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Abbasciano RG, Layton GR, Torre S, Abbaker N, Copperwheat A, Lucarelli C, Bhandari S, Nijjer S, Mikhail G, Casula R, Zakkar M, Viviano A. Fractional flow reserve and instantaneous wave-free ratio in coronary artery bypass grafting: a meta-analysis and practice review. Front Cardiovasc Med 2024; 11:1348341. [PMID: 38516003 PMCID: PMC10955066 DOI: 10.3389/fcvm.2024.1348341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/20/2024] [Indexed: 03/23/2024] Open
Abstract
Objective Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are invasive methods to assess the functional significance of intermediate severity coronary lesions. Both indexes have been extensively validated in clinical trials in guiding revascularisation in patients with stable ischaemic heart disease undergoing percutaneous coronary intervention (PCI) with improved clinical outcomes. However, the role of these tools in coronary artery bypass grafting (CABG) is less clear. Methods A meta-analysis of randomised trials and observational studies was carried out to help in determining the optimal strategy for assessing lesion severity and selecting graft targets in patients undergoing CABG. Electronic searches were carried out on Embase, MEDLINE, and Web of Science. A group of four authors independently screened and then assessed the retrieved records. Cochrane's Risk of Bias and Robins-I tools were used for bias assessment. A survey was conducted among surgeons and cardiologists to describe current attitudes towards the preoperative use of functional coronary investigations in practice. Results Clinical outcomes including mortality at 30 days, perioperative myocardial infarction, number of grafts, incidence of stroke, rate of further need for revascularisation, and patient-reported quality of life did not differ in CABG guided by functional testing from those guided by traditional angiography.The survey revealed that in half of the surgical and cardiology units functional assessment is performed in CABG patients; there is a general perception that functional testing has improved patient care and its use would clarify the role of moderate coronary lesions that often need multidisciplinary rediscussions; moderate stenosis are felt to be clinically relevant; and anatomical considerations need to be taken into account together with functional assessment. Conclusions At present, the evidence to support the routine use of functional testing in intermediate lesions for planning CABG is currently insufficient. The pooled data currently available do not show an increased risk in mortality, myocardial injury, and stroke in the FFR/iFR-guided group. Further trials with highly selected populations are needed to clarify the best strategy. Systematic Review Registration ClinicalTrials.gov, identifier (CRD42023414604).
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Affiliation(s)
- R. G. Abbasciano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - G. R. Layton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - S. Torre
- Cardiac Surgery Unit, Giaccone Hospital, Palermo, Italy
| | - N. Abbaker
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - A. Copperwheat
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - C. Lucarelli
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - S. Bhandari
- Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - S. Nijjer
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - G. Mikhail
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - R. Casula
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - M. Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - A. Viviano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
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2
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de Winter RW, van Diemen PA, Schumacher SP, Jukema RA, Somsen YBO, Hoek R, van Rossum AC, Twisk JWR, de Waard GA, Nap A, Raijmakers PG, Driessen RS, Knaapen P, Danad I. Hemodynamic Insights into Combined Fractional Flow Reserve and Instantaneous Wave-Free Ratio Assessment Through Quantitative [ 15O]H 2O PET Myocardial Perfusion Imaging. J Nucl Med 2024; 65:279-286. [PMID: 38176722 DOI: 10.2967/jnumed.123.265973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 11/01/2023] [Indexed: 01/06/2024] Open
Abstract
In patients evaluated for obstructive coronary artery disease (CAD), guidelines recommend using either fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) to guide coronary revascularization decision-making. The hemodynamic significance of lesions with discordant FFR and iFR measurements is debated. This study compared [15O]H2O PET-derived absolute myocardial perfusion between vessels with concordant and discordant FFR and iFR measurements. Methods: We included 197 patients suspected of obstructive CAD who had undergone [15O]H2O PET perfusion imaging and combined FFR/iFR interrogation in 468 vessels. Resting myocardial blood flow (MBF), hyperemic MBF, and coronary flow reserve (CFR) were compared among 4 groups: FFR low/iFR low (n = 79), FFR high/iFR low (n = 22), FFR low/iFR high (n = 22), and FFR high/iFR high (n = 345). Predefined [15O]H2O PET thresholds for ischemia were 2.3 mL·min-1·g-1 or less for hyperemic MBF and 2.5 or less for CFR. Results: Hyperemic MBF was lower in the concordant low (2.09 ± 0.67 mL·min-1·g-1), FFR high/iFR low (2.41 ± 0.80 mL·min-1·g-1), and FFR low/iFR high (2.40 ± 0.69 mL·min-1·g-1) groups compared with the concordant high group (2.91 ± 0.84 mL·min-1·g-1) (P < 0.001, P = 0.004, and P < 0.001, respectively). A lower CFR was observed in the concordant low (2.37 ± 0.76) and FFR high/iFR low (2.64 ± 0.84) groups compared with the concordant high group (3.35 ± 1.07, P < 0.01 for both). However, for vessels with either low FFR or low iFR, quantitative hyperemic MBF and CFR values exceeded the ischemic threshold in 38% and 49%, respectively. In addition, resting MBF exhibited a negative correlation with iFR (P < 0.001) and was associated with FFR low/iFR high discordance compared with concordant low FFR/low iFR measurements, independent of clinical and angiographic characteristics, as well as hyperemic MBF (odds ratio [OR], 0.41; 95% CI, 0.26-0.65; P < 0.001). Conclusion: We found reduced myocardial perfusion in vessels with concordant low and discordant FFR/iFR measurements. However, FFR/iFR combinations often inaccurately classified vessels as either ischemic or nonischemic when compared with hyperemic MBF and CFR. Furthermore, a lower resting MBF was associated with a higher iFR and the occurrence of FFR low/iFR high discordance. Our study showed that although combined FFR/iFR assessment can be useful to estimate the hemodynamic significance of coronary lesions, these pressure-derived indices provide a limited approximation of [15O]H2O PET-derived quantitative myocardial perfusion as the physiologic standard of CAD severity.
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Affiliation(s)
- Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yvemarie B O Somsen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roel Hoek
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and
| | - Guus A de Waard
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology, Nuclear Medicine, and PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands;
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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3
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Grines CL, DuPont A. Lesion Selection and Optimizing PCI: Intravascular Hemodynamics, Imaging, or Both? J Am Coll Cardiol 2023; 82:2177-2178. [PMID: 38030346 DOI: 10.1016/j.jacc.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Cindy L Grines
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia, USA.
| | - Allison DuPont
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia, USA
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4
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Kuno T, Kiyohara Y, Maehara A, Ueyama HA, Kampaktsis PN, Takagi H, Mehran R, Stone GW, Bhatt DL, Mintz GS, Bangalore S. Comparison of Intravascular Imaging, Functional, or Angiographically Guided Coronary Intervention. J Am Coll Cardiol 2023; 82:2167-2176. [PMID: 37995152 DOI: 10.1016/j.jacc.2023.09.823] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND In patients undergoing percutaneous coronary intervention (PCI), it remains unclear whether intravascular imaging guidance or functional guidance is the best strategy to optimize outcomes and if the results are different in patients with vs without acute coronary syndromes (ACS). OBJECTIVES The purpose of this study was to evaluate clinical outcomes with imaging-guided PCI or functionally guided PCI when compared with conventional angiography-guided PCI. METHODS We searched PUBMED and EMBASE for randomized controlled trials investigating outcomes with intravascular imaging-guided, functionally guided, or angiography-guided PCI. The primary outcome from this network meta-analysis was trial-defined major adverse cardiovascular event (MACE)-a composite of cardiovascular death, myocardial infarction (MI), and target lesion revascularization (TLR). PCI strategies were ranked (best to worst) using P scores. RESULTS Our search identified 32 eligible randomized controlled trials and included a total of 22,684 patients. Compared with angiography-guided PCI, intravascular imaging-guided PCI was associated with reduced risk of MACE (relative risk [RR]: 0.72; 95% CI: 0.62-0.82), cardiovascular death (RR: 0.56; 95% CI: 0.42-0.75), MI (RR: 0.81; 95% CI: 0.66-0.99), stent thrombosis (RR: 0.48; 95% CI: 0.31-0.73), and TLR (RR: 0.75; 95% CI: 0.57-0.99). Similarly, when compared with angiography-guided PCI, functionally guided PCI was associated with reduced risk of MACE and MI. Intravascular imaging-guided PCI ranked first for the outcomes of MACE, cardiovascular death, stent thrombosis, and TLR. The results were consistent in the ACS and non-ACS cohorts. CONCLUSIONS Angiography-guided PCI had consistently worse outcomes compared with intravascular imaging-guided and functionally guided PCI. Intravascular imaging-guided PCI was the best strategy to reduce the risk of cardiovascular events.
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Affiliation(s)
- Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA; Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA.
| | - Yuko Kiyohara
- Department of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Akiko Maehara
- Cardiovascular Research Foundation, New York, New York, USA; Division of Cardiology, Department of Medicine, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Hiroki A Ueyama
- Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Polydoros N Kampaktsis
- Division of Cardiology, Department of Medicine, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Gary S Mintz
- Cardiovascular Research Foundation, New York, New York, USA
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University Grossman School of Medicine, New York, New York, USA.
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5
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Zasada W, Zdzierak B, Rakowski T, Bobrowska B, Krawczyk-Ożóg A, Surowiec S, Bartuś S, Surdacki A, Dziewierz A. The Impact of Age on the Physiological Assessment of Borderline Coronary Stenoses. Medicina (Kaunas) 2023; 59:1863. [PMID: 37893581 PMCID: PMC10608417 DOI: 10.3390/medicina59101863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/29/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: Coronary angiography is the gold standard for diagnosing coronary artery disease (CAD). In the case of borderline changes, patients require further diagnosis through ischemia assessment via one of the recommended methods of invasive evaluation. This study aimed to assess whether clinical factors influence the risk of a positive result in invasive myocardial ischemia assessment and if these potential factors change with the patient's age and the consistency of ischemia assessment. Materials and Methods: Data were collected retrospectively on all consecutive patients hospitalized in the University Hospital in Krakow between 2020 and 2021, on whom physiological assessments of coronary circulation were performed. Patients were divided into two groups: patients aged 60 or younger and patients older than 60. Results: Despite the older patients having more risk factors for CAD, their physiological assessment results of borderline lesions were similar to those of the younger patients. Positive fractional flow reserve (FFR) assessments were obtained from almost 50% of vessels. In the younger patients, cigarette use and type 2 diabetes mellitus increased the risk of a positive FFR result by 3.5 and 2.5 times, respectively. In the older patients, male gender and peripheral vascular disease significantly increased the risk of a positive FFR by 2.5 and 2 times, respectively. Conclusions: Clinical characteristics of patients undergoing physiological assessment of borderline coronary stenosis varied significantly by age. Refining the definition of borderline lesions to include age, gender, and other factors may improve the identification of patients who would benefit from physiological assessment and coronary revascularization.
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Affiliation(s)
- Wojciech Zasada
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (W.Z.); (T.R.)
- KCRI, 30-347 Krakow, Poland
| | - Barbara Zdzierak
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (W.Z.); (T.R.)
| | - Tomasz Rakowski
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (W.Z.); (T.R.)
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Beata Bobrowska
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (W.Z.); (T.R.)
| | - Agata Krawczyk-Ożóg
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (W.Z.); (T.R.)
- Department of Anatomy, HEART-Heart Embryology and Anatomy Research Team, Jagiellonian University Medical College, 31-034 Krakow, Poland
| | - Sławomir Surowiec
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (W.Z.); (T.R.)
| | - Stanisław Bartuś
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (W.Z.); (T.R.)
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Andrzej Surdacki
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (W.Z.); (T.R.)
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Artur Dziewierz
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (W.Z.); (T.R.)
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
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6
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Aleksandric S, Tesic M, Orlic D. Editorial: Challenges in the contemporary assessment of coronary physiology. Front Cardiovasc Med 2023; 10:1305913. [PMID: 37900567 PMCID: PMC10602796 DOI: 10.3389/fcvm.2023.1305913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 10/31/2023] Open
Affiliation(s)
- Srdjan Aleksandric
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milorad Tesic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dejan Orlic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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7
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Starczyński M, Dudek S, Baruś P, Niedzieska E, Wawrzeńczyk M, Ochijewicz D, Piasecki A, Gumiężna K, Milewski K, Grabowski M, Kochman J, Tomaniak M. Intravascular Imaging versus Physiological Assessment versus Biomechanics-Which Is a Better Guide for Coronary Revascularization. Diagnostics (Basel) 2023; 13:2117. [PMID: 37371012 DOI: 10.3390/diagnostics13122117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 10/23/2022] [Accepted: 10/26/2022] [Indexed: 06/29/2023] Open
Abstract
Today, coronary artery disease (CAD) continues to be a prominent cause of death worldwide. A reliable assessment of coronary stenosis represents a prerequisite for the appropriate management of CAD. Nevertheless, there are still major challenges pertaining to some limitations of current imaging and functional diagnostic modalities. The present review summarizes the current data on invasive functional and intracoronary imaging assessment using optical coherence tomography (OCT), and intravascular ultrasound (IVUS). Amongst the functional parameters-on top of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR)-we point to novel angiography-based measures such as quantitative flow ratio (QFR), vessel fractional flow reserve (vFFR), angiography-derived fractional flow reserve (FFRangio), and computed tomography-derived flow fractional reserve (FFR-CT), as well as hybrid approaches focusing on optical flow ratio (OFR), computational fluid dynamics and attempts to quantify the forces exaggerated by blood on the coronary plaque and vessel wall.
