. Patients with angiographically successful PCI and post-PCI FFR <0.90 underwent FFR, Pd/Pa, and IVUS pullbacks. dPR was calculated offline using dedicated software. Segmental pressure gradients (distal, in stent, and proximal) in segments ≥5 mm were evaluated against IVUS-detected residual disease (distal or proximal focal lesions and stent underexpansion). RESULTS A total of 139 vessels were included (mean post-PCI FFR: 0.83 ± 0.05, range 0.56-0.89). Focal distal and proximal lesions were detected by IVUS in 23 (17.4%) of 132 and 14 (12.6%) of 111 vessels, respectively, whereas stent underexpansion was present in 86 (61.9%) vessels. Diagnostic ability of segmental FFR gradients to predict IVUS-detected distal and proximal lesions was moderate to good (area under the curve [AUC]: 0.69 and 0.84, respectively) and poor to moderate for segmental Pd/Pa and dPR gradients (AUC ranging from 0.58 to 0.69). In-stent gradients had no discriminative ability to detect stent underexpansion (FFR AUC: 0.52; Pd/Pa AUC: 0.54; dPR AUC: 0.55). CONCLUSIONS In patients with post-PCI FFR <0.90, segmental post-PCI pressure gradients have moderate discriminative ability to identify IVUS-detected focal lesions but no discriminative ability to identify IVUS-detected stent underexpansion.
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Affiliation(s)
- Tara Neleman
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Alessandra Scoccia
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | | | - Jurgen M R Ligthart
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Karen T Witberg
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mattie J Lenzen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wijnand K den Dekker
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen Wilschut
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
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7
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Takagi H, Ihdayhid AR, Leipsic JA. Integration of fractional flow reserve derived from CT into clinical practice. J Cardiol 2023; 81:577-585. [PMID: 36805489 DOI: 10.1016/j.jjcc.2023.02.002] [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: 01/12/2023] [Accepted: 01/24/2023] [Indexed: 02/21/2023]
Abstract
Fractional flow reserve (FFR) is currently considered as the gold standard for revascularization decision-making in patients with stable coronary artery disease (CAD). The application of computational fluid dynamics to coronary computed tomography (CT) angiography (CCTA) enables calculation of FFR without additional testing, radiation exposure, contrast medium injection, and hyperemia (FFRCT). Although multiple diagnostic and clinical studies have enriched the scientific evidence, it is still challenging to integrate FFRCT into clinical practice. Both meticulous scientific backgrounds and precise anatomical data derived from CCTA are fundamental for FFRCT computation, and there are numerous factors impacting on FFRCT calculation and interpretation: coronary artery stenosis, calcium, atherosclerosis, luminal volume, and left ventricular myocardial mass. Further, there is a gap that clinicians using FFRCT need to recognize in interpretation of FFRCT results between diagnostic studies and clinical studies. In this review, we summarize multiple evidence related to FFRCT computation and interpretation to refine the FFRCT strategy in patients with stable CAD.
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Affiliation(s)
- Hidenobu Takagi
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Miyagi, Japan.
| | - Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Harry Perkins Institute of Medical Research, Curtin University, Perth, Australia
| | - Jonathon A Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
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8
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Budrys P, Baranauskas A, Davidavicius G. Intravascular Ultrasound Guidance Is Associated with a Favorable One-Year Target Vessel Failure Rate and No Residual Myocardial Ischemia after the Percutaneous Treatment of Very Long Coronary Artery Lesions. J Cardiovasc Dev Dis 2022; 9:jcdd9120445. [PMID: 36547442 PMCID: PMC9788518 DOI: 10.3390/jcdd9120445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022] Open
Abstract
Background: Studies have shown that percutaneous coronary intervention (PCI) in long coronary artery lesions (≥30 mm) is associated with more frequent target vessel failure (TVF), and a significant proportion of patients have lesions that continue to induce ischemia after PCI (FFR ≤ 0.8). We investigated the impact of intravascular ultrasound (IVUS) on the functional PCI result and one-year TVF rate after the percutaneous treatment of long coronary artery lesions. Methods: A total of 80 patients underwent IVUS-guided PCI in long coronary artery lesions. The PCI results were validated with IVUS and FFR. Procedural outcomes were the proportion of patients with: (1) optimal physiology result (post PCI FFR value ≥ 0.9); (2) optimal anatomy result (all IVUS PCI optimization criteria met); and (3) optimal physiology and anatomy result. The clinical outcome was TVF during a one-year follow-up (target vessel (TV)-related death, TV myocardial infarction, ischemia-driven TV revascularization). Results: The mean stented segment length was 62 mm. The target vessel (TV) was the left anterior descending artery in 82.5% of cases. There were no patients with residual ischemia (FFR ≤ 0.8) after PCI. Optimal coronary flow (FFR ≥ 0.9) was achieved in 37.5%; optimal anatomy, as assessed by IVUS, was achieved in 68.4%; and both optimal flow and anatomy were achieved in 25% of patients. Target vessel failure during the 12-month follow-up was 2.5%. Conclusions: In the percutaneous treatment of very long coronary artery lesions, the use of IVUS guidance is associated with a low TVF rate during a one-year follow-up and no residual myocardial ischemia, as assessed by FFR.
