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Liu H, Leung TWH, Shi L. Microvascular resistance and collateral circulation in simulating the stenotic coronary arteries. J Appl Physiol (1985) 2018; 125:1352. [PMID: 30354945 DOI: 10.1152/japplphysiol.00283.2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Haipeng Liu
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.,Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Thomas Wai Hong Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Lin Shi
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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Moscona JC, Stencel JD, Milligan G, Salmon C, Maini R, Katigbak P, Saleh Q, Nelson R, Srivastav S, Mogabgab O, Samson R, Le Jemtel T. Physiologic assessment of moderate coronary lesions: a step towards complete revascularization in coronary artery bypass grafting. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:300. [PMID: 30211188 DOI: 10.21037/atm.2018.06.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background An accurate diagnostic assessment of coronary artery disease is crucial for patients undergoing coronary artery bypass grafting (CABG). Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) to guide complete revascularization have not been adequately studied in patients prior to CABG. We compared an anatomic to a physiologic assessment of moderate coronary lesions (40-70% stenosis) in patients referred for CABG. Methods We retrospectively reviewed 109 medical records of patients who underwent CABG at Tulane Medical Center from 2014 to 2016. Patients were divided into an FFR/iFR-guided and an angiography-guided group. Clinical characteristics, procedural outcomes, and clinical outcomes for the two groups were compared over an 18-month follow-up period. Results There were significantly higher rates of three-vessel anastomoses (85.7% vs. 74.7%, P<0.05) and venous grafting (85.7% vs. 76.8%, P<0.05) in the FFR/iFR group. The FFR/iFR group had a lower rate of grafts placed to the left anterior descending artery (LAD) distribution than the angiography group (7.1% vs. 29.5%, P<0.05). The FFR/iFR group had a higher rate of grafts placed to the left circumflex (LCx) artery distribution than the angiography group (28.6% vs. 9.5%, P<0.05). We observed a trend toward reduction in major adverse cardiac events (MACEs) (7.1% vs. 11.6%, P=0.369) and angina (0.0% vs. 6.3%, P=0.429) in the FFR/iFR group compared to the angiography group over 18 months. Conclusions Physiologic assessment of coronary lesions can effectively guide complete revascularization in patients undergoing CABG. Moreover, FFR/iFR-guided CABG was associated with significantly higher rates of three-vessel anastomoses, venous grafting, and graft distribution to the circumflex system.
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Affiliation(s)
- John C Moscona
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Jason D Stencel
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Gregory Milligan
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Christopher Salmon
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Rohit Maini
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Paul Katigbak
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Qusai Saleh
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Ryan Nelson
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sudesh Srivastav
- Department of Global Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Owen Mogabgab
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Rohan Samson
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Thierry Le Jemtel
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
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Coronary artery disease in post-menopausal women: are there appropriate means of assessment? Clin Sci (Lond) 2018; 132:1937-1952. [DOI: 10.1042/cs20180067] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 08/07/2018] [Accepted: 08/10/2018] [Indexed: 01/08/2023]
Abstract
The recognition of sex differences in cardiovascular disease, particularly the manifestations of coronary artery disease (CAD) in post-menopausal women, has introduced new challenges in not only understanding disease mechanisms but also identifying appropriate clinical means of assessing the efficacy of management strategies. For example, the majority of treatment algorithms for CAD are derived from the study of males, focus on epicardial stenoses, and inadequately account for the small intramyocardial vessel disease in women. However, newer investigational modalities, including stress perfusion cardiac magnetic resonance imaging and positron emission tomography are providing enhanced diagnostic accuracy and prognostication for women with microvascular disease. Moreover, these investigations may soon be complemented by simpler screening tools such as retinal vasculature imaging, as well as novel biomarkers (e.g. heat shock protein 27). Hence, it is vital that robust, sex-specific cardiovascular imaging modalities and biomarkers continue to be developed and are incorporated into practice guidelines that are used to manage women with CAD, as well as gauge the efficacy of any new treatment modalities. This review provides an overview of some of the sex differences in CAD and highlights emerging advances in the investigation of CAD in post-menopausal women.