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Affiliation(s)
- Miłosz Starczyński
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Stanisław Dudek
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Piotr Baruś
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Emilia Niedzieska
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Mateusz Wawrzeńczyk
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Dorota Ochijewicz
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Adam Piasecki
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Karolina Gumiężna
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Krzysztof Milewski
- Center for Cardiovascular Research and Development, American Heart of Poland, 43-316 Bielsko-Biała, Poland
| | - Marcin Grabowski
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Janusz Kochman
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
| | - Mariusz Tomaniak
- First Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097 Warsaw, Poland
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8
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Warisawa T, Cook CM, Ahmad Y, Howard JP, Seligman H, Rajkumar C, Toya T, Doi S, Nakajima A, Nakayama M, Vera-Urquiza R, Yuasa S, Sato T, Kikuta Y, Kawase Y, Nishina H, Al-Lamee R, Sen S, Lerman A, Matsuo H, Akashi YJ, Escaned J, Davies JE. Deferred Versus Performed Revascularization for Left Main Coronary Disease With Hemodynamic Significance. Circ Cardiovasc Interv 2023; 16:e012700. [PMID: 37339234 DOI: 10.1161/circinterventions.122.012700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 03/24/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The majority of randomized controlled trials of revascularization decision-making excludes left main coronary artery disease (LMD). Therefore, contemporary clinical outcomes of patients with stable coronary artery disease and LMD with proven ischemia remain poorly understood. The aim of this study was to assess the long-term clinical outcomes of physiologically significant LMD according to the treatment strategies of revascularization versus revascularization deferral. METHODS In this international multicenter registry of stable LMD interrogated with the instantaneous wave-free ratio, patients with physiologically significant ischemia (instantaneous wave-free ratio ≤0.89) were analyzed according to the coronary revascularization (n=151) versus revascularization deferral (n=74). Propensity score matching was performed to adjust for baseline clinical characteristics. The primary end point was a composite of death, nonfatal myocardial infarction, and ischemia-driven target lesion revascularization of left main stem. The secondary end points were as follows: cardiac death or spontaneous LMD-related myocardial infarction; and ischemia-driven target lesion revascularization of left main stem. RESULTS At a median follow-up period of 2.8 years, the primary end point occurred in 11 patients (14.9%) in the revascularized group and 21 patients (28.4%) in the deferred group (hazard ratio, 0.42 [95% CI, 0.20-0.89]; P=0.023). For the secondary end points, cardiac death or LMD-related myocardial infarction occurred significantly less frequently in the revascularized group (0.0% versus 8.1%; P=0.004). The rate of ischemia-driven target lesion revascularization of left main stem was also significantly lower in the revascularized group (5.4% versus 17.6%; hazard ratio, 0.20 [95% CI, 0.056-0.70]; P=0.012). CONCLUSIONS In patients who underwent revascularization for stable coronary artery disease and physiologically significant LMD determined by instantaneous wave-free ratio, the long-term clinical outcomes were significantly improved as compared with those in whom revascularization was deferred.
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Affiliation(s)
- Takayuki Warisawa
- Division of Cardiology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Japan (T.W., S.D., Y.J.A.)
- Department of Cardiology, NTT Medical Center Tokyo, Japan (T.W.)
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
| | - Christopher M Cook
- The Essex Cardiothroacic Centre, UK (C.M.K.)
- Anglia Ruskin University, Essex, UK (C.M.K.)
| | - Yousif Ahmad
- Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (Y.A.)
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK (J.P.H., H.S., C.R., R.A.-L., S.S.)
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK (J.P.H., H.S., C.R., R.A.-L., S.S.)
| | - Christopher Rajkumar
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK (J.P.H., H.S., C.R., R.A.-L., S.S.)
| | - Takumi Toya
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan (T.T.)
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (T.T., A.L.)
| | - Shunichi Doi
- Division of Cardiology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Japan (T.W., S.D., Y.J.A.)
| | - Akihiro Nakajima
- Department of Cardiovascular Medicine, New Tokyo Hospital, Matsudo, Japan (A.N.)
| | - Masafumi Nakayama
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (M.N., Y.K., H.M.)
- Cardiovascular Center, Toda Central General Hospital, Japan (M.N.)
| | - Rafael Vera-Urquiza
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Spain (R.V.-U., S.Y., J.E.)
| | - Sonoka Yuasa
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Spain (R.V.-U., S.Y., J.E.)
| | - Takao Sato
- Department of Cardiology, Tachikawa General Hospital, Nagaoka, Japan (T.S.)
| | - Yuetsu Kikuta
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (M.N., Y.K., H.M.)
- Division of Cardiology, Fukuyama Cardiovascular Hospital, Japan (Y.K.)
| | | | - Hidetaka Nishina
- Department of Cardiology, Tsukuba Medical Center Hospital, Japan (H.N.)
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK (J.P.H., H.S., C.R., R.A.-L., S.S.)
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK (J.P.H., H.S., C.R., R.A.-L., S.S.)
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (T.T., A.L.)
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (M.N., Y.K., H.M.)
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Japan (T.W., S.D., Y.J.A.)
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Spain (R.V.-U., S.Y., J.E.)
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9
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Stader J, Antoniadis M, Ussat M, Wachter R, Lavall D, Metze M, Neef M, Spies C, Laufs U, Lenk K. Comparison of quantitative flow ratio with instantaneous wave-free ratio and resting full-cycle ratio during daily routine in the catheterization laboratory. Catheter Cardiovasc Interv 2023. [PMID: 37194726 DOI: 10.1002/ccd.30690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/09/2023] [Accepted: 04/28/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Quantitative flow ratio (QFR) is a novel, software-based method to evaluate the physiology of coronary lesions. The aim of this study was to compare QFR with the established invasive measurements of coronary blood flow using instantaneous wave-free ratio (iFR) or resting full-cycle ratio (RFR) in daily cathlab routine. METHODS 102 patients with stable coronary artery disease and a coronary stenosis of 40%-90% were simultaneously assessed with QFR and iFR or RFR. QFR-computation was performed by two certified experts using the appropriate software (QAngio XA 3D 3.2). RESULTS QFR showed a significant correlation (r = 0.75, p < 0.001) to iFR and RFR. The area under the receiver curve for all measurements was 0.93 (95% confidence interval, 0.87-0.98) for QFR compared to iFR or RFR. QFR based assessment required less time with a median of 501 s (IQR 421-659 s) compared to iFR or RFR which required a median of 734 s to obtain the result (IQR 512-967 s; p < 0.001). The median use of contrast medium was similar with 21 mL (IQR 16-30 mL) for the QFR-based and 22 mL (IQR 15-35 mL) for the iFR- or RFR-based diagnostic. QFR diagnostic required less radiation. The median dose area product for QFR was 307cGycm2 (IQR 151-429 cGycm2 ) compared to 599 cGycm2 (IQR 345-1082 cGycm2 ) for iFR or RFR, p < 0.001. CONCLUSION QFR measurements of coronary artery blood flow correlate with iFR or RFR measurements and are associated with shorter procedure times and reduced radiation dose.
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Affiliation(s)
- Jannis Stader
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Marios Antoniadis
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Matti Ussat
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Daniel Lavall
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Michael Metze
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Martin Neef
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Christian Spies
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Karsten Lenk
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
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10
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Zdzierak B, Zasada W, Krawczyk-Ożóg A, Rakowski T, Bartuś S, Surdacki A, Dziewierz A. Comparison of Fractional Flow Reserve with Resting Non-Hyperemic Indices in Patients with Coronary Artery Disease. J Cardiovasc Dev Dis 2023; 10:jcdd10020034. [PMID: 36826530 PMCID: PMC9959762 DOI: 10.3390/jcdd10020034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/14/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
Guidelines recommend using hyperemic (FFR) and non-hyperemic (iFR/RFR) methods of evaluating coronary artery stenoses in patients with coronary artery disease. However, in some cases, achieved results indicating significant ischemia may differ between those methods. Thus, we sought to identify predictors of such a discrepancy. Data were collected on all consecutive patients with chronic coronary syndrome hospitalized between 2020 and 2021. For 279 patients (417 vessels), results for both FFR and iFR/RFR were available. Values of ≤0.80 for FFR and ≤0.89 for iFR/RFR were considered positive for ischemia. Discordant measurements of FFR and iFR/RFR were observed in 80 (19.2%) patients. Atrial fibrillation was the only predictor of the overall FFR and iFR/RFR discordance - OR (95%CI) 1.90 (1.02-3.51); p = 0.040. The chance of positive FFR and negative iFR/RFR decreased independently with age - OR (95%CI) 0.96 (0.93-0.99); p = 0.024. On the contrary, insulin-treated diabetes mellitus was the predictor of negative FFR and positive iFR/RFR discrepancy - OR (95%CI) 4.61 (1.38-15.40); p = 0.013. In everyday clinical practice, iFR/FFR correlates well with FFR. However, discordance between these methods is quite common. Physicians should be aware of the risk of such discordance in patients with atrial fibrillation, advanced age, and insulin-treated diabetes mellitus.
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Affiliation(s)
- Barbara Zdzierak
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
| | - Wojciech Zasada
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- KCRI, 30-347 Krakow, Poland
| | - Agata Krawczyk-Ożóg
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- Department of Anatomy, HEART-Heart Embryology and Anatomy Research Team, Jagiellonian University Medical College, 33-332 Krakow, Poland
| | - Tomasz Rakowski
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Stanisław Bartuś
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Andrzej Surdacki
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Artur Dziewierz
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
- Correspondence: ; Tel.: +48-12-400-2250
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11
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Davies JE. iFR-SWEDEHEART: Answering the Questions of a Decade of Scientific Debate About iFR and FFR. J Am Coll Cardiol 2022; 79:975-976. [PMID: 35272802 DOI: 10.1016/j.jacc.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/03/2022] [Indexed: 01/10/2023]
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12
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Götberg M, Berntorp K, Rylance R, Christiansen EH, Yndigegn T, Gudmundsdottir IJ, Koul S, Sandhall L, Danielewicz M, Jakobsen L, Olsson SE, Olsson H, Omerovic E, Calais F, Lindroos P, Maeng M, Venetsanos D, James SK, Kåregren A, Carlsson J, Jensen J, Karlsson AC, Erlinge D, Fröbert O. 5-Year Outcomes of PCI Guided by Measurement of Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve. J Am Coll Cardiol 2022; 79:965-74. [PMID: 35272801 DOI: 10.1016/j.jacc.2021.12.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Instantaneous wave-free ratio (iFR) is a coronary physiology index used to assess the severity of coronary artery stenosis to guide revascularization. iFR has previously demonstrated noninferior short-term outcome compared to fractional flow reserve (FFR), but data on longer-term outcome have been lacking. OBJECTIVES The purpose of this study was to investigate the prespecified 5-year follow-up of the primary composite outcome of all-cause mortality, myocardial infarction, and unplanned revascularization of the iFR-SWEDEHEART trial comparing iFR vs FFR in patients with chronic and acute coronary syndromes. METHODS iFR-SWEDEHEART was a multicenter, controlled, open-label, registry-based randomized clinical trial using the Swedish Coronary Angiography and Angioplasty Registry for enrollment. A total of 2,037 patients were randomized to undergo revascularization guided by iFR or FFR. RESULTS No patients were lost to follow-up. At 5 years, the rate of the primary composite endpoint was 21.5% in the iFR group and 19.9% in the FFR group (HR: 1.09; 95% CI: 0.90-1.33). The rates of all-cause death (9.4% vs 7.9%; HR: 1.20; 95% CI: 0.89-1.62), nonfatal myocardial infarction (5.7% vs 5.8%; HR: 1.00; 95% CI: 0.70-1.44), and unplanned revascularization (11.6% vs 11.3%; HR: 1.02; 95% CI: 0.79-1.32) were also not different between the 2 groups. The outcomes were consistent across prespecified subgroups. CONCLUSIONS In patients with chronic or acute coronary syndromes, an iFR-guided revascularization strategy was associated with no difference in the 5-year composite outcome of death, myocardial infarction, and unplanned revascularization compared with an FFR-guided revascularization strategy. (Evaluation of iFR vs FFR in Stable Angina or Acute Coronary Syndrome [iFR SWEDEHEART]; NCT02166736).
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13
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Patel MR, Jeremias A, Maehara A, Matsumura M, Zhang Z, Schneider J, Tang K, Talwar S, Marques K, Shammas NW, Gruberg L, Seto A, Samady H, Sharp ASP, Ali ZA, Mintz G, Davies J, Stone GW. 1-Year Outcomes of Blinded Physiological Assessment of Residual Ischemia After Successful PCI: DEFINE PCI Trial. JACC Cardiovasc Interv 2022; 15:52-61. [PMID: 34991824 DOI: 10.1016/j.jcin.2021.09.042] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to identify the post-percutaneous coronary intervention (PCI) target value of instantaneous wave-free ratio (iFR) that would best discriminate clinical events at 1 year in the DEFINE PCI (Physiologic Assessment of Coronary Stenosis Following PCI) study. BACKGROUND The impact of residual ischemia detected by iFR post-PCI on clinical and symptom-related outcomes is unknown. METHODS Blinded iFR pull back was performed after successful stent implantation in 500 patients. The primary endpoint was the rate of residual ischemia, defined as iFR ≤0.89, after operator-assessed angiographically successful PCI. Secondary endpoints included clinical events at 1 year and change in Seattle Angina Questionnaire angina frequency (SAQ-AF) score during follow-up. RESULTS As reported, 24.0% of patients had residual ischemia (iFR ≤0.89) after successful PCI, with 81.6% of cases attributable to angiographically inapparent focal lesions. Post-PCI iFR ≥0.95 (present in 182 cases [39%]) was associated with a significant reduction in the composite of cardiac death, spontaneous myocardial infarction, or clinically driven target vessel revascularization compared with post-PCI iFR <0.95 (1.8% vs 5.7%; P = 0.04). Baseline SAQ-AF score was 73.3 ± 22.8. For highly symptomatic patients (baseline SAQ-AF score ≤60), SAQ-AF score increased by ≥10 points more frequently in patients with versus without post-PCI iFR ≥0.95 (100.0% vs 88.5%; P = 0.01). CONCLUSIONS In DEFINE PCI, despite angiographically successful PCI, highly symptomatic patients at baseline without residual ischemia by post-PCI iFR had greater reductions in anginal symptoms at 1 year compared with patients with residual ischemia. Achieving post-PCI iFR ≥0.95 was also associated with improved 1-year event-free survival. (Physiologic Assessment of Coronary Stenosis Following PCI [DEFINE PCI]; NCT03084367).