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Affiliation(s)
- Povilas Budrys
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
- Correspondence:
| | - Arvydas Baranauskas
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
| | - Giedrius Davidavicius
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
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9
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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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10
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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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11
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Tzimas G, Gulsin GS, Takagi H, Mileva N, Sonck J, Muller O, Leipsic JA, Collet C. Coronary CT Angiography to Guide Percutaneous Coronary Intervention. Radiol Cardiothorac Imaging 2022; 4:e210171. [PMID: 35782760 PMCID: PMC8893214 DOI: 10.1148/ryct.210171] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/08/2021] [Accepted: 11/22/2021] [Indexed: 05/03/2023]
Abstract
Coronary CT angiography (CCTA) has emerged as a powerful noninvasive tool for characterizing the presence, extent, and severity of coronary artery disease (CAD) in patients with stable angina. Recent technological advancements in CT scanner hardware and software have augmented the rich information that can be derived from a single CCTA study. Beyond merely identifying the presence of CAD and assessing stenosis severity, CCTA now allows for the identification and characterization of plaques, lesion length, and fluoroscopic angle optimization, as well as enables the assessment of the physiologic extent of stenosis through CT-derived fractional flow reserve, and may even allow for the prediction of the response to revascularization. These and other features make CCTA capable of not only guiding invasive coronary angiography referral, but also give it the unique ability to help plan coronary intervention. This review summarizes current and future applications of CCTA in procedural planning for percutaneous coronary intervention, provides rationale for wider integration of CCTA in the workflow of the interventional cardiologist, and details how CCTA may help improve patient care and clinical outcomes. Keywords: CT Angiography © RSNA, 2022.
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Affiliation(s)
- Georgios Tzimas
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Gaurav S. Gulsin
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Hidenobu Takagi
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Niya Mileva
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Jeroen Sonck
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Olivier Muller
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Jonathon A. Leipsic
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Carlos Collet
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
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12
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Takagi H, Leipsic JA, McNamara N, Martin I, Fairbairn TA, Akasaka T, Nørgaard BL, Berman DS, Chinnaiyan K, Hurwitz-Koweek LM, Pontone G, Kawasaki T, Rønnow Sand NP, Jensen JM, Amano T, Poon M, Øvrehus KA, Sonck J, Rabbat MG, Mullen S, De Bruyne B, Rogers C, Matsuo H, Bax JJ, Douglas PS, Patel MR, Nieman K, Ihdayhid AR. Trans-lesional fractional flow reserve gradient as derived from coronary CT improves patient management: ADVANCE registry. J Cardiovasc Comput Tomogr 2022; 16:19-26. [PMID: 34518113 PMCID: PMC9719736 DOI: 10.1016/j.jcct.2021.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/30/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND The role of change in fractional flow reserve derived from CT (FFRCT) across coronary stenoses (ΔFFRCT) in guiding downstream testing in patients with stable coronary artery disease (CAD) is unknown. OBJECTIVES To investigate the incremental value of ΔFFRCT in predicting early revascularization and improving efficiency of catheter laboratory utilization. MATERIALS Patients with CAD on coronary CT angiography (CCTA) were enrolled in an international multicenter registry. Stenosis severity was assessed as per CAD-Reporting and Data System (CAD-RADS), and lesion-specific FFRCT was measured 2 cm distal to stenosis. ΔFFRCT was manually measured as the difference of FFRCT across visible stenosis. RESULTS Of 4730 patients (66 ± 10 years; 34% female), 42.7% underwent ICA and 24.7% underwent early revascularization. ΔFFRCT remained an independent predictor for early revascularization (odds ratio per 0.05 increase [95% confidence interval], 1.31 [1.26-1.35]; p < 0.001) after adjusting for risk factors, stenosis features, and lesion-specific FFRCT. Among the 3 models (model 1: risk factors + stenosis type and location + CAD-RADS; model 2: model 1 + FFRCT; model 3: model 2 + ΔFFRCT), model 3 improved discrimination compared to model 2 (area under the curve, 0.87 [0.86-0.88] vs 0.85 [0.84-0.86]; p < 0.001), with the greatest incremental value for FFRCT 0.71-0.80. ΔFFRCT of 0.13 was the optimal cut-off as determined by the Youden index. In patients with CAD-RADS ≥3 and lesion-specific FFRCT ≤0.8, a diagnostic strategy incorporating ΔFFRCT >0.13, would potentially reduce ICA by 32.2% (1638-1110, p < 0.001) and improve the revascularization to ICA ratio from 65.2% to 73.1%. CONCLUSIONS ΔFFRCT improves the discrimination of patients who underwent early revascularization compared to a standard diagnostic strategy of CCTA with FFRCT, particularly for those with FFRCT 0.71-0.80. ΔFFRCT has the potential to aid decision-making for ICA referral and improve efficiency of catheter laboratory utilization.