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54
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Piek JJ. Coronary pressure-derived parameters. Neth Heart J 2018; 26:375-376. [PMID: 29943116 PMCID: PMC6046663 DOI: 10.1007/s12471-018-1128-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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55
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Corcoran D, Young R, Cialdella P, McCartney P, Bajrangee A, Hennigan B, Collison D, Carrick D, Shaukat A, Good R, Watkins S, McEntegart M, Watt J, Welsh P, Sattar N, McConnachie A, Oldroyd KG, Berry C. The effects of remote ischaemic preconditioning on coronary artery function in patients with stable coronary artery disease. Int J Cardiol 2018; 252:24-30. [PMID: 29249435 PMCID: PMC5761717 DOI: 10.1016/j.ijcard.2017.10.082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 10/09/2017] [Accepted: 10/19/2017] [Indexed: 01/06/2023]
Abstract
Background Remote ischaemic preconditioning (RIPC) is a cardioprotective intervention invoking intermittent periods of ischaemia in a tissue or organ remote from the heart. The mechanisms of this effect are incompletely understood. We hypothesised that RIPC might enhance coronary vasodilatation by an endothelium-dependent mechanism. Methods We performed a prospective, randomised, sham-controlled, blinded clinical trial. Patients with stable coronary artery disease (CAD) undergoing elective invasive management were prospectively enrolled, and randomised to RIPC or sham (1:1) prior to angiography. Endothelial-dependent vasodilator function was assessed in a non-target coronary artery with intracoronary infusion of incremental acetylcholine doses (10− 6, 10− 5, 10− 4 mol/l). Venous blood was sampled pre- and post-RIPC or sham, and analysed for circulating markers of endothelial function. Coronary luminal diameter was assessed by quantitative coronary angiography. The primary outcome was the between-group difference in the mean percentage change in coronary luminal diameter following the maximal acetylcholine dose (Clinicaltrials.gov identifier: NCT02666235). Results 75 patients were enrolled. Following angiography, 60 patients (mean ± SD age 57.5 ± 8.5 years; 80% male) were eligible and completed the protocol (n = 30 RIPC, n = 30 sham). The mean percentage change in coronary luminal diameter was − 13.3 ± 22.3% and − 2.0 ± 17.2% in the sham and RIPC groups respectively (difference 11.32%, 95%CI: 1.2– 21.4, p = 0.032). This remained significant when age and sex were included as covariates (difference 11.01%, 95%CI: 1.01– 21.0, p = 0.035). There were no between-group differences in endothelial-independent vasodilation, ECG parameters or circulating markers of endothelial function. Conclusions RIPC attenuates the extent of vasoconstriction induced by intracoronary acetylcholine infusion. This endothelium-dependent mechanism may contribute to the cardioprotective effects of RIPC.
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Affiliation(s)
- D Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - R Young
- Robertson Centre for Biostatistics, University of Glasgow, Scotland, UK
| | - P Cialdella
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - P McCartney
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - A Bajrangee
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - B Hennigan
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - D Collison
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK
| | - D Carrick
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - A Shaukat
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - R Good
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - S Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - M McEntegart
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - J Watt
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - P Welsh
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK
| | - N Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK
| | - A McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Scotland, UK
| | - K G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK
| | - C Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland, UK.