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Affiliation(s)
- Manesh R Patel
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.
| | - Allen Jeremias
- St. Francis Hospital, Roslyn, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Akiko Maehara
- Cardiovascular Research Foundation, New York, New York, USA; Columbia University Medical Center, New York, New York, USA
| | - Mitsuaki Matsumura
- Cardiovascular Research Foundation, New York, New York, USA; Columbia University Medical Center, New York, New York, USA
| | - Zixuan Zhang
- Cardiovascular Research Foundation, New York, New York, USA; Columbia University Medical Center, New York, New York, USA
| | - Joel Schneider
- North Carolina Heart and Vascular, Raleigh, North Carolina, USA
| | - Kare Tang
- Essex Cardiothoracic Centre, Basildon, United Kingdom
| | - Suneel Talwar
- Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - Koen Marques
- VU University Medical Center, Amsterdam, the Netherlands
| | | | | | - Arnold Seto
- Veterans Affairs Medical Center of Long Beach, Long Beach, California, USA
| | - Habib Samady
- Emory University Hospital, Atlanta, Georgia, USA
| | - Andrew S P Sharp
- University Hospital of Wales, Cardiff, United Kingdom; University of Exeter, Exeter, United Kingdom
| | - Ziad A Ali
- St. Francis Hospital, Roslyn, New York, USA; Cardiovascular Research Foundation, New York, New York, USA; Columbia University Medical Center, New York, New York, USA
| | - Gary Mintz
- Cardiovascular Research Foundation, New York, New York, USA; Columbia University Medical Center, New York, New York, USA
| | | | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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14
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Hidalgo F, Gonzalez-Manzanares R, Ojeda S, Benito-González T, Gutiérrez-Barrios A, De la Torre Hernández JM, Minguito-Carazo C, Izaga-Torralba E, Cabrera-Rubio I, Flores-Vergara G, de Lezo JS, Romero-Moreno M, de Prado AP, Pan M. Instantaneous wave-free ratio for guiding treatment of nonculprit lesions in patients with acute coronary syndrome: A retrospective study. Catheter Cardiovasc Interv 2021; 99:489-496. [PMID: 34862839 DOI: 10.1002/ccd.30025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/25/2021] [Accepted: 11/17/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND The aim of this study was to analyze the feasibility of a physiological coronary evaluation with the instantaneous wave-free ratio (iFR) of nonculprit lesions in patients with acute coronary syndrome (ACS) successfully revascularized. METHODS A multicenter registry including patients of four high-volume PCI centers with ACS and underwent successful revascularization of the culprit vessel and had other nonculprit lesions that were physiologically evaluated with the iFR between January 2017 and December 2019. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction, probable or definitive stent thrombosis and new revascularization (MACEs). RESULTS A total of 356 patients with 472 nonculprit lesions were included. The mean age was 66 ± 11 years. The clinical presentation was ACS without persistent ST-segment elevation (NSTE-ACS) in 235 patients (66%) and ST-segment elevation myocardial infarction (STEMI) in 121 patients (34%). After a median follow-up period of 21 (14-30) months, the primary endpoint occurred in 32 patients (9%). There were no differences in outcomes regarding clinical presentation (NSTEMI vs. NSTE-ACS, 9.1 vs. 8.9%, padj = 0.570) or iFR induced treatment strategy (patients with all lesions revascularized vs. patients with at least one lesion with an iFR > 0.89 deferred for revascularization, 10.5 vs. 8.4%, padj = 0.476). CONCLUSIONS The use of the iFR to guide percutaneous coronary intervention decision making in nonculprit lesions seems to be feasible, with an acceptable percentage of MACEs at the mid-term follow-up. Patients with deferred revascularization of lesions without physiological significance and patients undergoing complete revascularization had a similar risk of MACEs.
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Affiliation(s)
- Francisco Hidalgo
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Rafael Gonzalez-Manzanares
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Soledad Ojeda
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Tomás Benito-González
- Interventional Cardiology Unit, Department of Cardiology, University Hospital of León, León, Spain
| | | | | | - Carlos Minguito-Carazo
- Interventional Cardiology Unit, Department of Cardiology, University Hospital of León, León, Spain
| | | | - Indira Cabrera-Rubio
- Department of Cardiology, IDIVAL, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Guisela Flores-Vergara
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Javier Suárez de Lezo
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Miguel Romero-Moreno
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Armando Pérez de Prado
- Interventional Cardiology Unit, Department of Cardiology, University Hospital of León, León, Spain
| | - Manuel Pan
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
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15
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Winkler MA, Patel R, Fu W, Arora V, Weintraub NL. Three Technologies That Will Guide Revascularization of Chronic Coronary Syndrome Patients into the 21st Century: A Review. Int J Angiol 2021; 30:212-220. [PMID: 34776821 DOI: 10.1055/s-0041-1735201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Although medical therapy is the preferred first-line treatment for patients with chronic coronary syndrome (CCS), revascularization remains an important consideration. We present a review that identifies the three diagnostic technologies most important to guiding the decision to revascularize patients with CCS: (1) cardiac computed tomography, (2) intracoronary imaging, and (3) lesion-specific physiological guidance.
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Affiliation(s)
- Michael A Winkler
- Department of Radiology, Medical College of Georgia at Augusta University, Augusta, Georgia.,Department of Internal Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia
| | - Ripa Patel
- Department of Internal Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia
| | - Weibo Fu
- Department of Radiology, Medical College of Georgia at Augusta University, Augusta, Georgia
| | - Vishal Arora
- Department of Internal Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia
| | - Neal L Weintraub
- Department of Internal Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia.,Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, Georgia
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16
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Biscaglia S, Uretsky B, Barbato E, Collet C, Onuma Y, Jeremias A, Tebaldi M, Hakeem A, Kogame N, Sonck J, Escaned J, Serruys PW, Stone GW, Campo G. Invasive Coronary Physiology After Stent Implantation: Another Step Toward Precision Medicine. JACC Cardiovasc Interv 2021; 14:237-46. [PMID: 33541534 DOI: 10.1016/j.jcin.2020.10.055] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/15/2020] [Accepted: 10/13/2020] [Indexed: 01/10/2023]
Abstract
Intracoronary physiology is routinely used in setting the indication for percutaneous coronary intervention (PCI) but seldom in assessing procedural results. This attitude is increasingly challenged by accumulated evidence demonstrating the value of post-PCI functional assessment in predicting long-term patient outcomes. Besides fractional flow reserve, a number of new indexes recently incorporated to clinical practice, including nonhyperemic pressure and functional angiographic indexes, provide new opportunities for the physiological assessment of PCI results. Largely, the benefit of these tools is derived from longitudinal analysis of the treated vessel, which allows precise identification of the vessel segment accounting for a suboptimal functional result and enabling operators to perform accurate PCI optimization. In this document the authors review available evidence supporting why physiological assessment should be extended to immediate post-PCI with the aim of improving patient outcomes. A step-by-step guide on how available physiological tools can be used for such purpose is provided.
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17
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El Hajj SC, Toya T, Warisawa T, Nan J, Lewis BR, Cook CM, Rajkumar C, Howard JP, Seligman H, Ahmad Y, Doi S, Nakajima A, Nakayama M, Goto S, Vera-Urquiza R, Sato T, Kikuta Y, Kawase Y, Nishina H, Nakamura S, Matsuo H, Escaned J, Akashi YJ, Davies JE, Lerman A. Correlation of Intravascular Ultrasound and Instantaneous Wave-Free Ratio in Patients With Intermediate Left Main Coronary Artery Disease. Circ Cardiovasc Interv 2021; 14:e009830. [PMID: 34092096 DOI: 10.1161/circinterventions.120.009830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Stephanie C El Hajj
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.C.H., T.T., J.N., A.L.)
| | - Takumi Toya
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.C.H., T.T., J.N., A.L.).,Division of Cardiology, National Defense Medical College, Tokorozawa, Japan (T.T.)
| | - Takayuki Warisawa
- National Heart and Lung Institute, Imperial College London (T.W., C.M.C., C.R., J.P.H., H.S., Y.A., Y. Kikuta, J.E.D.).,Department of Cardiovascular Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Japan (T.W.)
| | - John Nan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.C.H., T.T., J.N., A.L.)
| | - Bradley R Lewis
- Department of Biomedical Statistics and Informatics, Mao Clinic, Rochester, MN (B.R.L.)
| | - Christopher M Cook
- National Heart and Lung Institute, Imperial College London (T.W., C.M.C., C.R., J.P.H., H.S., Y.A., Y. Kikuta, J.E.D.)
| | - Christopher Rajkumar
- National Heart and Lung Institute, Imperial College London (T.W., C.M.C., C.R., J.P.H., H.S., Y.A., Y. Kikuta, J.E.D.)
| | - James P Howard
- National Heart and Lung Institute, Imperial College London (T.W., C.M.C., C.R., J.P.H., H.S., Y.A., Y. Kikuta, J.E.D.)
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London (T.W., C.M.C., C.R., J.P.H., H.S., Y.A., Y. Kikuta, J.E.D.)
| | - Yousif Ahmad
- National Heart and Lung Institute, Imperial College London (T.W., C.M.C., C.R., J.P.H., H.S., Y.A., Y. Kikuta, J.E.D.)
| | - Shunichi Doi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan (S.D.)
| | - Akihiro Nakajima
- Department of Cardiovascular Medicine, New Tokyo Hospital, Matsudo, Japan (A.N., S.N.)
| | - Masafumi Nakayama
- Cardiovascular Centre, Toda Central General Hospital, Japan (M.N.).,Tokyo Women's Medical University - Waseda University Joint Institution for Advanced Biomedical Sciences, Japan (M.N.)
| | - Sonoka Goto
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Spain (S.G., R.V.-U., J.E.).,Department of Cardiology, Tachikawa General Hospital, Nagaoka, Japan (S.G., T.S., Y. Kawase)
| | - Rafael Vera-Urquiza
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Spain (S.G., R.V.-U., J.E.)
| | - Takao Sato
- Department of Cardiology, Tachikawa General Hospital, Nagaoka, Japan (S.G., T.S., Y. Kawase)
| | - Yuetsu Kikuta
- National Heart and Lung Institute, Imperial College London (T.W., C.M.C., C.R., J.P.H., H.S., Y.A., Y. Kikuta, J.E.D.).,Division of Cardiology, Fukuyama Cardiovascular Hospital, Japan (Y. Kikuta)
| | - Yoshiaki Kawase
- Department of Cardiology, Tachikawa General Hospital, Nagaoka, Japan (S.G., T.S., Y. Kawase)
| | - Hidetaka Nishina
- Department of Cardiology, Tsukuba Medical Center Hospital, Japan (H.N.)
| | - Sunao Nakamura
- Department of Cardiovascular Medicine, New Tokyo Hospital, Matsudo, Japan (A.N., S.N.)
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (H.M.)
| | - Javier Escaned
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Spain (S.G., R.V.-U., J.E.)
| | | | - Justin E Davies
- National Heart and Lung Institute, Imperial College London (T.W., C.M.C., C.R., J.P.H., H.S., Y.A., Y. Kikuta, J.E.D.)
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.C.H., T.T., J.N., A.L.)