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Affiliation(s)
- Hidenobu Takagi
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada; Department of Radiology, Iwate Medical University Hospital, Iwate, Japan; Department of Diagnostic Radiology, Tohoku University Hospital, Miyagi, Japan
| | - Jonathon A Leipsic
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
| | - Noah McNamara
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Isabella Martin
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Timothy A Fairbairn
- Department of Cardiology, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, UK
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Daniel S Berman
- Division of Nuclear Imaging, Department of Imaging, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Kavitha Chinnaiyan
- Division of Cardiology, Beaumont Academic Heart and Vascular Group, Royal Oak, MI, USA
| | - Lynne M Hurwitz-Koweek
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Niels Peter Rønnow Sand
- Cardiac Research Unit, Institute of Regional Health Research, University Hospital of Southern DK, Esbjerg and University of Southern DK, Denmark
| | - Jesper M Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Michael Poon
- Department of Noninvasive Cardiac Imaging, Northwell Health, New York, NY, USA
| | | | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Mark G Rabbat
- Division of Cardiology, Loyola University Chicago, Chicago, IL, USA
| | | | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Cardiology, University Hospital of Lausanne, Lausanne, CH, USA
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Pamela S Douglas
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Manesh R Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Koen Nieman
- Department of Cardiovascular Medicine and Radiology, Stanford University, Stanford, CA, USA
| | - Abdul Rahman Ihdayhid
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada; Department of Cardiology, Fiona Stanley Hospital, Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Australia
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13
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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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14
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Shin D, Dai N, Lee SH, Choi KH, Lefieux A, Molony D, Hwang D, Kim HK, Jeon KH, Lee HJ, Jang HJ, Ha SJ, Park TK, Yang JH, Song YB, Hahn JY, Choi SH, Doh JH, Shin ES, Nam CW, Koo BK, Gwon HC, Ge J, Lee JM. Physiological Distribution and Local Severity of Coronary Artery Disease and Outcomes After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2021; 14:1771-1785. [PMID: 34412795 DOI: 10.1016/j.jcin.2021.06.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/27/2021] [Accepted: 06/10/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate prognostic implications of physiological 2-dimensional disease patterns on the basis of distribution and local severity of coronary atherosclerosis determined by quantitative flow ratio (QFR) virtual pull back. BACKGROUND The beneficial effect of percutaneous coronary intervention (PCI) is determined by physiological distribution and local severity of coronary atherosclerosis. METHODS The study population included 341 patients who underwent angiographically successful PCI and post-PCI fractional flow reserve (FFR) measurement. Using pre-PCI virtual pull backs of QFR, physiological distribution was determined by pull back pressure gradient index, with a cutoff value of 0.78 to define predominant focal versus diffuse disease. Physiological local severity was assessed by instantaneous QFR gradient per unit length, with a cutoff value of ≥0.025/mm to define a major gradient. Suboptimal post-PCI physiological results were defined as both post-PCI FFR ≤0.85 and percentage FFR increase ≤15%. Clinical outcome was assessed by target vessel failure (TVF) at 2 years. RESULTS QFR pull back pressure gradient index was correlated with post-PCI FFR (R = 0.423; P < 0.001), and instantaneous QFR gradient per unit length was correlated with percentage FFR increase (R = 0.370; P < 0.001). Using the 2 QFR-derived indexes, disease patterns were classified into 4 categories: predominant focal disease with and without major gradient (group 1 [n = 150] and group 2 [n = 21], respectively) and predominant diffuse disease with and without major gradient (group 3 [n = 115] and group 4 [n = 55], respectively). Proportions of suboptimal post-PCI physiological results were significantly different according to the 4 disease patterns (18.7%, 23.8%, 22.6%, and 56.4% from group 1 to group 4, respectively; P < 0.001). Cumulative incidence of TVF after PCI was significantly higher in patients with predominant diffuse disease (8.1% in group 3 and 9.9% in group 4 vs 1.4% in group 1 and 0.0% in group 2; overall P = 0.024). CONCLUSIONS Both physiological distribution and local severity of coronary atherosclerosis could be characterized without pressure-wire pull backs, which determined post-PCI physiological results. After successful PCI, TVF risk was determined mainly by the physiological distribution of coronary atherosclerosis. (Automated Algorithm Detecting Physiologic Major Stenosis and Its Relationship With Post-PCI Clinical Outcomes [Algorithm-PCI], NCT04304677; Influence of FFR on the Clinical Outcome After Percutaneous Coronary Intervention [PERSPECTIVE], NCT01873560).
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Affiliation(s)
- Doosup Shin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Neng Dai
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan 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
| | | | - David Molony
- Emory University School of Medicine and Emory University Hospital, Atlanta, Georgia, USA
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Ki-Hyun Jeon
- Division of Cardiology, Cardiovascular Center, Mediplex Sejong Hospital, Incheon, Korea
| | - Hyun-Jong Lee
- Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea
| | - Ho-Jun Jang
- Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea
| | - Sang Jin Ha
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan Medical Center, Ulsan, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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15
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Collison D, Didagelos M, Aetesam-Ur-Rahman M, Copt S, McDade R, McCartney P, Ford TJ, McClure J, Lindsay M, Shaukat A, Rocchiccioli P, Brogan R, Watkins S, McEntegart M, Good R, Robertson K, O'Boyle P, Davie A, Khan A, Hood S, Eteiba H, Berry C, Oldroyd KG. Post-stenting fractional flow reserve vs coronary angiography for optimisation of percutaneous coronary intervention: TARGET-FFR trial. Eur Heart J 2021; 42:4656-4668. [PMID: 34279606 PMCID: PMC8634564 DOI: 10.1093/eurheartj/ehab449] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/29/2021] [Accepted: 06/28/2021] [Indexed: 11/14/2022] Open
Abstract
Aims A fractional flow reserve (FFR) value ≥0.90 after percutaneous coronary intervention (PCI) is associated with a reduced risk of adverse cardiovascular events. TARGET-FFR is an investigator-initiated, single-centre, randomized controlled trial to determine the feasibility and efficacy of a post-PCI FFR-guided optimization strategy vs. standard coronary angiography in achieving final post-PCI FFR values ≥0.90. Methods and results After angiographically guided PCI, patients were randomized 1:1 to receive a physiology-guided incremental optimization strategy (PIOS) or a blinded coronary physiology assessment (control group). The primary outcome was the proportion of patients with a final post-PCI FFR ≥0.90. Final FFR ≤0.80 was a prioritized secondary outcome. A total of 260 patients were randomized (131 to PIOS, 129 to control) and 68.1% of patients had an initial post-PCI FFR <0.90. In the PIOS group, 30.5% underwent further intervention (stent post-dilation and/or additional stenting). There was no significant difference in the primary endpoint of the proportion of patients with final post-PCI FFR ≥0.90 between groups (PIOS minus control 10%, 95% confidence interval −1.84 to 21.91, P = 0.099). The proportion of patients with a final FFR ≤0.80 was significantly reduced when compared with the angiography-guided control group (−11.2%, 95% confidence interval −21.87 to −0.35], P = 0.045). Conclusion Over two-thirds of patients had a physiologically suboptimal result after angiography-guided PCI. An FFR-guided optimization strategy did not significantly increase the proportion of patients with a final FFR ≥0.90, but did reduce the proportion of patients with a final FFR ≤0.80.