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Williams RP, Asrress KN, Lumley M, Arri S, Patterson T, Ellis H, Manou‐Stathopoulou V, Macfarlane C, Chandran S, Moschonas K, Oakeshott P, Lockie T, Chiribiri A, Clapp B, Perera D, Plein S, Marber MS, Redwood SR. Deleterious Effects of Cold Air Inhalation on Coronary Physiological Indices in Patients With Obstructive Coronary Artery Disease. J Am Heart Assoc 2018; 7:e008837. [PMID: 30762468 PMCID: PMC6064824 DOI: 10.1161/jaha.118.008837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 04/11/2018] [Indexed: 01/09/2023]
Abstract
Background Cold air inhalation during exercise increases cardiac mortality, but the pathophysiology is unclear. During cold and exercise, dual-sensor intracoronary wires measured coronary microvascular resistance ( MVR ) and blood flow velocity ( CBF ), and cardiac magnetic resonance measured subendocardial perfusion. Methods and Results Forty-two patients (62±9 years) undergoing cardiac catheterization, 32 with obstructive coronary stenoses and 10 without, performed either (1) 5 minutes of cold air inhalation (5°F) or (2) two 5-minute supine-cycling periods: 1 at room temperature and 1 during cold air inhalation (5°F) (randomized order). We compared rest and peak stress MVR , CBF , and subendocardial perfusion measurements. In patients with unobstructed coronary arteries (n=10), cold air inhalation at rest decreased MVR by 6% ( P=0.41), increasing CBF by 20% ( P<0.01). However, in patients with obstructive stenoses (n=10), cold air inhalation at rest increased MVR by 17% ( P<0.01), reducing CBF by 3% ( P=0.85). Consequently, in patients with obstructive stenoses undergoing the cardiac magnetic resonance protocol (n=10), cold air inhalation reduced subendocardial perfusion ( P<0.05). Only patients with obstructive stenoses performed this protocol (n=12). Cycling at room temperature decreased MVR by 29% ( P<0.001) and increased CBF by 61% ( P<0.001). However, cold air inhalation during cycling blunted these adaptations in MVR ( P=0.12) and CBF ( P<0.05), an effect attributable to defective early diastolic CBF acceleration ( P<0.05) and associated with greater ST -segment depression ( P<0.05). Conclusions In patients with obstructive coronary stenoses, cold air inhalation causes deleterious changes in MVR and CBF . These diminish or abolish the normal adaptations during exertion that ordinarily match myocardial blood supply to demand.
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Affiliation(s)
- Rupert P. Williams
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Kaleab N. Asrress
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Matthew Lumley
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Satpal Arri
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Tiffany Patterson
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Howard Ellis
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | | | - Catherine Macfarlane
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Shruthi Chandran
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Kostantinos Moschonas
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Pippa Oakeshott
- Population Health Research InstituteSt George's University of LondonUnited Kingdom
| | - Timothy Lockie
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Amedeo Chiribiri
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Brian Clapp
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Divaka Perera
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Sven Plein
- Leeds UniversityLeeds Teaching Hospitals NHS TrustLeedsUnited Kingdom
| | - Michael S. Marber
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Simon R. Redwood
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
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Driessen RS, Danad I, Stuijfzand WJ, Schumacher SP, Knuuti J, Mäki M, Lammertsma AA, van Rossum AC, van Royen N, Raijmakers PG, Knaapen P. Impact of Revascularization on Absolute Myocardial Blood Flow as Assessed by Serial [
15
O]H
2
O Positron Emission Tomography Imaging. Circ Cardiovasc Imaging 2018; 11:e007417. [DOI: 10.1161/circimaging.117.007417] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 03/27/2018] [Indexed: 01/07/2023]
Abstract
Background:
The main goal of coronary revascularization is to restore myocardial perfusion in case of ischemia, causing coronary artery disease. Yet, little is known on the effect of revascularization on absolute myocardial blood flow (MBF). Therefore, the present prospective study assesses the impact of coronary revascularization on absolute MBF as measured by [
15
O]H
2
O positron emission tomography and fractional flow reserve (FFR) in patients with stable coronary artery disease.
Methods and Results:
Fifty-three patients (87% men, mean age 58.7±9.0 years) with suspected coronary artery disease were included prospectively. All patients underwent serial [
15
O]H
2
O positron emission tomography perfusion imaging at baseline and after revascularization by either percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery. FFR was routinely measured at baseline and directly post-PCI. After revascularization, regional rest and stress MBF improved from 0.77±0.16 to 0.86±0.25 mL/min/g and from 1.57±0.59 to 2.48±0.91 mL/min/g, respectively, yielding an increase in coronary flow reserve from 2.02±0.69 to 2.94±0.94 (
P
<0.01 for all). Mean FFR at baseline improved post-PCI from 0.61±0.17 to 0.89±0.08 (
P
<0.01). After PCI, an increase in FFR paralleled improvement in absolute myocardial perfusion as reflected by stress MBF and coronary flow reserve (
r
= 0.74 and
r
= 0.71, respectively,
P
<0.01 for both). PCI demonstrated a greater improvement of regional stress MBF as compared with coronary artery bypass graft surgery (1.14±1.11 versus 0.66±0.69 mL/min/g, respectively,
P
=0.02). However, patients undergoing bypass grafting had a more advanced stage of coronary artery disease and more incomplete revascularizations.