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Boretto P, Depaoli A, Conrotto F, Omedè P, De Filippo O, Serafini A, Strazzarino GA, Fonio P, De Ferrari GM, D'Ascenzo F. "Pressure Pressing Down on Me": Importance of Intracoronary Physiology and Inotropic Challenge for Myocardial Bridge. JACC Cardiovasc Interv 2021; 14:e157-e159. [PMID: 33992545 DOI: 10.1016/j.jcin.2021.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Paolo Boretto
- Division of Cardiology, Cardiovascular and Thoracic Department, University of Turin, Città Della Salute e della Scienza, Turin, Italy.
| | - Alessandro Depaoli
- University Radiodiagnostic Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Federico Conrotto
- Division of Cardiology, Cardiovascular and Thoracic Department, University of Turin, Città Della Salute e della Scienza, Turin, Italy
| | - Pierluigi Omedè
- Division of Cardiology, Cardiovascular and Thoracic Department, University of Turin, Città Della Salute e della Scienza, Turin, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, University of Turin, Città Della Salute e della Scienza, Turin, Italy
| | - Alessandro Serafini
- University Radiodiagnostic Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | | | - Paolo Fonio
- University Radiodiagnostic Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, University of Turin, Città Della Salute e della Scienza, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, University of Turin, Città Della Salute e della Scienza, Turin, Italy
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Travieso A, Castro-Mejia AF, Jeronimo-Baza A, Perez-Vizcayno MJ, Mejia-Renteria H, Macaya F, Tirado-Conte G, Nombela L, Jimenez-Quevedo P, Salinas P, Nunez-Gil IJ, Fernandez-Ortiz A, Escaned J, Gonzalo N. Safety of coronary revascularization deferral based on fractional flow reserve and instantaneous wave-free ratio in patients with chronic kidney disease. Cardiol J 2021; 29:553-562. [PMID: 33843040 PMCID: PMC9273258 DOI: 10.5603/cj.a2021.0035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/27/2021] [Accepted: 02/26/2021] [Indexed: 11/25/2022] Open
Abstract
Background The safety of revascularization deferral according to pressure wire examination in patients with chronic kidney disease (CKD) has not been fully established. Methods From a retrospective cohort of 439 patients in whom revascularization was deferred after physiological assessment, we examined the incidence of patient-oriented composite endpoint (POCE: all-cause death, myocardial infarction [MI] and unplanned revascularization) in patients with CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2) and without it. Results At 4 years of follow-up, the primary endpoint was met by 25.0% of patients with CKD and by 14.4% of patients without CKD (hazard ratio [HR] 1.56, 95% confidence interval [CI] 0.96–2.53, p = 0.071). The incidence of POCE was even higher in patients with an eGFR < 30 mL/min/1.73 m2: 43.8% (HR 3.10, 95% CI 1.08–8.92, p = 0.036). However, no differences were observed in the incidence of MI (4.2% vs. 4.4% in non-CKD), target vessel revascularization (5.8% vs. 5.9%), and target vessel MI (0.8% vs. 4.6%). Conclusions Patients with CKD in whom pressure-wire evaluation led to deferral of coronary revascularization develop more POCE in the long term, compared to patients with normal renal function. However, the increase in POCE in patients with CKD was seldom related to deferred vessels, thus suggesting an epiphenomenon of an intrinsically higher cardiovascular risk of CKD patients.
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Affiliation(s)
- Alejandro Travieso
- Hospital Clínico San Carlos, Profesor Martín Lagos, s/n, 28040 Madrid, Spain
| | | | | | | | | | - Fernando Macaya
- Hospital Clínico San Carlos, Profesor Martín Lagos, s/n, 28040 Madrid, Spain
| | | | - Luis Nombela
- Hospital Clínico San Carlos, Profesor Martín Lagos, s/n, 28040 Madrid, Spain
| | | | - Pablo Salinas
- Hospital Clínico San Carlos, Profesor Martín Lagos, s/n, 28040 Madrid, Spain
| | - Ivan J Nunez-Gil
- Hospital Clínico San Carlos, Profesor Martín Lagos, s/n, 28040 Madrid, Spain
| | | | - Javier Escaned
- Hospital Clínico San Carlos, Profesor Martín Lagos, s/n, 28040 Madrid, Spain
| | - Nieves Gonzalo
- Hospital Clínico San Carlos, Profesor Martín Lagos, s/n, 28040 Madrid, Spain.
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21
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Celebi OO. The Diagnostic Accuracy of the Instantaneous Wave-Free Ratio. Angiology 2021; 72:693. [PMID: 33813875 DOI: 10.1177/00033197211006975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Ozlem Ozcan Celebi
- Department of Cardiology, 64241University of Health Sciences, Ankara City Hospital, Turkey
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Ziubryte G, Jarusevicius G. Fractional flow reserve, quantitative flow ratio, and instantaneous wave-free ratio: a comparison of the procedure-related dose of ionising radiation. Postepy Kardiol Interwencyjnej 2021; 17:33-8. [PMID: 33868415 DOI: 10.5114/aic.2021.104765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/30/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction The development of interventional cardiology increases the number of invasive procedures which are inevitably associated with increased exposure to ionizing radiation and associated risks. A percutaneous coronary intervention (PCI) substantiated by evaluation of the coronary artery lesion’s functional significance is recommended by both European and American cardiologists. Nevertheless, the prevalence of physiology-guided PCIs does not exceed 10% all over the globe. Aim To identify the physiology evaluation method which is associated with the lowest exposure to ionising radiation. Material and methods Anonymised data of 421 patients with stable angina pectoris for whom elective coronary artery angiography followed by physiological assessment of intermediate coronary artery stenosis was performed were prospectively included in this study. Only diagnostic-procedure-related data of dose of ionizing radiation were analysed. Physiological assessment of coronary artery lesions was performed by fractional flow reserve (FFR), quantitative flow ratio (QFR), or instantaneous wave-free ratio (iFR). Results Compared to FFR as a reference, fluoroscopy time (FT) was almost half in QFR and almost double in iFR, p < 0.001. QFR was associated with more than 3 times shorter FT compared to iFR. The dose area product was 663.87 ±260.51 cGy/cm2 (p = 0.03) lower in QFR compared to iFR. Conclusions QFR is associated with significantly reduced exposure to ionising radiation compared to both FFR and iFR. Therefore, wider QFR application in clinical practice could eliminate any additional exposure to ionising radiation and increase the prevalence of physiology-guided coronary artery revascularization.
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Rajachandran M, Dahal R. Slow and Steady May Not Win This Race! Angiology 2021; 72:903-904. [PMID: 33685247 DOI: 10.1177/0003319721999166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Manu Rajachandran
- Division of Cardiology, Department of Internal Medicine, Paul L. Foster School of Medicine, 37316Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Ranjan Dahal
- Division of Cardiology, Department of Internal Medicine, Paul L. Foster School of Medicine, 37316Texas Tech University Health Sciences Center, El Paso, TX, USA
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Verdoia M, Gioscia R, Nardin M, Viola O, Brancati MF, Soldà PL, Marcolongo M, De Luca G. Preprocedural β-Blockers in the Functional Assessment of Intermediate Coronary Lesions by Instantaneous Wave-Free Ratio. Angiology 2021; 72:687-692. [PMID: 33626884 DOI: 10.1177/0003319721996170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM Instantaneous wave-free ratio (iFR) has emerged as the strategy of choice for the assessment of intermediate coronary lesions. The impact of preprocedural β-blockers therapy on the iFR was the aim of this study. METHODS We included patients undergoing functional assessment of intermediate (40%-70%) coronary lesions in 2 centers. The iFR measurement was performed by pressure-recording guidewire and calculated at the core laboratory using the manufacturers' dedicated software. Minimal luminal diameter, reference diameter, percent diameter stenosis, and length of the lesion were measured. Positive iFR was considered for values <0.90. RESULTS We included 197 patients undergoing functional evaluation of 223 coronary lesions. Patients on β-blockers (69%) had more frequently hypertension (P = .05); previous myocardial infarction (P = .01); therapy with clopidogrel (P = .02), statins, and aspirin; and acute coronary syndrome at presentation (P < .001, respectively). Mean iFR values were slightly higher in patients on β-blockers (0.94 ± 0.06 vs 0.92 ± 0.06, P = .11). The rate of positive iFR was significantly lower with β-blockers (14.9% vs 27.5%, P = .04). On multivariate analysis, β-blockers use was a predictor of the significance of coronary stenoses (odds ratio [OR] = 0.48; 95% CI = 0.23-0.98; P = .05) together with lesion length (OR = 1.04; 95% CI = 1.01-1.07; P = .007). CONCLUSION Among patients undergoing iFR, preprocedural β-blockers are associated with higher absolute values and a lower rate of positive iFR.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy.,Eastern Piedmont University, Novara Italy
| | - Rocco Gioscia
- Department of Cardiology Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
| | - Matteo Nardin
- Department of Cardiology Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
| | - Orazio Viola
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | | | - Pier Luigi Soldà
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | - Marco Marcolongo
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | - Giuseppe De Luca
- Eastern Piedmont University, Novara Italy.,Department of Cardiology Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
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25
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Gong Y, Zheng B, Yi T, Yang F, Hong T, Liu Z, Huo Y, Li J, Huo Y. Coronary angiography-derived contrast fractional flow reserve. Catheter Cardiovasc Interv 2021; 99:763-771. [PMID: 33590679 DOI: 10.1002/ccd.29558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/09/2021] [Accepted: 02/02/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Based on coronary angiography and mean aortic pressure, a specially designed computational flow dynamics (CFD) method is proposed to determine contrast fractional flow reserve (cFFR) without using invasive pressure wire. This substudy assessed diagnostic performance of coronary angiography-derived cFFR in catheterization laboratory, based on a previous multicenter trial for online assessment of coronary angiography-derived FFR (caFFR). METHODS Patients with diagnosis of stable angina pectoris or unstable angina pectoris were enrolled in six centers. Wire-based FFR was measured in coronary arteries with 30-90% diameter stenosis. Offline angiography-derived cFFR was computed in blinded fashion against the wire-based FFR and caFFR at an independent core laboratory. RESULTS A total of 330 patients were enrolled to fulfill inclusion/exclusion criteria from June 26 to December 18, 2018. Offline angiography-derived cFFR and wire-based FFR results were compared in 328 interrogated vessels. The statistical analysis showed the highest diagnostic accuracy of 89.0 and 86.6% for angiography-derived cFFR with a cutoff value of 0.94 and 0.93 against the wire-based FFR with a cutoff value of 0.80 and 0.75, respectively. The corresponding sensitivity and specificity were 92.2 and 87.3% for the cutoff value of 0.94 and 80.0 and 88.4% for the cutoff value of 0.93, which are similar to those against the caFFR. The receiver-operating curve has area under the curve of 0.951 and 0.972 for the wire-based FFR with the cutoff value of 0.80 and 0.75, respectively. CONCLUSIONS Coronary angiography-derived cFFR showed higher accuracy, sensitivity, and specificity against wired-based FFR and caFFR. Hence, angiography-derived cFFR could enhance the hemodynamic assessment of coronary lesions.
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Affiliation(s)
- Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Tieci Yi
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Fan Yang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Tao Hong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Zhaoping Liu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yunlong Huo
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, Guangdong, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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Abstract
Myocardial bridging occurs when coronary arteries run intramurally. Episodes of tachycardia can cause a dynamic obstruction that extends into diastole, compromising coronary filling time, and subsequently leading to ischaemia. Myocardial ischaemia, acute coronary syndrome, coronary spasm, myocardial stunning, arrhythmia, takotsubo cardiomyopathy, and sudden cardiac death have all been reported with bridging. Atherosclerotic plaques develop proximally in the bridge due to low shear stress and high oscillatory wall-flow. Factors affecting atherosclerotic build-up include disrupted flow patterns (particularly flow recirculation, which exacerbates LDL internalisation), cell adhesion and monocyte adhesion to the endothelium. Endothelial health depends on arterial flow patterns, given that the vessel reacts differently to various flow types, as confirmed in 3D simulations. Medication is the first-line therapy, while surgical de-roofing and coronary bypass are reserved for severe stenosis. Distinguishing physiological arterial compression from pathological stenosis is essential. Deeper bridges correlating with recurrent angina with an instantaneous wave-free ratio ≤0.89 or fractional flow reserve ≤0.80 are treated.
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Affiliation(s)
- Sumanth Khadke
- Our Lady of Fatima University, Fatima College of MedicineManila, Philippines
| | | | - Vinod Patel
- Division of Cardiology, Mount Sinai HospitalsNew York, NY, US
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Tolegenuly A, Ordiene R, Mamedov A, Unikas R, Benetis R. Correlation between Preoperative Coronary Artery Stenosis Severity Measured by Instantaneous Wave-Free Ratio and Intraoperative Transit Time Flow Measurement of Attached Grafts. ACTA ACUST UNITED AC 2020; 56:medicina56120714. [PMID: 33353214 PMCID: PMC7767172 DOI: 10.3390/medicina56120714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 01/16/2023]
Abstract
Background and Objectives: To assess the correlation between the degree of target coronary artery stenosis measured by instantaneous wave-free ratio (iFR) and the intraoperative transit time flow measurement (TTFM) of attached grafts as well as evaluate flow competition between the native coronary artery and the attached graft according to the severity of stenosis. Materials and Methods: In total, 89 grafts were subjected to intraoperative transit time flow measurement after coronary artery bypass grafting (CABG) in 25 patients with multivessel coronary artery disease (CAD). The iFR was evaluated for all coronary arteries with grafts. The coronary artery stenoses were divided into three groups based on the iFR value: iFR < 0.86 (group 1); iFR 0.86–0.90 (group 2); and iFR > 0.90 (group 3). Results: The mean graft flow (MGF) was 46.9 ± 18.4 mL/min for group 1, 45.3 ± 20.9 mL/min for group 2, and 31.3 ± 18.5 mL/min for group 3. A statistically significant difference was confirmed between groups 1 and 3 (p = 0.002) and between groups 2 and 3 (p = 0.025). The pulsatility index (PI) was 2.49 ± 1.20 for group 1, 2.66 ± 2.13 for group 2, and 4.70 ± 3.66 for group 3. A statistically significant difference was found between groups 1 and 3 (p = 0.006) and between groups 2 and 3 (p = 0.032). Backward flow was detected in 7.5% of grafts for group 1, in 16.6% of grafts for group 2, and in 16% of grafts for group 3. A statistically significant difference was found between groups 1 and 2 (p = 0.025) and between groups 1 and 3 (p = 0.029). Conclusions: The iFR is a useful tool for predicting the impact of competitive flow observed between a native artery and an attached graft. The effect of competitive flow significantly increases when the graft is attached to a vessel with mild coronary stenosis. In a coronary artery where the iFR was not hemodynamically significant, the MGF was lower, the PI was higher, and a larger proportion of grafts with backward flow (BF) was detected compared to when there was significant stenosis (iFR < 0.86).
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Affiliation(s)
- Almas Tolegenuly
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50009 Kaunas, Lithuania; (A.M.); (R.B.)