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Affiliation(s)
- Damien Collison
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Matthaios Didagelos
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Muhammad Aetesam-Ur-Rahman
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Samuel Copt
- University of Geneva, 24 rue de Général-Dufour, 1211 Genève 4, Switzerland
| | - Robert McDade
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Peter McCartney
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Thomas J Ford
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - John McClure
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Mitchell Lindsay
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Aadil Shaukat
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Paul Rocchiccioli
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Richard Brogan
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Stuart Watkins
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Margaret McEntegart
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Richard Good
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Keith Robertson
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Patrick O'Boyle
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Andrew Davie
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Adnan Khan
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Stuart Hood
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Hany Eteiba
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Colin Berry
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Keith G Oldroyd
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
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16
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Hakeem A, Hou L, Shah K, Agarwal SK, Almomani A, Edupuganti M, Kasula S, Pothineni NV, Al-Hawwas M, Miller K, Zakir R, Ghosh B, Uretsky BF. Derivation and validation of Pd/Pa in the assessment of residual ischemia post-intervention: A prospective all-comer registry. Catheter Cardiovasc Interv 2021; 99:714-722. [PMID: 34101336 DOI: 10.1002/ccd.29790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/27/2021] [Accepted: 05/13/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Measurement of post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) demonstrates residual ischemia in a large percentage of cases deemed angiographically successful which, in turn, has been associated with worse long-term outcomes. It has recently been shown that a resting pressure index, Pd/Pa, has prognostic value post stenting, however, its diagnostic value relative to FFR post-PCI has not been evaluated. METHODS The diagnostic accuracy of Pd/Pa in identifying ischemia (FFR≤0.80) pre- and post-PCI was evaluated. Three patient subsets were analyzed. A reference pre-PCI cohort of 1,255 patients (1,560 vessels) was used to measure the accuracy of pre-PCI Pd/Pa vs. FFR. A derivation post-PCI group of 574 patient (664 vessels) was then used to calculate the diagnostic accuracy of post-PCI Pd/Pa vs. FFR. A final prospective validation cohort of 230 patients (255 vessels) was used to test and validate the diagnostic performance of post-PCI Pd/Pa. RESULTS Median Pd/Pa and FFR were 0.90 (IQR 0.90-0.98) and 0.80 (IQR 0.71-0.88) in the reference pre-PCI model, 0.96 (IQR 0.93-1.00) and 0.87 (IQR 0.77-0.90) in the post-PCI derivation model, and 0.94 (IQR 0.89-0.97) and 0.84 (IQR 0.77-0.90) in the post-PCI validation model respectively. There was a strong linear correlation between Pd/Pa and FFR in all three models (p < 0.0001). Using ROC analysis, the optimal Pd/Pa cutoff value to predict a FFR ≤ 0.80 was ≤0.92 (AUC 0.87) in the pre-PCI model, ≤0.93 (AUC 0.85) in the post-PCI derivation model, and ≤ 0.90 (AUC 0.91) in the post-PCI validation model. Using a hybrid strategy of post-PCI Pd/Pa and post-PCI FFR when necessary (25% patients), overall diagnostic accuracy was improved to 95%. CONCLUSIONS Pd/Pa has excellent diagnostic accuracy for identifying ischemia post-intervention. Using a hybrid strategy of post-PCI Pd/Pa first, and FFR afterwards, if required, adenosine administration can be avoided in over 75% of physiologic assessments post intervention.
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Affiliation(s)
- Abdul Hakeem
- Department of Cardiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Linle Hou
- Department of Cardiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Kulin Shah
- Department of Cardiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Shiv K Agarwal
- John L McClellan Memorial Veterans Hospital, Central Arkansas VA Healthy System, Little Rock, Arkansas, USA
| | - Ahmed Almomani
- John L McClellan Memorial Veterans Hospital, Central Arkansas VA Healthy System, Little Rock, Arkansas, USA
| | - Mallik Edupuganti
- John L McClellan Memorial Veterans Hospital, Central Arkansas VA Healthy System, Little Rock, Arkansas, USA
| | - Sirkanth Kasula
- John L McClellan Memorial Veterans Hospital, Central Arkansas VA Healthy System, Little Rock, Arkansas, USA
| | - Naga V Pothineni
- John L McClellan Memorial Veterans Hospital, Central Arkansas VA Healthy System, Little Rock, Arkansas, USA
| | - Malek Al-Hawwas
- John L McClellan Memorial Veterans Hospital, Central Arkansas VA Healthy System, Little Rock, Arkansas, USA
| | - Kristin Miller
- John L McClellan Memorial Veterans Hospital, Central Arkansas VA Healthy System, Little Rock, Arkansas, USA
| | - Ramzan Zakir
- Department of Cardiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Bobby Ghosh
- Department of Cardiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Barry F Uretsky
- John L McClellan Memorial Veterans Hospital, Central Arkansas VA Healthy System, Little Rock, Arkansas, USA
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17
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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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18
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Porkhanov VA, Belash SA, Polyakov IS, Barbukhatti KO, Kononenko VB, Kovalenko AL, Sitnik SD. [Simultaneous surgery for concomitant lung cancer and diffuse coronary atherosclerosis]. Khirurgiia (Mosk) 2021:42-49. [PMID: 33710825 DOI: 10.17116/hirurgia202103142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the early outcomes of simultaneous surgeries in patients with concomitant lung cancer and coronary artery disease. MATERIAL AND METHODS We retrospectively reviewed 37 consecutive patients who underwent CABG with adjunct endarterectomy (n=21) or long segmental coronary artery reconstruction (n=25) and lung resection between 2003 and 2019. Mean age was 61.4±6.7 (range 58-71) years. Males prevailed (n=32, 86.4%). Median sternotomy was used in all patients. Myocardial revascularization was followed by on-pump lung resection. The most common procedure was lobectomy (94.6%) of the right upper lobe (83.7%). Lymph node dissection was performed in all patients. RESULTS CPB time was 162±19.3 min, aortic cross-clamping time 71±14.2 min. There was no in-hospital mortality. Incidence of perioperative myocardial infarction was 5.4%. Postoperative complications were atrial fibrillation (n=6, 16.6%), re-exploration for bleeding (n=1, 2.7%), pneumonia (n=2, 5.4%). Mean hospital-stay was 14.4 days (range 11-21). CONCLUSION Simultaneous lung resections and coronary artery reconstruction is a safe and reliable surgical method in patients with diffuse coronary atherosclerosis and lung cancer. The developed system of choice, evaluation and surgical treatment of patients with concomitant cardiopulmonary pathology is fundamental for successful treatment of these difficult patients. We need larger randomized studies for certainty.