Conclusion:
Successful coronary revascularization has a significant and positive impact on absolute myocardial perfusion as assessed by serial quantitative [
15
O]H
2
O positron emission tomography. Notably, improvement of FFR after PCI was directly related to the increase in hyperemic MBF.
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Affiliation(s)
- Roel S. Driessen
- Department of Cardiology (R.S.D., I.D., W.J.S., S.P.S., A.C.v.R., N.v.R., P.K.)
| | - Ibrahim Danad
- Department of Cardiology (R.S.D., I.D., W.J.S., S.P.S., A.C.v.R., N.v.R., P.K.)
| | | | | | - Juhani Knuuti
- VU University Medical Center, Amsterdam, The Netherlands. Turku PET Centre, Turku University Hospital and University of Turku, Finland (J.K., M.M.)
| | - Maija Mäki
- VU University Medical Center, Amsterdam, The Netherlands. Turku PET Centre, Turku University Hospital and University of Turku, Finland (J.K., M.M.)
| | | | | | - Niels van Royen
- Department of Cardiology (R.S.D., I.D., W.J.S., S.P.S., A.C.v.R., N.v.R., P.K.)
| | | | - Paul Knaapen
- Department of Cardiology (R.S.D., I.D., W.J.S., S.P.S., A.C.v.R., N.v.R., P.K.)
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Lee JM, Kim HK, Lim KS, Park JK, Choi KH, Park J, Hwang D, Rhee TM, Yang JH, Shin ES, Nam CW, Doh JH, Hahn JY, Koo BK, Jeong MH. Influence of Local Myocardial Damage on Index of Microcirculatory Resistance and Fractional Flow Reserve in Target and Nontarget Vascular Territories in a Porcine Microvascular Injury Model. JACC Cardiovasc Interv 2018; 11:717-724. [PMID: 29605246 DOI: 10.1016/j.jcin.2017.11.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 11/21/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the influence of microvascular damage in one vessel territory on invasively measured physiological parameters in the other vessel, using a porcine microvascular damage model. BACKGROUND Although fractional flow reserve (FFR)-guided decision-making for the nonculprit stenosis in patients with acute myocardial infarction has been reported to be better than angiography-guided revascularization, there have been debates regarding the influence of microvascular dysfunction on measured FFR in nonculprit vessels. METHODS In Yorkshire swine, microvascular damage was induced with selective intracoronary injection of microspheres (100 μm × 105 each) into the left anterior descending artery (LAD). Coronary stenosis was created in both the LAD and the left circumflex artery (LCx) using balloon catheters. Coronary physiological changes were assessed with index of microcirculatory resistance (IMR) and FFR at baseline and at each subsequent injection of microsphere up to a fifth dose in both the LAD and LCx. Measurements were repeated 5 times at each stage, and a total of 424 measurements were made in 12 Yorkshire swine models. RESULTS The median area stenosis in LAD and LCx was 48.1% (interquartile range: 40.8% to 50.4%) and 47.9% (interquartile range: 31.1% to 62.9%), respectively. At baseline, FFR in the LAD was lower than that in the LCx (0.89 ± 0.01 and 0.94 ± 0.01; p < 0.001). There was no difference in the IMR (18.4 ± 5.8 U and 17.9 ± 1.2 U; p = 0.847). With repeated injections of microspheres, IMR in LAD was significantly increased, up to 77.7 ± 15.7 U (p < 0.001). Given the same stenosis, FFR in the LAD was also significantly increased, up to 0.98 ± 0.01 along with IMR increase (p < 0.001). Conversely, IMR and FFR were not changed in the LCx throughout repeated injury to the LAD territory (p = 0.105 and p = 0.286 for IMR and FFR, respectively). The increase in LAD IMR was mainly driven by the increase in hyperemic mean transit time (p < 0.001). CONCLUSIONS In Yorkshire swine models, local microvascular damage increased both FFR and IMR in a vessel supplying target myocardial territory. However, IMR and FFR were maintained in the other vessel. These physiological results in swine support the concept that FFR measurement might provide useful information for evaluating nonculprit lesions in clinical settings involving significant acute myocardial injury.
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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, Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Kyung Seob Lim
- 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
| | - Jonghanne Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Tae-Min Rhee
- National Maritime Medical Center, Changwon, 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; Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, 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
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea; Institute on Aging, Seoul National University, Seoul, Korea.
| | - Myung Ho Jeong
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea.