- Correspondence:
| | - Rasa Ordiene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50009 Kaunas, Lithuania; (R.O.); (R.U.)
| | - Arslan Mamedov
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50009 Kaunas, Lithuania; (A.M.); (R.B.)
| | - Ramunas Unikas
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50009 Kaunas, Lithuania; (R.O.); (R.U.)
| | - Rimantas Benetis
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50009 Kaunas, Lithuania; (A.M.); (R.B.)
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Kim CH, Koo BK, Dehbi HM, Lee JM, Doh JH, Nam CW, Shin ES, Cook CM, Al-Lamee R, Petraco R, Sen S, Malik IS, Nijjer SS, Mejía-Rentería H, Alegria-Barrero E, Alghamdi A, Altman J, Baptista SB, Bhindi R, Bojara W, Brugaletta S, Silva PC, Di Mario C, Erglis A, Gerber RT, Going O, Härle T, Hellig F, Indolfi C, Janssens L, Jeremias A, Kharbanda RK, Khashaba A, Kikuta Y, Krackhardt F, Laine M, Lehman SJ, Matsuo H, Meuwissen M, Niccoli G, Piek JJ, Ribichini F, Samady H, Sapontis J, Seto AH, Sezer M, Sharp ASP, Singh J, Takashima H, Talwar S, Tanaka N, Tang K, Van Belle E, van Royen N, Vinhas H, Vrints CJ, Walters D, Yokoi H, Samuels B, Buller C, Patel MR, Serruys PW, Escaned J, Davies JE. Sex Differences in Instantaneous Wave-Free Ratio or Fractional Flow Reserve-Guided Revascularization Strategy. JACC Cardiovasc Interv 2020; 12:2035-2046. [PMID: 31648764 DOI: 10.1016/j.jcin.2019.06.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study sought to evaluate sex differences in procedural characteristics and clinical outcomes of instantaneous wave-free ratio (iFR)- and fractional flow reserve (FFR)-guided revascularization strategies. BACKGROUND An iFR-guided strategy has shown a lower revascularization rate than an FFR-guided strategy, without differences in clinical outcomes. METHODS This is a post hoc analysis of the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate stenosis to guide Revascularization) study, in which 601 women and 1,891 men were randomized to iFR- or FFR-guided strategy. The primary endpoint was 1-year major adverse cardiac events (MACE), a composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization. RESULTS Among the entire population, women had a lower number of functionally significant lesions per patient (0.31 ± 0.51 vs. 0.43 ± 0.59; p < 0.001) and less frequently underwent revascularization than men (42.1% vs. 53.1%; p < 0.001). There was no difference in mean iFR value according to sex (0.91 ± 0.09 vs. 0.91 ± 0.10; p = 0.442). However, the mean FFR value was lower in men than in women (0.83 ± 0.09 vs. 0.85 ± 0.10; p = 0.001). In men, an FFR-guided strategy was associated with a higher rate of revascularization than an iFR-guided strategy (57.1% vs. 49.3%; p = 0.001), but this difference was not observed in women (41.4% vs. 42.6%; p = 0.757). There was no difference in MACE rates between iFR- and FFR-guided strategies in both women (5.4% vs. 5.6%, adjusted hazard ratio: 1.10; 95% confidence interval: 0.50 to 2.43; p = 0.805) and men (6.6% vs. 7.0%, adjusted hazard ratio: 0.98; 95% confidence interval: 0.66 to 1.46; p = 0.919). CONCLUSIONS An FFR-guided strategy was associated with a higher rate of revascularization than iFR-guided strategy in men, but not in women. However, iFR- and FFR-guided strategies showed comparable clinical outcomes, regardless of sex. (Functional Lesion Assessment of Intermediate Stenosis to guide Revascularization [DEFINE-FLAIR]; NCT02053038).
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Affiliation(s)
- Chee Hae Kim
- Division of Cardiology, Department of Internal Medicine, VHS Medical Center, Seoul, South Korea
| | - Bon-Kwon Koo
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University, Seoul, South Korea; Institute on Aging, Seoul National University, Seoul, South Korea.
| | - Hakim-Moulay Dehbi
- Cancer Research UK and University College London Cancer Trials Centre, University College London, London, United Kingdom
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Daehwa-dong, South Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Eun-Seok Shin
- Division of Cardiology, Department of Internal Medicine, Ulsan Medical Center, Ulsan Hospital, Ulsan, South Korea
| | | | - Rasha Al-Lamee
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Ricardo Petraco
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Sayan Sen
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Iqbal S Malik
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | | | - Hernán Mejía-Rentería
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Ali Alghamdi
- King Abdulaziz Medical City Cardiac Center, Riyadh, Saudi Arabia
| | - John Altman
- Colorado Heart and Vascular, Lakewood, Colorado
| | | | | | - Waldemar Bojara
- Gemeinschaftsklinikum Mittelrhein, Kemperhof Koblenz, Koblenz, Germany
| | - Salvatore Brugaletta
- Cardiovascular Institute, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | | | - Carlo Di Mario
- Royal Brompton Hospital, Imperial College London, London, United Kingdom; University of Florence, Florence, Italy
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | - Olaf Going
- Sana Klinikum Lichtenberg, Lichtenberg, Germany
| | - Tobias Härle
- Klinikum Oldenburg, European Medical School, Carl von Ossietzky University, Oldenburg, Germany
| | | | | | | | - Allen Jeremias
- Stony Brook University Medical Center, New York, New York
| | - Rajesh K Kharbanda
- John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford, United Kingdom
| | | | | | | | - Mika Laine
- Helsinki University Hospital, Helsinki, Finland
| | | | | | | | | | - Jan J Piek
- AMC Heart Center, Academic Medical Center, Amsterdam, the Netherlands
| | | | | | | | - Arnold H Seto
- Veterans Affairs Long Beach Healthcare System, Long Beach, California
| | - Murat Sezer
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Andrew S P Sharp
- Royal Devon and Exeter Hospital, University of Exeter, Exeter, United Kingdom
| | - Jasvindar Singh
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | | | - Suneel Talwar
- Royal Bournemouth General Hospital, Bournemouth, United Kingdom
| | | | - Kare Tang
- Essex Cardiothoracic Centre, Basildon, United Kingdom; Anglia Ruskin University, Chelmsford, United Kingdom
| | - Eric Van Belle
- Institut Coeur Poumon, Lille University Hospital, Lille, France; UMR INSERM 1011, Centre Hospitalier Universitaire de Lille et de Institut Pasteur de Lille, Université de Lille, Lille, France
| | | | | | | | | | | | - Bruce Samuels
- Cedars-Sinai Heart Institute, Los Angeles, California
| | | | | | - Patrick W Serruys
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Javier Escaned
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Justin E Davies
- Hammersmith Hospital, Imperial College London, London, United Kingdom
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Lee JM, Lee SH, Hwang D, Rhee TM, Choi KH, Kim J, Park J, Kim HY, Jung HW, Cho YK, Yoon HJ, Song YB, Hahn JY, Nam CW, Shin ES, Doh JH, Hur SH, Koo BK. Long-Term Clinical Outcomes of Nonhyperemic Pressure Ratios: Resting Full-Cycle Ratio, Diastolic Pressure Ratio, and Instantaneous Wave-Free Ratio. J Am Heart Assoc 2020; 9:e016818. [PMID: 32914672 PMCID: PMC7726993 DOI: 10.1161/jaha.120.016818] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Nonhyperemic pressure ratios (NHPRs) such as instantaneous wave‐free ratio, resting full‐cycle ratio, or diastolic pressure ratio have emerged as invasive physiologic indices precluding the need for hyperemic agents. The current study sought to evaluate the long‐term prognostic implications of NHPRs compared with fractional flow reserve (FFR). Methods and Results NHPRs were calculated from resting pressure tracings by an independent core laboratory in 1024 vessels (435 patients). The association between NHPRs and the risk of 5‐year vessel‐oriented composite outcomes (VOCO, a composite of cardiac death, vessel‐related myocardial infarction, and ischemia‐driven revascularization) were analyzed among 864 deferred vessels. Lesions with positive NHPRs (instantaneous wave free ratio, resting full‐cycle ratio, and diastolic pressure ratio ≤0.89) or FFR (≤0.80) showed significantly higher risk of VOCO at 5 years than those with negative NHPRs or FFR, respectively. Discriminant ability for 5‐year VOCO was not different among NHPRs and FFR (C‐index: 0.623–0.641, P for comparison=0.215). In comparison of VOCO among the groups with deferred concordant negative (NHPRs−/FFR−), deferred discordant (NHPRs+/FFR− or NHPRs−/FFR+), and revascularized vessels, the cumulative incidence of VOCO were 7.5%, 14.4%, and 14.8% (log‐rank P<0.001), respectively. The deferred discordant group showed similar risk of VOCO with the revascularized vessel group (hazard ratio, 0.981; 95% CI 0.434–2.217, P=0.964). Conclusions Currently available invasive pressure‐derived indices showed similar prognostic implications for vessel‐related events at 5 years. Deferred lesions with discordant results between NHPRs and FFR did not show higher risk of vessel‐related events at 5 years than revascularized vessels. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01621438, NCT01621438.
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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 South Korea
| | - Seung Hun Lee
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - Tae-Min Rhee
- Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - Ki Hong Choi
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Jinseob Kim
- Department of Epidemiology School of Public Health Seoul National University Seoul South Korea
| | - Jinhyoung Park
- Department of Biomedical Engineering Sungkyunkwan University Suwon Gyeonggi-do South Korea
| | - Hyung Yoon Kim
- Department of Cardiovascular Medicine Chonnam National University Hospital Gwangju South Korea
| | - Hae Won Jung
- Department of Cardiology Daegu Catholic University Medical Center Daegu South Korea
| | - Yun-Kyeong Cho
- Department of Medicine Keimyung University Dongsan Medical Center Daegu South Korea
| | - Hyuck-Jun Yoon
- Department of Medicine Keimyung University Dongsan Medical Center Daegu South Korea
| | - Young Bin Song
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Joo-Yong Hahn
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Chang-Wook Nam
- Department of Medicine Keimyung University Dongsan Medical Center Daegu South Korea
| | - Eun-Seok Shin
- Division of Cardiology Ulsan Medical Center Ulsan South Korea
| | - Joon-Hyung Doh
- Department of Medicine Inje University Ilsan Paik Hospital Goyang South Korea
| | - Seung-Ho Hur
- Department of Medicine Keimyung University Dongsan Medical Center Daegu South Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul South Korea.,Institute on Aging Seoul National University Seoul South Korea
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Verdoia M, Gioscia R, Nardin M, Negro F, Tonon F, Suryapranata H, Khedi E, Marcolongo M, De Luca G. Impact of Age on the Functional Evaluation of Intermediate Coronary Stenoses With Instantaneous Wave-Free Ratio and Fractional Flow Reserve. Angiology 2020; 72:62-69. [PMID: 32815383 DOI: 10.1177/0003319720947578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The optimal strategy for assessing the ischemic significance of intermediate coronary stenoses with adenosine-induced fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) is still debated. Few studies have previously assessed the impact of age on FFR and iFR, which was the aim of our study. Patients undergoing FFR and iFR evaluation for intermediate (40%-70%) coronary lesions were included and divided according to age. Fractional flow reserve was performed by intracoronary boluses of adenosine (60-1440 μg). Instantaneous wave-free ratio was automatically calculated. Among 148 patients undergoing FFR measurement of 166 lesions, 45.3% were ≥70 years. Elderly patients had higher minimal lumen diameter (P = .03). We also observed a linear relationship between iFR and FFR independently of age. Fractional flow reserve values were higher in the elderly patients, whereas iFR was not related to age. A total of 33 lesions had a positive iFR with no difference for age (17.3% vs 22%, P = .56), while FFR <0.80 was more infrequent in the elderly patients (17.1% vs 34.8%, P = .02). In intermediate coronary stenoses, iFR and FFR correlation is unaffected by age. Fractional flow reserve is higher in the elderly patients, whereas iFR is less affected by age. Future large-scale studies are needed to define whether iFR should be the preferred choice in elderly patients.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology Ospedale degli Infermi, ASL Biella, Biella, Italy.,Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Rocco Gioscia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Matteo Nardin
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.,Internal Medicine, 18515ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Federica Negro
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Francesco Tonon
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Harry Suryapranata
- Department of Cardiology, UMC St. 6034Radboud, Nijmegen, the Netherlands
| | - Elvin Khedi
- Department of Cardiology, ISALA Hospital, Zwolle, the Netherlands
| | - Marco Marcolongo
- Division of Cardiology Ospedale degli Infermi, ASL Biella, Biella, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
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Cook CM, Warisawa T, Howard JP, Keeble TR, Iglesias JF, Schampaert E, Bhindi R, Ambrosia A, Matsuo H, Nishina H, Kikuta Y, Shiono Y, Nakayama M, Doi S, Takai M, Goto S, Yakuta Y, Karube K, Akashi YJ, Clesham GJ, Kelly PA, Davies JR, Karamasis GV, Kawase Y, Robinson NM, Sharp ASP, Escaned J, Davies JE. Algorithmic Versus Expert Human Interpretation of Instantaneous Wave-Free Ratio Coronary Pressure-Wire Pull Back Data. JACC Cardiovasc Interv 2020; 12:1315-1324. [PMID: 31320025 PMCID: PMC6645043 DOI: 10.1016/j.jcin.2019.05.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/15/2019] [Accepted: 05/21/2019] [Indexed: 11/03/2022]
Abstract
Objectives The aim of this study was to investigate whether algorithmic interpretation (AI) of instantaneous wave-free ratio (iFR) pressure-wire pull back data would be noninferior to expert human interpretation. Background Interpretation of iFR pressure-wire pull back data can be complex and is subjective. Methods Fifteen human experts interpreted 1,008 iFR pull back traces (691 unique, 317 duplicate). For each trace, experts determined the hemodynamic appropriateness for percutaneous coronary intervention (PCI) and, in such cases, the optimal physiological strategy for PCI. The heart team (HT) interpretation was determined by consensus of the individual expert opinions. The same 1,008 pull back traces were also interpreted algorithmically. The coprimary hypotheses of this study were that AI would be noninferior to the interpretation of the median expert human in determining: 1) the hemodynamic appropriateness for PCI; and 2) the physiological strategy for PCI. Results Regarding the hemodynamic appropriateness for PCI, the median expert human demonstrated 89.3% agreement with the HT in comparison with 89.4% for AI (p < 0.01 for noninferiority). Across the 372 cases judged as hemodynamically appropriate for PCI according to the HT, the median expert human demonstrated 88.8% agreement with the HT in comparison with 89.7% for AI (p < 0.0001 for noninferiority). On reproducibility testing, the HT opinion itself changed 1 in 10 times for both the appropriateness for PCI and the physiological PCI strategy. In contrast, AI showed no change. Conclusions AI of iFR pressure-wire pull back data was noninferior to expert human interpretation in determining both the hemodynamic appropriateness for PCI and the optimal physiological strategy for PCI.