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Affiliation(s)
- V A Porkhanov
- Research Institute - Ochapovskiy Regional Clinical Hospital No.1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - S A Belash
- Research Institute - Ochapovskiy Regional Clinical Hospital No.1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - I S Polyakov
- Research Institute - Ochapovskiy Regional Clinical Hospital No.1, Krasnodar, Russia
| | - K O Barbukhatti
- Research Institute - Ochapovskiy Regional Clinical Hospital No.1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - V B Kononenko
- Research Institute - Ochapovskiy Regional Clinical Hospital No.1, Krasnodar, Russia
| | - A L Kovalenko
- Research Institute - Ochapovskiy Regional Clinical Hospital No.1, Krasnodar, Russia
| | - S D Sitnik
- Research Institute - Ochapovskiy Regional Clinical Hospital No.1, Krasnodar, Russia
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19
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Argacha JF, Decamp J, Vandeloo B, Babin D, Lochy S, Van den Bussche K, de Hemptinne Q, Xaplanteris P, Magne J, Segers P, Cosyns B. Guiding Myocardial Revascularization by Algorithmic Interpretation of FFR Pullback Curves: A Proof of Concept Study. Front Cardiovasc Med 2021; 8:623841. [PMID: 33778020 PMCID: PMC7990785 DOI: 10.3389/fcvm.2021.623841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/19/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Coronary artery disease distribution along the vessel is a main determinant of FFR improvement after PCI. Identifying focal from diffuse disease from visual inspections of coronary angiogram (CA) and FFR pullback (FFR-PB) are operator-dependent. Computer science may standardize interpretations of such curves. Methods: A virtual stenting algorithm (VSA) was developed to perform an automated FFR-PB curve analysis. A survey analysis of the evaluations of 39 vessels with intermediate disease on CA and a distal FFR <0.8, rated by 5 interventional cardiologists, was performed. Vessel disease distribution and PCI strategy were successively rated based on CA and distal FFR (CA); CA and FFR-PB curve (CA/FFR-PB); and CA and VSA (CA/VSA). Inter-rater reliability was assessed using Fleiss kappa and an agreement analysis of CA/VSA rating with both algorithmic and human evaluation (operator) was performed. We hypothesize that VSA would increase rater agreement in interpretation of epicardial disease distribution and subsequent evaluation of PCI eligibility. Results: Inter-rater reliability in vessel disease assessment by CA, CA/FFR-PB, and CA/VSA were respectively, 0.32 (95% CI: 0.17-0.47), 0.38 (95% CI: 0.23-0.53), and 0.4 (95% CI: 0.25-0.55). The raters' overall agreement in vessel disease distribution and PCI eligibility was higher with the VSA than with the operator (respectively, 67 vs. 42%, and 80 vs. 70%, both p < 0.05). Compared to CA/FFR-PB, CA/VSA induced more reclassification toward a focal disease (92 vs. 56.2%, p < 0.01) with a trend toward more reclassification as eligible for PCI (70.6 vs. 33%, p = 0.06). Change in PCI strategy did not differ between CA/FFR-PB and CA/VSA (23.6 vs. 28.5%, p = 0.38). Conclusions: VSA is a new program to facilitate and standardize the FFR pullback curves analysis. When expert reviewers integrate VSA data, their assessments are less variable which might help to standardize PCI eligibility and strategy evaluations. Clinical Trial Registration: https://www.clinicaltrials.gov/ct2/show/NCT03824600.
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Affiliation(s)
- Jean-François Argacha
- Department of Cardiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jean Decamp
- Centre for Quantum Technologies, National University of Singapore, Singapore, Singapore
| | - Bert Vandeloo
- Department of Cardiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Danilo Babin
- imec-TELIN-IPI, Ghent University, Ghent, Belgium
| | - Stijn Lochy
- Department of Cardiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Karen Van den Bussche
- Department of Cardiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Quentin de Hemptinne
- Department of Cardiology, Centre Hospitalier Universitaire (CHU) Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Panagiotis Xaplanteris
- Department of Cardiology, Centre Hospitalier Universitaire (CHU) Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Julien Magne
- Department of Cardiology, Dupuytren University Hospital 2, Limoges, France.,INSERM U1094 and IRD, Limoges University, Limoges, France
| | - Patrick Segers
- Department of Electronics and Information Systems, IBiTech-bioMMeda, Ghent University, Ghent, Belgium
| | - Bernard Cosyns
- Department of Cardiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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20
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Diletti R, Masdjedi K, Daemen J, van Zandvoort LJ, Neleman T, Wilschut J, Den Dekker WK, van Bommel RJ, Lemmert M, Kardys I, Cummins P, de Jaegere P, Zijlstra F, Van Mieghem NM. Impact of Poststenting Fractional Flow Reserve on Long-Term Clinical Outcomes: The FFR-SEARCH Study. Circ Cardiovasc Interv 2021; 14:e009681. [PMID: 33685214 PMCID: PMC7982137 DOI: 10.1161/circinterventions.120.009681] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 11/23/2020] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Roberto Diletti
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
| | - Kaneshka Masdjedi
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
| | - Joost Daemen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
| | - Laurens J.C. van Zandvoort
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
| | - Tara Neleman
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
| | - Jeroen Wilschut
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
| | - Wijnand K. Den Dekker
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
| | | | - Miguel Lemmert
- Department of Cardiology, Isala Hospital, Zwolle, the Netherlands (M.L.)