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AL-Obaidi FR, Fearon WF, Yong AS. Invasive physiological indices to determine the functional significance of coronary stenosis. IJC HEART & VASCULATURE 2018; 18:39-45. [PMID: 29876502 PMCID: PMC5988484 DOI: 10.1016/j.ijcha.2018.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/13/2018] [Indexed: 01/10/2023]
Abstract
Physiological measurements are now commonly used to assess coronary lesions in the cardiac catheterisation laboratory, and this practice is evidence-based and supported by clinical guidelines. Fractional flow reserve is currently the gold standard method to determine whether coronary lesions are functionally significant, and is used to guide revascularization. There are however several other physiological measurements that have been proposed as alternatives to the fractional flow reserve. This review aims to comprehensively discuss physiological indices that can be used in the cardiac catheterisation laboratory to determine the functional significance of coronary lesions. We will focus on their advantages and disadvantages, and the current evidence supporting their use.
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Affiliation(s)
- Firas R. AL-Obaidi
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- College of Medicine, University of Thi Qar, Iraq
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andy S.C. Yong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- ANZAC Research Institute, Concord Hospital, Sydney, Australia
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Ahn SG, Suh J, Hung OY, Lee HS, Bouchi YH, Zeng W, Gandhi R, Eshtehardi P, Gogas BD, Samady H. Discordance Between Fractional Flow Reserve and Coronary Flow Reserve: Insights From Intracoronary Imaging and Physiological Assessment. JACC Cardiovasc Interv 2018; 10:999-1007. [PMID: 28521932 DOI: 10.1016/j.jcin.2017.03.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/15/2017] [Accepted: 03/06/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the epicardial and microvascular substrates associated with discordances between fractional flow reserve (FFR) and coronary flow reserve (CFR) values. BACKGROUND Discordances between FFR and CFR remain poorly characterized. METHODS FFR, hyperemic stenosis resistance (HSR), and intravascular ultrasound were performed as indexes of epicardial function and CFR and hyperemic microvascular resistance (HMR) as measures of microvascular function in 94 patients with moderate coronary stenosis. Maximal plaque burden (PBmax), HSR, and HMR were calculated in 4 quadrants based on values of FFR ≤0.80 and CFR ≤2.0 as follows: concordant normal (preserved FFR and CFR), concordant abnormal (low FFR and CFR), discordant low FFR and preserved CFR, and discordant preserved FFR and low CFR. RESULTS Sixty-four patients (68%) had concordant FFR and CFR findings, and 30 patients (32%) had discordant FFR and CFR. Compared with patients with preserved FFR and CFR, those with low FFR and CFR had higher PBmax (p = 0.003), higher HSR (p < 0.001), and similar HMR. Among patients with preserved FFR, those with reduced CFR had similar PBmax and HSR but a trend toward higher HMR (p = 0.058) compared with patients with preserved CFR. Among patients with reduced FFR, those with preserved CFR had lower PBmax (p = 0.004), a trend toward lower HSR (p = 0.065), and lower HMR (p = 0.03) compared with patients with reduced CFR. Furthermore, compared with patients with preserved FFR and low CFR, those with low FFR and preserved CFR had higher HSR (p = 0.022) but lower HMR (p = 0.003). CONCLUSIONS In patients with moderate coronary stenosis, preserved FFR and low CFR is associated with increased microvascular resistance, while low FFR and preserved CFR has modest epicardial stenosis and preserved microvascular function.