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Affiliation(s)
- Christopher M Cook
- Hammersmith Hospital, Imperial College NHS Trust, London, United Kingdom
| | - Takayuki Warisawa
- Hammersmith Hospital, Imperial College NHS Trust, London, United Kingdom; St. Marianna University School of Medicine, Kawasaki, Japan
| | - James P Howard
- Hammersmith Hospital, Imperial College NHS Trust, London, United Kingdom
| | - Thomas R Keeble
- Essex Cardiothoracic Centre, Basildon, United Kingdom; Anglia Ruskin School of Medicine, Chelmsford, Essex, United Kingdom
| | | | - Erick Schampaert
- Hôpital Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | | | | | | | | | | | | | | | - Shunichi Doi
- St. Marianna University School of Medicine, Kawasaki, Japan
| | - Manabu Takai
- St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Sonoka Goto
- Toda Central General Hospital, Toda, Japan; Hospital Clinico San Carlos, Madrid, Spain
| | - Yohei Yakuta
- Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | | | | | - Gerald J Clesham
- Essex Cardiothoracic Centre, Basildon, United Kingdom; Anglia Ruskin School of Medicine, Chelmsford, Essex, United Kingdom
| | - Paul A Kelly
- Essex Cardiothoracic Centre, Basildon, United Kingdom
| | - John R Davies
- Essex Cardiothoracic Centre, Basildon, United Kingdom; Anglia Ruskin School of Medicine, Chelmsford, Essex, United Kingdom
| | - Grigoris V Karamasis
- Essex Cardiothoracic Centre, Basildon, United Kingdom; Anglia Ruskin School of Medicine, Chelmsford, Essex, United Kingdom
| | | | | | | | | | - Justin E Davies
- Hammersmith Hospital, Imperial College NHS Trust, London, United Kingdom.
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32
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Lee SH, Kim HK, Lee JM, Hong YJ, Lim KS, Kim HB, Choi KH, Shin ES, Nam CW, Doh JH, Yang JH, Song YB, Hahn JY, Choi SH, Jeong MH, Samady H, Escaned J. Coronary Circulatory Indexes in Non-Infarct-Related Vascular Territories in a Porcine Acute Myocardial Infarction Model. JACC Cardiovasc Interv 2020; 13:1155-1167. [PMID: 32438986 DOI: 10.1016/j.jcin.2020.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/21/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate temporal changes in coronary hemodynamic and physiological indexes in the non-infarct-related artery (IRA), which might be affected by adjacent infarcted myocardium, using an experimental animal model of acute myocardial infarction. BACKGROUND There has been debate on the reliability of fractional flow reserve and resting pressure-derived indexes, including instantaneous wave-free ratio, in the non-IRA in patients with acute ST-segment elevation myocardial infarction. METHODS In Yorkshire swine, acute myocardial infarction was simulated with selective balloon occlusion at the left circumflex coronary artery as the IRA for 30 min. Non-IRA stenosis was created using bare-metal stent implantation in the left anterior descending coronary artery 4 weeks before the experiments. Serial changes in systemic hemodynamic status, coronary pressure, and Doppler-derived coronary flow velocity were measured in a nonoccluded left anterior descending coronary artery as the non-IRA from baseline, balloon occlusion of the left circumflex coronary artery, and 15 min after reperfusion of the left circumflex coronary artery. RESULTS Among the 6 experimental subjects, the median diameter stenosis of the non-IRA was 33.9% (interquartile range: 21.7% to 46.1%). During balloon occlusion of the IRA, there were transient significant changes in both resting and hyperemic aortic pressure, distal coronary pressure, averaged peak velocity, transstenotic pressure gradient, and microvascular resistance of the non-IRA (p < 0.020 for all). After reperfusion of the IRA, the resting averaged peak velocity (p = 0.002) and resting transstenotic pressure gradient (p = 0.004) were significantly increased and resting microvascular resistance (p = 0.004) was significantly decreased compared with their values in the baseline phase. However, the hyperemic averaged peak velocity (p = 0.479), hyperemic transstenotic pressure gradient (p = 0.778), and hyperemic microvascular resistance (p = 0.816) were not significantly different compared with those in the baseline phase. After reperfusion, fractional flow reserve in the non-IRA was not significantly different (0.94 ± 0.01 vs. 0.93 ± 0.01; p = 0.353), while coronary flow reserve (1.93 ± 0.07 vs. 1.36 ± 0.07; p = 0.025) and instantaneous wave-free ratio (0.97 ± 0.01 vs. 0.93 ± 0.01; p = 0.001) were significantly lower than baseline values. CONCLUSIONS In a porcine model of acute myocardial infarction, occlusion of the IRA induced significant changes in systemic hemodynamic status and coronary circulatory indexes of the non-IRA. However, after reperfusion of the IRA, fractional flow reserve did not change significantly, whereas coronary flow reserve and instantaneous wave-free ratio showed significant changes compared with baseline values.
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Affiliation(s)
- Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Young Joon Hong
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea.
| | - Kyung Seob Lim
- Futuristic Animal Resource & Research Center, Korea Research Institute of Bioscience and Biotechnology, Cheongju, Korea
| | - Han Byul Kim
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, 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
| | - Eun-Seok Shin
- Division of Cardiology, Department of Internal Medicine, Ulsan Medical Center, Ulsan Hospital, Ulsan, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, 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
| | - Myung Ho Jeong
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Habib Samady
- Andreas Gruentzig Cardiovascular Center, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
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Doan TT, Wilkinson JC, Agrawal H, Molossi S, Alam M, Mery CM, Qureshi AM. Instantaneous Wave-Free Ratio (iFR) Correlates With Fractional Flow Reserve (FFR) Assessment of Coronary Artery Stenoses and Myocardial Bridges in Children. J Invasive Cardiol 2020; 32:176-179. [PMID: 32357130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Instantaneous wave-free ratio (iFR) has been proven to correlate with coronary flow reserve better than fractional flow reserve (FFR) and is non-inferior to FFR in guiding coronary revascularization in ischemic heart disease. There has been no study validating the utility of iFR in children. METHODS We performed a retrospective review of clinically indicated cases in which both FFR and iFR were obtained at Texas Children's Hospital from July, 2016 to March, 2019. FFR and iFR were obtained at baseline. Adenosine FFR (FFRa) was used for assessment of coronary artery (CA) stenoses and diastolic dobutamine FFR (dFFRd) for myocardial bridges (MBs). FFRa or dFFRd ≤0.8 and iFR ≤0.89 indicated significant flow impairment. RESULTS A total of 22 coronary arteries (9 CA stenoses and 13 MBs) were assessed in 20 patients with median age of 13 years (range, 4-21 years) and median weight of 60 kg (range, 19-110 kg). iFR correlated with FFRa (Spearman's rho, 0.87; P<.01) in CA stenoses and with dFFRd (Spearman's rho, 0.74; P<.01) in MBs and agreed with FFR in 20/22 cases (90.9%). In 1 patient with CA stenosis and 1 MB with normal FFR, iFR was positive and both patients underwent coronary revascularization. CONCLUSIONS iFR correlated with FFR in the assessment of CA stenoses in children. iFR does not require administration of pharmacological agents; thus, it may reduce procedural time, cost, and complications, and result in more widespread adoption of invasive assessment of CA lesions in young patients.
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Affiliation(s)
- Tam T Doan
- The Lillie Frank Abercrombie Section of Cardiology, Department of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, 6651 Main Street, Legacy Tower, 20th Floor, Suite E. 1920, Houston, TX 77030 USA.
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Abstract
BACKGROUND Traditional coronary angiography (CA) as a main technique has been used to determine the coronary artery anatomy and guide percutaneous coronary intervention (PCI). We mainly focused on whether the new techniques could improve the patients' mortality, major adverse cardiovascular events (MACEs), and myocardial infarction. METHODS For the network meta-analysis, we searched the trials of different PCI guidances from MEDLINE, Current Contents Connect, Google Scholar, EMBASE, Cochrane Library, PubMed, Science Direct, and Web of Science. The last search date was December 10, 2018. RESULTS The analyses of all results found that there was no significant difference in mortality among the groups. Randomized clinical trials (RCT) analysis showed that intravascular ultrasound (IVUS)-guided PCI was significantly superior to CA, fractional flow reserve, instantaneous wave-free ratio, optical coherence tomography. However, CA, fractional flow reserve, instantaneous wave-free ratio, and optical coherence tomography showed no difference in reducing mortality. The analyses of all results found that there was no significant difference in the incidence of MACEs among the groups. RCTs analysis showed that IVUS-guided PCI was significantly superior to CA, but there was no significant difference among the other groups. The analyses of all results or RCTs showed that there was no significant difference in myocardial infarction incidence among the groups. CONCLUSION IVUS-guided PCI is an effective method to decrease all-cause death MACEs.
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Choi KH, Lee JM, Kim HK, Kim J, Park J, Hwang D, Rhee TM, Park TK, Yang JH, Song YB, Shin ES, Nam CW, Doh JH, Hahn JY, Choi JH, Choi SH, Koo BK, Gwon HC. Fractional Flow Reserve and Instantaneous Wave-Free Ratio for Nonculprit Stenosis in Patients With Acute Myocardial Infarction. JACC Cardiovasc Interv 2018; 11:1848-58. [PMID: 30236358 DOI: 10.1016/j.jcin.2018.06.045] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The aim of this study was to compare the changes of fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) with severity of epicardial coronary stenosis between nonculprit vessel of acute myocardial infarction (AMI) and stable ischemic heart disease (SIHD). BACKGROUND There has been debate regarding the reliability of FFR or iFR for nonculprit stenosis in the acute stage of AMI. METHODS A total of 100 AMI patients underwent comprehensive physiologic assessment including FFR, iFR, coronary flow reserve (CFR), and index of microcirculatory resistance (IMR) for nonculprit vessel stenosis after primary percutaneous coronary intervention (PCI) for culprit vessel. The changes in FFR and iFR for diameter stenosis (%DS) of nonculprit vessel stenosis were compared with FFR and iFR measured in 203 patients with SIHD. RESULTS From 40% to 80% stenosis, FFR and iFR measured in nonculprit vessel of AMI patient showed significant decrease with worsening stenosis severity (all p values < 0.001). Nonculprit vessels of AMI patients showed lower CFR than SIHD; however, IMR was not different between the nonculprit vessel of AMI and SIHD patients. FFR and iFR were not significantly different between the nonculprit vessel of AMI and SIHD patients in all %DS groups from 40% to 80% (all p values > 0.05). In addition, percent difference of FFR and iFR according to the increase in %DS was also not significantly different between nonculprit vessel of AMI or SIHD. There was no significant interaction between clinical presentation and the changes of FFR and iFR for worsening %DS (interaction p value = 0.698 and 0.257, respectively). CONCLUSIONS Changes in FFR and iFR for the nonculprit stenosis of AMI patients were not significantly different from those in SIHD patients. These data support the use of invasive physiological parameters to guide treatment of nonculprit stenoses in the acute stage of successfully revascularized AMI.
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Sen S, Ahmad Y, Dehbi HM, Howard JP, Iglesias JF, Al-Lamee R, Petraco R, Nijjer S, Bhindi R, Lehman S, Walters D, Sapontis J, Janssens L, Vrints CJ, Khashaba A, Laine M, Van Belle E, Krackhardt F, Bojara W, Going O, Härle T, Indolfi C, Niccoli G, Ribichini F, Tanaka N, Yokoi H, Takashima H, Kikuta Y, Erglis A, Vinhas H, Silva PC, Baptista SB, Alghamdi A, Hellig F, Koo BK, Nam CW, Shin ES, Doh JH, Brugaletta S, Alegria-Barrero E, Meuwissen M, Piek JJ, van Royen N, Sezer M, Di Mario C, Gerber RT, Malik IS, Sharp ASP, Talwar S, Tang K, Samady H, Altman J, Seto AH, Singh J, Jeremias A, Matsuo H, Kharbanda RK, Patel MR, Serruys P, Escaned J, Davies JE. Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment. J Am Coll Cardiol 2019; 73:444-53. [PMID: 30704577 DOI: 10.1016/j.jacc.2018.10.070] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/04/2018] [Accepted: 10/22/2018] [Indexed: 01/10/2023]
Abstract
Background Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR). Objectives The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial. Methods MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex. Results A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06). Conclusions iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.