| | - Isabella Kardys
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
| | - Paul Cummins
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
| | - Peter de Jaegere
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
| | - Felix Zijlstra
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
| | - Nicolas M. Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.D., K.M., J.D., L.J.C.v.Z., T.N., J.W., W.K.D.D., I.K., P.C., P.d.J., F.Z., N.M.V.M.)
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21
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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22
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Fractional Flow Reserve following Percutaneous Coronary Intervention. J Interv Cardiol 2020; 2020:7467943. [PMID: 32565755 PMCID: PMC7293753 DOI: 10.1155/2020/7467943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 11/18/2022] Open
Abstract
Fractional flow reserve (FFR) is routinely used to determine lesion severity prior to percutaneous coronary intervention (PCI). However, there is an increasing recognition that FFR may also be useful following PCI to identify mechanisms leading to restenosis and the need for repeat revascularization. Post-PCI FFR is associated with the presence and severity of stent under-expansion and may help identify peri-stent-related complications. FFR pullback may also unmask other functionally significant lesions within the target vessel that were not appreciable on angiography. Recent studies have confirmed the prognostic utility of performing routine post-PCI FFR and suggest possible interventional targets that would improve stent durability. In this review, we detail the theoretical basis underlying post-PCI FFR, provide practical tips to facilitate measurement, and discuss the growing evidence supporting its use.
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23
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Warisawa T, Cook CM, Seligman H, Howard JP, Ahmad Y, Rajkumar C, Doi S, Nakayama M, Tanigaki T, Omori H, Nakajima A, Yamanaka F, Goto S, Yakuta Y, Karube K, Uetani T, Kikuta Y, Shiono Y, Kawase Y, Nishina H, Nakamura S, Escaned J, Akashi YJ, Matsuo H, Davies JE. Per-Vessel Level Analysis of Fractional Flow Reserve and Instantaneous Wave-Free Ratio Discordance - Insights From the AJIP Registry. Circ J 2020; 84:1034-1038. [PMID: 32321880 DOI: 10.1253/circj.cj-19-0785] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The per-vessel level impact of physiological pattern of disease on the discordance between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) has not been clarified.Methods and Results:Using the AJIP registry, vessels with FFR/iFR discordance (133/671 [19.8%]) were analyzed. In the left anterior descending artery (LAD), physiologically diffuse disease, as assessed by pressure-wire pullback, was associated with FFR-/iFR+ (83.3% [40/48]), while physiologically focal disease was associated with FFR+/iFR- (57.4% [31/54]), significantly (P<0.0001). These differences were not significant in non-LAD (P=0.17). CONCLUSIONS The impact of physiological pattern of disease on FFR/iFR discordance is more pronounced in the LAD.
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Affiliation(s)
- Takayuki Warisawa
- Cardiovascular Science, Imperial College London.,Department of Cardiovascular Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital
| | | | | | | | | | | | - Shunichi Doi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Masafumi Nakayama
- Cardiovascular Center, Toda Central General Hospital.,Tokyo Women's Medical University - Waseda University Joint Institution for Advanced Biomedical Sciences
| | - Toru Tanigaki
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Hiroyuki Omori
- Department of Cardiovascular Medicine, Gifu Heart Center
| | | | - Futoshi Yamanaka
- Department of Cardiovascular Medicine, Shonan Kamakura General Hospital
| | - Sonoka Goto
- Cardiovascular Institute, Hospital Clínico San Carlos
| | - Yohei Yakuta
- Department of Cardiology, Kanazawa Cardiovascular Hospital
| | - Kenichi Karube
- Department of Cardiovascular Medicine, Okaya City Hospital
| | - Teruyoshi Uetani
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | - Yuetsu Kikuta
- Division of Cardiology, Fukuyama Cardiovascular Hospital
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | | | - Sunao Nakamura
- Department of Cardiovascular Medicine, New Tokyo Hospital
| | | | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
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24
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Warisawa T, Cook CM, Howard JP, Ahmad Y, Doi S, Nakayama M, Goto S, Yakuta Y, Karube K, Shun-Shin MJ, Petraco R, Sen S, Nijjer S, Al Lamee R, Ishibashi Y, Matsuda H, Escaned J, di Mario C, Francis DP, Akashi YJ, Davies JE. Physiological Pattern of Disease Assessed by Pressure-Wire Pullback Has an Influence on Fractional Flow Reserve/Instantaneous Wave-Free Ratio Discordance. Circ Cardiovasc Interv 2020; 12:e007494. [PMID: 31084237 PMCID: PMC6553990 DOI: 10.1161/circinterventions.118.007494] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [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 Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) disagree on the hemodynamic significance of a coronary lesion in ≈20% of cases. It is unknown whether the physiological pattern of disease is an influencing factor for this. This study assessed whether the physiological pattern of coronary artery disease influences discordance between FFR and iFR measurement. METHODS AND RESULTS Three-hundred and sixty intermediate coronary lesions (345 patients; mean age, 64.4±10.3 years; 76% men) with combined FFR, iFR, and iFR pressure-wire pullback were included for analysis from an international multicenter registry. Cut points for hemodynamic significance were FFR ≤0.80 and iFR ≤0.89, respectively. Lesions were classified into FFR+/iFR+ (n=154; 42.7%), FFR-/iFR+ (n=38; 10.6%), FFR+/iFR- (n=41; 11.4%), and FFR-/iFR- (n=127; 35.3%) groups. The physiological pattern of disease was classified according to the iFR pullback recordings as predominantly physiologically focal (n=171; 47.5%) or predominantly physiologically diffuse (n=189; 52.5%). Median FFR and iFR were 0.80 (interquartile range, 0.75-0.85) and 0.89 (interquartile range, 0.86-0.92), respectively. FFR disagreed with iFR in 22% (79 of 360). The physiological pattern of disease was the only influencing factor relating to FFR/iFR discordance: predominantly physiologically focal was significantly associated with FFR+/iFR- (58.5% [24 of 41]), and predominantly physiologically diffuse was significantly associated with FFR-/iFR+ (81.6% [31 of 38]; P<0.001 for pattern of disease between FFR+/iFR- and FFR-/iFR+ groups). CONCLUSIONS The physiological pattern of coronary artery disease was an important influencing factor for FFR/iFR discordance.