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Affiliation(s)
- Sung Gyun Ahn
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jon Suh
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea; Division of Cardiology, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, Bucheon, Korea
| | - Olivia Y Hung
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Hee Su Lee
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Yasir H Bouchi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Wenjie Zeng
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rounak Gandhi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Parham Eshtehardi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bill D Gogas
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Habib Samady
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
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GOVINDARAJU KALIMUTHU, VISWANATHAN GIRISHN, BADRUDDIN IRFANANJUM, WELDEMARIAM SIRAKAREGAWI, GEBREHIWOT WOLDUZINA, KAMANGAR SARFARAZ. THE MECHANICAL FACTORS INFLUENCING THE ASSESSMENT OF INTERMEDIATE STENOSIS SEVERITY EXPLAINED THROUGH FRACTIONAL FLOW RESERVE. J MECH MED BIOL 2017. [DOI: 10.1142/s0219519417300010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Assessment of intermediate coronary lesions with diameter stenosis of 40% to 70% severity is being a challenge for cardiologist to identify potentially ischemic stenosis for revascularization and nonculprit stenosis which can be deferred from stenting. An invasive coronary angiography and intravascular ultrasound provide anatomic information of stenosis severity whereas an invasive fractional flow reserve index (FFR) provides the functional significance of the stenosis severity. The measurement of functional significance of stenosis severity minimizes the procedural complications such as coronary dissection, in stent restenosis etc. rather than anatomical significance measure. The FFR cutoff value of [Formula: see text]0.8 is used to distinguish ischemic and nonischemic stenosis. The FFR is clinically well validated even though it is influenced by the mechanical factors such as hyperemic flow and guide wire insertion. In recent times, noninvasive coronary computed tomography (CCTA) modality has become popular in the diagnosis of coronary artery disease. The CCTA permits the assessment of cross-sectional parameters such as minimum lumen area and lumen diameter, lesion length and plaque morphology. However, the CCTA provides limited information on the functional significance of stenotic lesions as compared to FFR. The purpose of this review is to discuss the mechanical factors influencing the invasive FFR while assessing the functional significance of intermediate stenosis severity. In addition, the hidden mechanical factors influencing the noninvasive CCTA assessment of stenosis severity will be discussed from the critical information obtained from FFR which could be beneficial for the clinician particularly in the assessment of intermediate stenosis severity.
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Affiliation(s)
- KALIMUTHU GOVINDARAJU
- Ethiopian Institute of Technology, School of Mechanical and Industrial Engineering, Mekelle University, Mekelle, Ethiopia
| | | | | | - SIRAK AREGAWI WELDEMARIAM
- Ethiopian Institute of Technology, School of Mechanical and Industrial Engineering, Mekelle University, Mekelle, Ethiopia
| | - WOLDU ZINA GEBREHIWOT
- Ethiopian Institute of Technology, School of Mechanical and Industrial Engineering, Mekelle University, Mekelle, Ethiopia
| | - SARFARAZ KAMANGAR
- Department of Mechanical Engineering, University of Malaya, Malaysia
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van de Hoef TP, Petraco R, van Lavieren MA, Nijjer S, Nolte F, Sen S, Echavarria-Pinto M, Henriques JPS, Koch KT, Baan J, de Winter RJ, Siebes M, Spaan JAE, Tijssen JGP, Meuwissen M, Escaned J, Davies JE, Piek JJ. Basal stenosis resistance index derived from simultaneous pressure and flow velocity measurements. EUROINTERVENTION 2017; 12:e199-207. [PMID: 27290679 DOI: 10.4244/eijv12i2a33] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIMS Vasodilator-free basal stenosis resistance (BSR) equals fractional flow reserve (FFR) accuracy for ischaemia-inducing stenoses. Nonetheless, basal haemodynamic variability may impair BSR accuracy compared with hyperaemic stenosis resistance (HSR). We evaluated the influence of basal haemodynamic variability, as encountered in practice, on BSR accuracy versus HSR when derived from simultaneous pressure and flow velocity measurements, and determined its diagnostic performance for HSR-defined significant stenoses. METHODS AND RESULTS Simultaneous coronary pressure and flow velocity were obtained in 131 stenoses. The impact of basal haemodynamic conditions on BSR was evaluated by means of their relationship with the relative difference between BSR and HSR. Diagnostic performance of BSR, FFR, iFR, and resting Pd/Pa was assessed by comparing the area under the curve (AUC), using HSR as reference standard. The relative difference between BSR and HSR was not associated with basal heart rate, aortic pressure or rate pressure product. Among all stenoses, as well as within the 0.6-0.9 FFR range, BSR AUC was significantly greater than resting Pd/Pa and iFR AUC; all other AUCs were equivalent. CONCLUSIONS With simultaneous pressure and flow velocity measurements, basal conditions do not systematically limit BSR accuracy compared with HSR. Consequently, diagnostic performance of BSR is equivalent to FFR, and closely approximates HSR.