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Lee SH, Choi KH, Lee JM, Hwang D, Rhee TM, Park J, Kim HK, Cho YK, Yoon HJ, Park J, Song YB, Hahn JY, Doh JH, Nam CW, Shin ES, Hur SH, Koo BK. Physiologic Characteristics and Clinical Outcomes of Patients With Discordance Between FFR and iFR. JACC Cardiovasc Interv 2019; 12:2018-2031. [PMID: 31563683 DOI: 10.1016/j.jcin.2019.06.044] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/12/2019] [Accepted: 06/18/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study evaluated the physiologic characteristics of discordant lesions between instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) and the prognosis at 5 years. BACKGROUND FFR or iFR have been standard methods for assessing the functional significance of coronary artery stenosis. However, limited data exist about the physiologic characteristics of discordant lesions and the prognostic implications resulting from these lesions. METHODS A total of 840 vessels from 596 patients were classified according to iFR and FFR; high iFR-high FFR (n = 580), low iFR-high FFR (n = 40), high iFR-low FFR (n = 69), and low iFR-low FFR (n = 128) groups, which were compared with a control group (n = 23). The differences in coronary circulatory indices including the coronary flow reserve (CFR), index of microcirculatory resistance (IMR), and resistance reserve ratio (RRR) (resting distal arterial pressure × mean transit time / hyperemic distal arterial pressure × hyperemic mean transit time), which reflect the vasodilatory capacity of coronary microcirculation, were compared. Patient-oriented composite outcomes (POCO) at 5 years including all-cause death, any myocardial infarction, and any revascularization were compared among patients with deferred lesions. RESULTS In the low iFR-high FFR group, CFR, RRR, and IMR measurements were similar to the low iFR-low FFR group: CFR 2.71 versus 2.43 (p = 0.144), RRR 3.36 versus 3.68 (p = 0.241), and IMR 18.51 versus 17.38 (p = 0.476). In the high iFR-low FFR group, the CFR, RRR, and IMR measurements were similar to the control group: CFR 2.95 versus 3.29 (p = 0.160), RRR 4.28 versus 4.00 (p = 0.414), and IMR 17.44 versus 17.06 (p = 0.818). Among the 4 groups, classified by iFR and FFR, CFR and RRR were all significantly different, except for IMR. However, there were no significant differences in the rates of POCO, regardless of discordance between the iFR and FFR. Only the low iFR-low FFR group had a higher POCO rate compared with the high iFR-high FFR group (adjusted hazard ratio: 2.46; 95% confidence interval: 1.17 to 5.16; p = 0.018). CONCLUSIONS Differences in coronary circulatory function were found, especially in the vasodilatory capacity between the low iFR-high FFR and high iFR-low FFR groups. FFR-iFR discordance was not related to an increased risk of POCO among patients with deferred lesions at 5 years. (Clinical, Physiological and Prognostic Implication of Microvascular Status;NCT02186093; Physiologic Assessment of Microvascular Function in Heart Transplant Patients; NCT02798731).
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Affiliation(s)
- 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
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Tae-Min Rhee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jonghanne Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Naju National Hospital, Ministry of Health and Welfare, Naju, Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Yun-Kyeong Cho
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyuck-Jun Yoon
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jinhyoung Park
- Department of Biomedical Engineering, Sungkyunkwan University, Suwon, 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
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan Hospital, Ulsan, Korea; Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Ho Hur
- 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; Institute on Aging, Seoul National University, Seoul, Korea
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Allahwala UK, De Silva K, Bhindi R. Utilizing coronary physiology to guide acute coronary syndrome management: are we there yet? Future Cardiol 2019; 15:323-327. [PMID: 31290332 DOI: 10.2217/fca-2019-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Usaid K Allahwala
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia
| | - Kalpa De Silva
- Bristol Heart Institute, University Hospitals Bristol & University of Bristol, BS2 8ED Bristol, UK
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia
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Cook CM, Jeremias A, Petraco R, Sen S, Nijjer S, Shun-Shin MJ, Ahmad Y, de Waard G, van de Hoef T, Echavarria-Pinto M, van Lavieren M, Al Lamee R, Kikuta Y, Shiono Y, Buch A, Meuwissen M, Danad I, Knaapen P, Maehara A, Koo BK, Mintz GS, Escaned J, Stone GW, Francis DP, Mayet J, Piek JJ, van Royen N, Davies JE. Fractional Flow Reserve/Instantaneous Wave-Free Ratio Discordance in Angiographically Intermediate Coronary Stenoses: An Analysis Using Doppler-Derived Coronary Flow Measurements. JACC Cardiovasc Interv 2017; 10:2514-24. [PMID: 29268881 DOI: 10.1016/j.jcin.2017.09.021] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/15/2017] [Accepted: 09/19/2017] [Indexed: 01/10/2023]
Abstract
Objectives The study sought to determine the coronary flow characteristics of angiographically intermediate stenoses classified as discordant by fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR). Background Discordance between FFR and iFR occurs in up to 20% of cases. No comparisons have been reported between the coronary flow characteristics of FFR/iFR discordant and angiographically unobstructed vessels. Methods Baseline and hyperemic coronary flow velocity and coronary flow reserve (CFR) were compared across 5 vessel groups: FFR+/iFR+ (108 vessels, n = 91), FFR–/iFR+ (28 vessels, n = 24), FFR+/iFR– (22 vessels, n = 22), FFR–/iFR– (208 vessels, n = 154), and an unobstructed vessel group (201 vessels, n = 153), in a post hoc analysis of the largest combined pressure and Doppler flow velocity registry (IDEAL [Iberian-Dutch-English] collaborators study). Results FFR disagreed with iFR in 14% (50 of 366). Baseline flow velocity was similar across all 5 vessel groups, including the unobstructed vessel group (p = 0.34 for variance). In FFR+/iFR– discordants, hyperemic flow velocity and CFR were similar to both FFR–/iFR– and unobstructed groups; 37.6 (interquartile range [IQR]: 26.1 to 50.4) cm/s vs. 40.0 [IQR: 29.7 to 52.3] cm/s and 42.2 [IQR: 33.8 to 53.2] cm/s and CFR 2.36 [IQR: 1.93 to 2.81] vs. 2.41 [IQR: 1.84 to 2.94] and 2.50 [IQR: 2.11 to 3.17], respectively (p > 0.05 for all). In FFR–/iFR+ discordants, hyperemic flow velocity, and CFR were similar to the FFR+/iFR+ group; 28.2 (IQR: 20.5 to 39.7) cm/s versus 23.5 (IQR: 16.4 to 34.9) cm/s and CFR 1.44 (IQR: 1.29 to 1.85) versus 1.39 (IQR: 1.06 to 1.88), respectively (p > 0.05 for all). Conclusions FFR/iFR disagreement was explained by differences in hyperemic coronary flow velocity. Furthermore, coronary stenoses classified as FFR+/iFR– demonstrated similar coronary flow characteristics to angiographically unobstructed vessels.
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Abstract
BACKGROUND The only indication for coronary revascularization is elimination of ischaemia. Invasive hemodynamic methods (fractional flow reserve - FFR and instantaneous wave-free ratio (iFR) are superior to coronary angiography in detection of lesions causing myocardial ischaemia. Current European guidelines for myocardial revascularization recommend using of FFR for detection of functional assessment of lesions severity in category IA and number of these procedures increases. However, routine usage of these methods requires knowledge of technical requirements and limitations. AIM The aim of the study is to summarise good clinical practice for FFR and iFR measurements with explanation of possible technical challenges, that are necessary for increasing of measurement accuracy. CONCLUSIONS Authors describe frequent technical mistakes and malpractice during invasive assessment of lesion severity in coronary arteries.
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Affiliation(s)
- Stepan Jerabek
- 2nd Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Praha, Czech Republic
| | - Tomas Kovarnik
- 2nd Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Praha, Czech Republic
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Baumann S, Mueller KSE, Hetjens S, Eder F, Schaefer AC, Becher T, Borggrefe M, Akin I, Loßnitzer D. One-year clinical outcome of angiography, fractional flow reserve and instantaneous wave-free ratio guided percutaneous coronary intervention: A PRISMA-compliant meta-analysis. Exp Ther Med 2019; 17:1939-1951. [PMID: 30783470 DOI: 10.3892/etm.2019.7156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 09/28/2018] [Indexed: 01/10/2023] Open
Abstract
The present study aimed to compare the clinical outcome of patients with coronary artery disease (CAD) who underwent a revascularization using conventional coronary angiography or a physiologically guided revascularization with Fractional Flow Reserve (FFR). Furthermore, outcomes in FFR guided percutaneous coronary intervention (PCI) and instantaneous wave-free ratio (iFR) guided PCI were compared. The analysis was performed for reported outcomes at a 1-year follow-up. After searching PubMed, EMBASE, and Web of Science for suitable publications, a total of 15,880 subjects were included. Comparing angiography guided and FFR guided PCI showed no significant difference in major adverse cardiac events [odds ratio (OR), 0.78; 95% confidence interval (CI), 0.59-1.04; P=0.09; I2=73%], death from any cause (OR, 0.74; 95% CI, 0.46-1.18; P=0.20; I2=74%), myocardial infarction (OR, 0.93; 95% CI, 0.81-1.07; P=0.31; I2=0%) or unplanned revascularization (OR, 0.71; 95% CI, 0.41-1.23; P=0.22; I2=79%). In addition, no significant difference could be found between iFR and FFR guided PCI for major adverse cardiac events (OR, 0.97; 95% CI; 0.76-1.23; P=0.81; I2=0%), death from any cause (OR, 0.66; 95% CI, 0.40-1.11; P=0.12; I2=0%), myocardial infarction (OR, 0.83; 95% CI, 0.56-1.24; P=0.37) or unplanned revascularization (OR, 1.16; 95% CI, 0.85-1.58; P=0.34; I2=16%). Overall, there was a tendency towards better outcomes of FFR in all four clinical endpoints compared with angiography guiding of PCI, and furthermore iFR showed no significant inferiority when compared to FFR in said clinical endpoints. When conducting a network meta-analysis, the results confirmed a non-inferiority of iFR compared to angiography guided revascularization.
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Affiliation(s)
- Stefan Baumann
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, University of Heidelberg, D-68167 Mannheim, Germany
| | - Klara S E Mueller
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, University of Heidelberg, D-68167 Mannheim, Germany
| | - Svetlana Hetjens
- Medical Faculty Mannheim, Department of Medical Statistics, University of Heidelberg, D-68167 Mannheim, Germany
| | - Frederik Eder
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, University of Heidelberg, D-68167 Mannheim, Germany
| | - Antonia C Schaefer
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, University of Heidelberg, D-68167 Mannheim, Germany
| | - Tobias Becher
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, D-68167 Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, University of Heidelberg, D-68167 Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, University of Heidelberg, D-68167 Mannheim, Germany
| | - Dirk Loßnitzer
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, University of Heidelberg, D-68167 Mannheim, Germany
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Ahmad Y, Götberg M, Cook C, Howard JP, Malik I, Mikhail G, Frame A, Petraco R, Rajkumar C, Demir O, Iglesias JF, Bhindi R, Koul S, Hadjiloizou N, Gerber R, Ramrakha P, Ruparelia N, Sutaria N, Kanaganayagam G, Ariff B, Fertleman M, Anderson J, Chukwuemeka A, Francis D, Mayet J, Serruys P, Davies J, Sen S. Coronary Hemodynamics in Patients With Severe Aortic Stenosis and Coronary Artery Disease Undergoing Transcatheter Aortic Valve Replacement: Implications for Clinical Indices of Coronary Stenosis Severity. JACC Cardiovasc Interv 2018; 11:2019-2031. [PMID: 30154062 PMCID: PMC6197079 DOI: 10.1016/j.jcin.2018.07.019] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/10/2018] [Accepted: 07/17/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVES In this study, a systematic analysis was conducted of phasic intracoronary pressure and flow velocity in patients with severe aortic stenosis (AS) and coronary artery disease, undergoing transcatheter aortic valve replacement (TAVR), to determine how AS affects: 1) phasic coronary flow; 2) hyperemic coronary flow; and 3) the most common clinically used indices of coronary stenosis severity, instantaneous wave-free ratio and fractional flow reserve. BACKGROUND A significant proportion of patients with severe aortic stenosis (AS) have concomitant coronary artery disease. The effect of the valve on coronary pressure, flow, and the established invasive clinical indices of stenosis severity have not been studied. METHODS Twenty-eight patients (30 lesions, 50.0% men, mean age 82.1 ± 6.5 years) with severe AS and coronary artery disease were included. Intracoronary pressure and flow assessments were performed at rest and during hyperemia immediately before and after TAVR. RESULTS Flow during the wave-free period of diastole did not change post-TAVR (29.78 ± 14.9 cm/s vs. 30.81 ± 19.6 cm/s; p = 0.64). Whole-cycle hyperemic flow increased significantly post-TAVR (33.44 ± 13.4 cm/s pre-TAVR vs. 40.33 ± 17.4 cm/s post-TAVR; p = 0.006); this was secondary to significant increases in systolic hyperemic flow post-TAVR (27.67 ± 12.1 cm/s pre-TAVR vs. 34.15 ± 17.5 cm/s post-TAVR; p = 0.02). Instantaneous wave-free ratio values did not change post-TAVR (0.88 ± 0.09 pre-TAVR vs. 0.88 ± 0.09 post-TAVR; p = 0.73), whereas fractional flow reserve decreased significantly post-TAVR (0.87 ± 0.08 pre-TAVR vs. 0.85 ± 0.09 post-TAVR; p = 0.001). CONCLUSIONS Systolic and hyperemic coronary flow increased significantly post-TAVR; consequently, hyperemic indices that include systole underestimated coronary stenosis severity in patients with severe AS. Flow during the wave-free period of diastole did not change post-TAVR, suggesting that indices calculated during this period are not vulnerable to the confounding effect of the stenotic aortic valve.