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Affiliation(s)
- Takayuki Warisawa
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.).,Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan (T.W., Y.I., Y.J.A.)
| | - Christopher M Cook
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - James P Howard
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Yousif Ahmad
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Shunichi Doi
- Department of Cardiovascular Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Japan (S.D., H.M.)
| | - Masafumi Nakayama
- Cardiovascular Center, Toda Central General Hospital, Japan (M.N., S.G.).,Tokyo Women's Medical University-Waseda University Joint Institution for Advanced Biomedical Sciences, Japan (M.N.)
| | - Sonoka Goto
- Cardiovascular Center, Toda Central General Hospital, Japan (M.N., S.G.).,Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (S.G., J.E.)
| | - Yohei Yakuta
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Japan (Y.Y.)
| | - Kenichi Karube
- Department of Cardiovascular Medicine, Okaya City Hospital, Japan (K.K.)
| | - Matthew J Shun-Shin
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Ricardo Petraco
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Sayan Sen
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Sukhjinder Nijjer
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Rasha Al Lamee
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Yuki Ishibashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan (T.W., Y.I., Y.J.A.)
| | - Hisao Matsuda
- Department of Cardiovascular Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Japan (S.D., H.M.)
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (S.G., J.E.)
| | - Carlo di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy (C.d.M.)
| | - Darrel P Francis
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan (T.W., Y.I., Y.J.A.)
| | - Justin E Davies
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
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25
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Collison D, McClure JD, Berry C, Oldroyd KG. A randomized controlled trial of a physiology-guided percutaneous coronary intervention optimization strategy: Rationale and design of the TARGET FFR study. Clin Cardiol 2020; 43:414-422. [PMID: 32037592 PMCID: PMC7244297 DOI: 10.1002/clc.23342] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 01/09/2023] Open
Abstract
Post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) ≥0.90 confers an improved cardiac prognosis. There are currently limited data available to determine how often it is possible to improve an angiographically acceptable but physiologically suboptimal result. A physiology-guided optimization strategy can achieve a clinically meaningful increase in the proportion of patients achieving a final post-PCI FFR ≥0.90 compared to standard care. Following angiographically successful PCI procedures, 260 patients will be randomized (1:1) to receive either a physiology-guided incremental optimization strategy (intervention group) or blinded post-PCI coronary physiology measurements (control group). Patients undergoing successful, standard-of-care PCI for either stable angina or non-ST-segment-elevation myocardial infarction who meet the study's inclusion and exclusion criteria will be eligible for randomization. The primary endpoint is defined as the proportion of patients with a final post-PCI FFR result ≥0.90. Secondary endpoints include change from baseline in Seattle Angina Questionnaire and EQ-5D-5L scores at 3 months and the rate of target vessel failure and its components (cardiac death, myocardial infarction, stent thrombosis, unplanned rehospitalization with target vessel revascularization) at 3 months and 1 year. 260 individual patients were successfully randomized between March 2018 and November 2019. Key baseline demographics of the study population are reported within. TARGET FFR is an investigator-initiated, prospective, single-center, randomized controlled trial of an FFR-guided PCI optimization strategy. The study has completed recruitment and is now in clinical follow-up. It is anticipated that primary results will be presented in Autumn 2020. ClinicalTrials.gov Identifier: NCT03259815. [Correction added on Apr 3 2020, after first online publication: Clinical Trials identifier added.].
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Affiliation(s)
- Damien Collison
- West of Scotland Regional Heart and Lung CentreGolden Jubilee National HospitalClydebankUK
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - John D. McClure
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - Colin Berry
- West of Scotland Regional Heart and Lung CentreGolden Jubilee National HospitalClydebankUK
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - Keith G. Oldroyd
- West of Scotland Regional Heart and Lung CentreGolden Jubilee National HospitalClydebankUK
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
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26
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The Clinical Significance of Physiological Assessment of Residual Ischemia After Percutaneous Coronary Intervention. Curr Cardiol Rep 2020; 22:17. [DOI: 10.1007/s11886-020-1269-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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27
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Validation of post-stenting fractional flow reserve with intravascular ultrasound parameters for optimal stent deployment. Int J Cardiovasc Imaging 2019; 36:197-203. [DOI: 10.1007/s10554-019-01712-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/03/2019] [Indexed: 11/26/2022]
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28
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Gosling RC, Morris PD, Lawford PV, Hose DR, Gunn JP. Personalised fractional flow reserve: a novel concept to optimise myocardial revascularisation. EUROINTERVENTION 2019; 15:707-713. [PMID: 30561366 DOI: 10.4244/eij-d-18-00668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIMS Fractional flow reserve (FFR) represents the percentage reduction in coronary flow relative to a hypothetically normal artery; however, percutaneous coronary intervention (PCI) seldom achieves physiological normality (FFR 1.00), particularly in the context of diffuse disease. In this study we describe a method for calculating the vessel-specific maximal achievable FFR (FFRmax) providing a personalised assessment of what PCI can achieve. METHODS AND RESULTS FFR measurements were obtained from 71 patients (100 arteries) undergoing angiography. Three-dimensional (3D) coronary anatomy was reconstructed from angiographic images. An ideal intervention, in which all stenoses are removed, was modelled, and the FFRmax calculated. The "personalised" FFR (FFRpers) was calculated as measured FFR/FFRmax. PCI was performed in 52 vessels and post-PCI FFR measured in 50. FFRmax was compared to post-PCI measured FFRs. The mean FFRmax was 0.92 (±0.04). This was on average 0.04 (±0.05) higher than the corresponding post-PCI measured FFR (p<0.001). FFRpers was significantly higher (0.06±0.04) than measured FFR (p<0.001), indicating that FFR overestimates flow restoration achievable with PCI. CONCLUSIONS A patient's maximal achievable FFR can now be determined prior to PCI. This approach provides a more realistic assessment of the physiological benefit of PCI than is implied by baseline FFR and may prevent unnecessary intervention.