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Affiliation(s)
- Tim P van de Hoef
- AMC Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Niccoli G, Indolfi C, Davies JE. Evaluation of intermediate coronary stenoses in acute coronary syndromes using pressure guidewire. Open Heart 2017; 4:e000431. [PMID: 28761673 PMCID: PMC5515130 DOI: 10.1136/openhrt-2016-000431] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 08/15/2016] [Accepted: 08/30/2016] [Indexed: 01/10/2023] Open
Abstract
Fractional flow reserve (FFR) is increasingly used to guide myocardial revascularisation. However, supporting evidence regarding its use originates from studies that have enrolled mainly patients with stable angina, while patients with acute coronary syndromes (ACS) have not been included. Notably, multifactorial microvascular dysfunction and an increased sympathetic tone in patients with ACS may lead to blunted response to adenosine and false-negative results of FFR due to submaximal hyperaemia. This may raise the possibility of deferring treatment of stenosis that instead would have needed dilatation, thus leaving a residual risk of preventable cardiac events. In this literature review, we aim at summarising laboratory and clinical investigations concerning the use of FFR in culprit and non-culprit lesions in ACS. Furthermore, we will report recent data on instantaneous wave-free ratio, an adenosine-free index of functional stenosis severity, in stable coronary artery disease and in patients with ACS.
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Affiliation(s)
- Giampaolo Niccoli
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences & URT CNR, Magna Graecia University, Catanzaro, Italy
| | - Justin E Davies
- National Heart and Lung Institute, International Centre for Circulatory Health, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
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Yonetsu T, Murai T, Kanaji Y, Lee T, Matsuda J, Usui E, Hoshino M, Araki M, Niida T, Hada M, Ichijo S, Hamaya R, Kanno Y, Kakuta T. Significance of Microvascular Function in Visual-Functional Mismatch Between Invasive Coronary Angiography and Fractional Flow Reserve. J Am Heart Assoc 2017; 6:e005916. [PMID: 28566295 PMCID: PMC5669189 DOI: 10.1161/jaha.117.005916] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/26/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite a moderate correlation between angiographical stenosis and physiological significance, the mechanism of discordance has not been fully elucidated, particularly regarding the significance of microvascular function. This study sought to clarify whether microvascular function affects visual-functional mismatch between quantitative coronary angiography (QCA) and fractional flow reserve (FFR). METHODS AND RESULTS We assessed QCA, FFR, coronary flow reserve, and the index of microcirculatory resistance in 849 non-left-main coronary lesions with visually estimated intermediate stenoses from 532 patients. Clinical and lesion-specific characteristics and physiological parameters associated with mismatch and reverse mismatch were studied. Coronary flow reserve and index of microcirculatory resistance showed a weak, but significant, correlation with FFR (R=0.306, P<0.001 and R=0.158, P<0.001, respectively). Four hundred twenty-two lesions were visually nonsignificant (diameter stenosis assessed by QCA [QCA-DS] ≤50%) and 427 lesions were visually significant (QCA-DS >50%). Among visually nonsignificant lesions, FFR ≤0.80 (reverse mismatch) was observed in 129 lesions (30.6%). Among visually significant lesions, FFR >0.80 (mismatch) were observed in 179 lesions (41.9%). The significant predictors of reverse mismatch were male sex, nonculprit lesions of acute coronary syndrome, left anterior descending artery location, smaller QCA reference diameter, greater QCA-DS, lower coronary flow reserve, and lower index of microcirculatory resistance. Mismatch was associated with right coronary artery location, greater QCA reference diameter, smaller QCA-DS, lesion length, higher coronary flow reserve, and higher index of microcirculatory resistance. CONCLUSIONS There was a high prevalence of visual-functional mismatches between QCA and FFR. The discrepancy was related to clinical characteristics, lesion-specific factors, and microvascular resistance that was undistinguishable by coronary angiography, thus suggesting the importance of physiological lesion assessment.