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Affiliation(s)
- Yousif Ahmad
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden
| | - Christopher Cook
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - James P Howard
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Iqbal Malik
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ghada Mikhail
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Angela Frame
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ricardo Petraco
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Christopher Rajkumar
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Ozan Demir
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Juan F Iglesias
- Cardiology Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden
| | - Nearchos Hadjiloizou
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Robert Gerber
- Department of Cardiology, Conquest Hospital, St. Leonards-on-Sea, United Kingdom
| | - Punit Ramrakha
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Neil Ruparelia
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nilesh Sutaria
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Gajen Kanaganayagam
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ben Ariff
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael Fertleman
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jon Anderson
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Andrew Chukwuemeka
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Darrel Francis
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Jamil Mayet
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Patrick Serruys
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Justin Davies
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Sayan Sen
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom.
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Van Belle E, Vincent F, Raposo L, Bravo Baptista S, Dupouy P. Reclassification of Treatment Strategy by Routine Coronary Pressure Assessment-Episode 7 of the Saga: The More You Look, the More You Find It! JACC Cardiovasc Interv 2018; 11:2095-8. [PMID: 30336813 DOI: 10.1016/j.jcin.2018.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 09/04/2018] [Indexed: 11/21/2022]
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Yamanaka F, Shishido K, Ochiai T, Moriyama N, Yamazaki K, Sugitani A, Tani T, Tobita K, Mizuno S, Tanaka Y, Murakami M, Takahashi S, Yamazaki S, Saito S. Instantaneous Wave-Free Ratio for the Assessment of Intermediate Coronary Artery Stenosis in Patients With Severe Aortic Valve Stenosis: Comparison With Myocardial Perfusion Scintigraphy. JACC Cardiovasc Interv 2018; 11:2032-2040. [PMID: 30154064 DOI: 10.1016/j.jcin.2018.07.027] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/19/2018] [Accepted: 07/24/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study investigated the diagnostic performance of instantaneous wave-free ratio (iFR) in patients with aortic valve stenosis (AS). BACKGROUND The iFR was introduced as a new, nonpharmacologic stress index of coronary stenosis severity. However, the diagnostic performance of iFR has not been sufficiently explored in patients with severe AS. METHODS We analyzed 95 consecutive patients with AS (57 women) demonstrating intermediate coronary artery stenosis (116 vessels), and compared the iFR values with fractional flow reserve (FFR) values and with adenosine-stress myocardial perfusion imaging as indicators of myocardial ischemia. RESULTS The median value and interquartile range (first quartile [Q1], third quartile [Q3]) of the iFR was 0.86 (Q1 to Q3 range, 0.76 to 0.93), and that of the FFR was 0.84 (Q1 to Q3 range, 0.76 to 0.91). The iFR values correlated well with the FFR values (R = 0.854; p < 0.0001). A receiver operating characteristic analysis demonstrated an optimal cutoff of 0.82 for the iFR to indicate an FFR ≤0.75, with an area under the curve of 0.92. The optimal iFR cutoff value indicating myocardial ischemia on perfusion scintigraphy was 0.82 (area under the curve: 0.84). CONCLUSIONS In patients with severe AS, a good correlation exists between iFR and FFR. Both the iFR and FFR values exhibit good correlation with perfusion scintigraphy-identified myocardial ischemia. The iFR could be a safe diagnostic tool for patients with severe AS. (The Impact of FFR and iFR in Patients with Severe Aortic Stenosis; UMIN000024479).
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Affiliation(s)
- Futoshi Yamanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan.
| | - Koki Shishido
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Tomoki Ochiai
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Noriaki Moriyama
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kazumasa Yamazaki
- Department of Cardiology, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Ayumu Sugitani
- Department of Biometrics, Institute of Biomedical Research, Sapporohigashi Tokushukai Hospital, Sapporo, Japan
| | - Tomoyuki Tani
- Department of Cardiology, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Kazuki Tobita
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shingo Mizuno
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yutaka Tanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Masato Murakami
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Saeko Takahashi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Seiji Yamazaki
- Department of Cardiology, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Shigeru Saito
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan; Department of Cardiology, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Ihdayhid AR, Seneviratne SK, Cameron J, Ko B. Resting Indexes in the Functional Assessment of Left Main and Left Anterior Descending Coronary Stenoses: A Case for Caution. JACC Cardiovasc Interv 2018; 11:1531-1533. [PMID: 30031720 DOI: 10.1016/j.jcin.2018.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Abdul Rahman Ihdayhid
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Clayton, Victoria, Australia
| | - Sujith K Seneviratne
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Clayton, Victoria, Australia
| | - James Cameron
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Clayton, Victoria, Australia
| | - Brian Ko
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Clayton, Victoria, Australia.
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Maini R, Moscona J, Sidhu G, Katigbak P, Fernandez C, Irimpen A, Mogabgab O, Ward C, Samson R, LeJemtel T. Pooled diagnostic accuracy of resting distal to aortic coronary pressure referenced to fractional flow reserve: The importance of resting coronary physiology. J Interv Cardiol 2018; 31:588-598. [PMID: 29707808 DOI: 10.1111/joic.12517] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 03/19/2018] [Accepted: 04/02/2018] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Both resting and hyperemic physiologic methods to guide coronary revascularization improve cardiovascular outcomes compared with angiographic guidance alone. Fractional flow reserve (FFR) remains underutilized due to concerns regarding hyperemia, prompting study of resting distal to aortic coronary pressure (Pd/Pa). Pd/Pa is a vasodilator-free resting index unlike FFR. While Pd/Pa is similar to another resting index, instantaneous wave-free ratio (iFR), it is a whole-cycle measurement not limited to the wave-free diastolic period. Pd/Pa is not validated clinically although multiple accuracy studies have been performed. Our meta-analysis examines the overall diagnostic accuracy of Pd/Pa referenced to FFR, the accepted invasive standard of ischemia. METHODS We searched PubMed, EMBASE, Central, ProQuest, and Web of Science databases for full text articles published through August 9, 2017 addressing the diagnostic accuracy of Pd/Pa referenced to FFR < 0.80. The following keywords were used: "distal coronary artery pressure" OR "Pd/Pa" AND "fractional flow reserve" OR "FFR." RESULTS In total, 14 studies comprising 7004 lesions were identified. Pooled diagnostic accuracy estimates of Pd/Pa versus FFR < 0.80 were: sensitivity, 0.77 (95% CI, 0.75-0.78); specificity, 0.82 (0.81-0.83); positive likelihood ratio, 4.7 (3.3-6.6); negative likelihood ratio, 0.29 (0.24-0.34); diagnostic odds ratio, 18.1 (14.4-22.6); area under the summary receiver-operating characteristic curve of 0.88; and diagnostic accuracy of 0.80 (0.76-0.83). CONCLUSIONS Pd/Pa shows adequate agreement with FFR as a resting index of coronary stenosis severity without the undesired effects and cost of hyperemic agents. Pd/Pa has the potential to guide coronary revascularization with easier application and availability compared with iFR and FFR.
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Affiliation(s)
- Rohit Maini
- Division of Cardiology, Department of Medicine, Tulane University, New Orleans, Louisiana
| | - John Moscona
- Division of Cardiology, Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Gursukhman Sidhu
- The Wright Center for Graduate Medical Education, Scranton, Pennsylvania
| | - Paul Katigbak
- Division of Cardiology, Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Camilo Fernandez
- Division of Precision Medicine, HeartGEN Institute, Boston, Massachusetts
| | - Anand Irimpen
- Division of Cardiology, Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Owen Mogabgab
- Division of Cardiology, Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Charisse Ward
- Division of Cardiology, Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Rohan Samson
- Division of Cardiology, Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Thierry LeJemtel
- Division of Cardiology, Department of Medicine, Tulane University, New Orleans, Louisiana
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Gupta A. "What is the impact of utilizing so-called best practices in percutaneous coronary intervention?": an interview with Atul Gupta. Future Cardiol 2018; 14:121-123. [PMID: 29359966 DOI: 10.2217/fca-2018-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Atul Gupta, MD speaks to Adam Price-Evans, Managing Commissioning Editor of Future Cardiology. Atul Gupta is the Global Chief Medical Officer for the business group Image Guided Therapy at Philips, providing medical guidance to Philips' clinical vision and strategy. As a practicing interventional and diagnostic radiologist, he also serves as a key external clinical voice for Image Guided Therapy. His key responsibilities include supporting innovation and product development in cardiology, peripheral vascular, surgical, oncology interventions, clinical education, office-based labs, medical affairs and new business development and ventures. He went to medical school and completed his postgraduate training in diagnostic radiology and a fellowship in interventional radiology. He maintains a clinical practice, performing interventional and diagnostic radiology in both hospital and office-based lab settings.
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Affiliation(s)
- Atul Gupta
- Royal Philips, Amstelplein 2, 1096 BC Amsterdam, The Netherlands
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Ansheles AA, Sergienko BV, Darenskiy ID, Gramovich VV, Zharova AE, Mitroshkin GM, Matchin GY, Atanesyan VR. [Comparison of Diagnostic Values of Instantaneous Wave-Free R atio and Fractional Flow R eserve With Noninvasive Methods for Evaluating Myocardial Ischemia in Assessment of the Functional Significance of Intermediate Coronary Stenoses in Patients With Chronic Ischemic Heart Disease]. Kardiologiia 2017; 57:11-19. [PMID: 29041887 DOI: 10.18087/cardio.2017.8.10012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare the diagnostic accuracy of instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) with noninvasive methods in assessment of the functional significance of moderate coronary stenoses in patients with chronic ischemic heart disease (IHD). METHODS We included in this study 50 patients with chronic or suspected IHD and moderate coronary stenoses (50-70%; 74 stenoses). Values of iFR and FFR were determined within 10 days after noninvasive stress tests (combination of stress-echo and SPECT). The values of iFR and FFR were compared with the results of noninvasive methods by ROC-analysis. Coronary artery stenosis was considered functionally important if at least one of noninvasive tests (stress-echo or SPECT) demonstrated positive result. RESULTS The results of noninvasive stress-tests were positive in 14 patients (28%). ROC area under the curve (AUC) for iFR - 0.961±0.019 (95%CI 0.888-0.992). The best cut-off point for iFR is 0.92 (sensitivity 100, specificity 84%). ROC AUC for FFR - 0.893±0.041 (95%CI 0.79-0.96). The best cut-off point for FFR is 0.81 (sensitivity 100% and specificity 69%). There was no significant difference between iFR and FFR ROC-curves (р=0.0845). CONCLUSION The values of iFR and FFR have equivalent agreement with the results of noninvasive tests commonly used to detect myocardial ischemia in patients with moderate coronary stenoses.
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Affiliation(s)
- A A Ansheles
- Russian Cardiology Research and Production Complex
| | | | - I D Darenskiy
- Institute of Cardiology of Russian Cardiology Scientific and Production Complex
| | - V V Gramovich
- Institute of Cardiology of Russian Cardiology Scientific and Production Complex
| | - A E Zharova
- Institute of Cardiology of Russian Cardiology Scientific and Production Complex
| | - G M Mitroshkin
- Institute of Cardiology of Russian Cardiology Scientific and Production Complex
| | - G Y Matchin
- Institute of Cardiology of Russian Cardiology Scientific and Production Complex
| | - V R Atanesyan
- Institute of Cardiology of Russian Cardiology Scientific and Production Complex
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Affiliation(s)
- Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (C.B., J.B.M.) .,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom (C.B., K.G.O.)
| | - John D McClure
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (C.B., J.B.M.)
| | - Keith G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom (C.B., K.G.O.)
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Ding WY, Nair S, Appleby C. Diagnostic accuracy of instantaneous wave free-ratio in clinical practice. J Interv Cardiol 2017; 30:564-569. [PMID: 28853190 DOI: 10.1111/joic.12422] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/11/2017] [Accepted: 07/17/2017] [Indexed: 01/10/2023] Open
Abstract
AIMS To evaluate the correlation between iFR and FFR in real-world clinical practice. METHODS AND RESULTS Retrospective, single-centre study of 229 consecutive pressure-wire studies (np = 158). Real-time iFR and FFR measurements were performed for angiographically borderline stenoses. Functionally significant stenoses were defined as iFR <0.86 or FFR ≤0.80. An iFR between 0.86 and 0.93 was considered within the grey zone (Hybrid approach). Median iFR and FFR (IQR) were 0.92 (0.87-0.95) and 0.83 (0.76-0.89), respectively. Pearson's correlation coefficient was 0.75 (P < 0.001). Bland-Altman plot showed a mean difference between iFR and FFR that remained consistent throughout the range of values. The optimal iFR cutoff was 0.91-sensitivity 80%, specificity 82% with ROC area under curve of 89%. Using the Hybrid iFR-FFR strategy, we demonstrated high accuracy of iFR results-sensitivity 95%, specificity 96%, PPV 95%, and NPV 96%. In addition, this method would have avoided adenosine in 56% of patients. Mean follow-up period was 17.2 (±3.4) months. All-cause mortality was 3.2% (np = 5) and repeat intervention was required in six lesions (2.6%). CONCLUSIONS This study demonstrates that iFR is a valuable adjunct to FFR using the Hybrid iFR-FFR strategy in a real-world population. The use of adenosine may be avoided in about half the cases.
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Affiliation(s)
- Wern Yew Ding
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Satheesh Nair
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Clare Appleby
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
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