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Affiliation(s)
- Rebecca C Gosling
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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29
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Measurement of Hyperemic Pullback Pressure Gradients to Characterize Patterns of Coronary Atherosclerosis. J Am Coll Cardiol 2019; 74:1772-1784. [DOI: 10.1016/j.jacc.2019.07.072] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/05/2019] [Accepted: 07/21/2019] [Indexed: 11/22/2022]
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30
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Hakeem A, Uretsky BF. Role of Postintervention Fractional Flow Reserve to Improve Procedural and Clinical Outcomes. Circulation 2019; 139:694-706. [DOI: 10.1161/circulationaha.118.035837] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Abdul Hakeem
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ (A.H.)
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31
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Karamasis GV, Kalogeropoulos AS, Mohdnazri SR, Al-Janabi F, Jones R, Jagathesan R, Aggarwal RK, Clesham GJ, Tang KH, Kelly PA, Davies JR, Werner GS, Keeble TR. Serial Fractional Flow Reserve Measurements Post Coronary Chronic Total Occlusion Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2018; 11:e006941. [DOI: 10.1161/circinterventions.118.006941] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Grigoris V. Karamasis
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom (G.V.K., S.R.M., F.A.-J., R. Jones, R. Jagathesan, R.K.A., G.J.C., K.H.T., P.A.K., J.R.D., T.R.K.)
- School of Medicine, Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, United Kingdom (G.V.K., S.R.M., F.A.-J., G.J.C., J.R.D., T.R.K.)
| | | | - Shah R. Mohdnazri
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom (G.V.K., S.R.M., F.A.-J., R. Jones, R. Jagathesan, R.K.A., G.J.C., K.H.T., P.A.K., J.R.D., T.R.K.)
- School of Medicine, Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, United Kingdom (G.V.K., S.R.M., F.A.-J., G.J.C., J.R.D., T.R.K.)
| | - Firas Al-Janabi
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom (G.V.K., S.R.M., F.A.-J., R. Jones, R. Jagathesan, R.K.A., G.J.C., K.H.T., P.A.K., J.R.D., T.R.K.)
- School of Medicine, Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, United Kingdom (G.V.K., S.R.M., F.A.-J., G.J.C., J.R.D., T.R.K.)
| | - Richard Jones
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom (G.V.K., S.R.M., F.A.-J., R. Jones, R. Jagathesan, R.K.A., G.J.C., K.H.T., P.A.K., J.R.D., T.R.K.)
| | - Rohan Jagathesan
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom (G.V.K., S.R.M., F.A.-J., R. Jones, R. Jagathesan, R.K.A., G.J.C., K.H.T., P.A.K., J.R.D., T.R.K.)
| | - Rajesh K. Aggarwal
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom (G.V.K., S.R.M., F.A.-J., R. Jones, R. Jagathesan, R.K.A., G.J.C., K.H.T., P.A.K., J.R.D., T.R.K.)
| | - Gerald J. Clesham
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom (G.V.K., S.R.M., F.A.-J., R. Jones, R. Jagathesan, R.K.A., G.J.C., K.H.T., P.A.K., J.R.D., T.R.K.)
- School of Medicine, Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, United Kingdom (G.V.K., S.R.M., F.A.-J., G.J.C., J.R.D., T.R.K.)
| | - Kare H. Tang
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom (G.V.K., S.R.M., F.A.-J., R. Jones, R. Jagathesan, R.K.A., G.J.C., K.H.T., P.A.K., J.R.D., T.R.K.)
| | - Paul A. Kelly
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom (G.V.K., S.R.M., F.A.-J., R. Jones, R. Jagathesan, R.K.A., G.J.C., K.H.T., P.A.K., J.R.D., T.R.K.)
| | - John R. Davies
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom (G.V.K., S.R.M., F.A.-J., R. Jones, R. Jagathesan, R.K.A., G.J.C., K.H.T., P.A.K., J.R.D., T.R.K.)
- School of Medicine, Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, United Kingdom (G.V.K., S.R.M., F.A.-J., G.J.C., J.R.D., T.R.K.)
| | - Gerald S. Werner
- Medizinische Klinik I (Cardiology & Intensive care), Klinikum Darmstadt GmbH, Darmstadt, Germany (G.S.W.)
| | - Thomas R. Keeble
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, United Kingdom (G.V.K., S.R.M., F.A.-J., R. Jones, R. Jagathesan, R.K.A., G.J.C., K.H.T., P.A.K., J.R.D., T.R.K.)
- School of Medicine, Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, United Kingdom (G.V.K., S.R.M., F.A.-J., G.J.C., J.R.D., T.R.K.)
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