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Affiliation(s)
- Taishi Yonetsu
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Tadashi Murai
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Tetsumin Lee
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Junji Matsuda
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Eisuke Usui
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Masahiro Hoshino
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Makoto Araki
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Takayuki Niida
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Masahiro Hada
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Sadamitsu Ichijo
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Rikuta Hamaya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Yoshinori Kanno
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
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van Brussel PM, van de Hoef TP, de Winter RJ, Vogt L, van den Born BJ. Hemodynamic Measurements for the Selection of Patients With Renal Artery Stenosis: A Systematic Review. JACC Cardiovasc Interv 2017; 10:973-985. [PMID: 28521931 DOI: 10.1016/j.jcin.2017.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/27/2017] [Accepted: 02/12/2017] [Indexed: 11/25/2022]
Abstract
Interventions targeting renal artery stenoses have been shown to lower blood pressure and preserve renal function. In recent studies, the efficacy of catheter-based percutaneous transluminal renal angioplasty with stent placement has been called into question. In the identification of functional coronary lesions, hyperemic measurements have earned a place in daily practice for clinical decision making, allowing discrimination between solitary coronary lesions and diffuse microvascular disease. Next to differences in clinical characteristics, the selection of renal arteries suitable for intervention is currently on the basis of anatomic grading of the stenosis by angiography rather than functional assessment under hyperemia. It is conceivable that, like the coronary circulation, functional measurements may better predict therapeutic efficacy of percutaneous transluminal renal angioplasty with stent placement. In this systematic review, the authors evaluate the available clinical evidence on the optimal hyperemic agents to induce intrarenal hyperemia, their association with anatomic grading, and their predictive value for treatment effects. In addition, the potential value of combined pressure and flow measurements to discriminate macrovascular from microvascular disease is discussed.
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Affiliation(s)
- Peter M van Brussel
- Heart Center, Department of Interventional Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Tim P van de Hoef
- Heart Center, Department of Interventional Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Robbert J de Winter
- Heart Center, Department of Interventional Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Liffert Vogt
- Department of Nephrology, Academic Medical Center, Amsterdam, the Netherlands
| | - Bert-Jan van den Born
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands.
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Shah T, Geleris JD, Zhong M, Swaminathan RV, Kim LK, Feldman DN. Fractional flow reserve to guide surgical coronary revascularization. J Thorac Dis 2017; 9:S317-S326. [PMID: 28540075 DOI: 10.21037/jtd.2017.03.55] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Coronary angiography has traditionally been used as the final diagnostic tool in the evaluation of coronary artery disease (CAD). However, conventional angiography identifies anatomically obstructive coronary disease, but it is limited in its ability to identify hemodynamically significant lesions. The emergence of fractional flow reserve (FFR) technology, in conjunction with angiography, offers a functional, as well as anatomic, assessment of epicardial coronary obstructions. Several pivotal studies have demonstrated that FFR-guided coronary revascularization is a safe and effective in patients with single and multivessel CAD. There are emerging data to suggest that FFR may also play an integral role in planning surgical revascularization and in the evaluation of post-coronary artery bypass patients and their graft patency. This review will explore the physiologic underpinnings of FFR methodology, its clinical value and limitations, and its applications in coronary artery bypass grafting (CABG) surgery.
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Affiliation(s)
- Tara Shah
- Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
| | - Joshua D Geleris
- Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
| | - Ming Zhong
- Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
| | - Rajesh V Swaminathan
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC 27705, USA
| | - Luke K Kim
- Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
| | - Dmitriy N Feldman
- Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
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68
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Practical Considerations of Fractional Flow Reserve Utilization to Guide Revascularization. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:13. [PMID: 28281238 DOI: 10.1007/s11936-017-0514-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OPINION STATEMENT Invasive angiography has long been the gold standard for the diagnosis of obstructive coronary artery disease (CAD). However, the relationship between angiographic measures of stenosis and coronary blood flow is complex, and there is frequent discordance between the visual assessment of a stenotic lesion and its effect on myocardial perfusion. Fractional flow reserve is a rapidly emerging invasive means of assessing the physiologic significance of an epicardial stenosis. This review provides a pragmatic understanding of the physiologic principles that guide fractional flow reserve (FFR), sheds light on its nuances, and explores the most landmark investigations. We will also discuss how the measurement of FFR can be helpful or limiting in several common clinical situations.
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69
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Shome JS, Perera D, Plein S, Chiribiri A. Current perspectives in coronary microvascular dysfunction. Microcirculation 2017; 24. [DOI: 10.1111/micc.12340] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 12/06/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Joy S. Shome
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
| | - Divaka Perera
- Cardiovascular Division; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
| | - Sven Plein
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
- Division of Biomedical Imaging; Multidisciplinary Cardiovascular Research Centre; Leeds Institute of Cardiovascular and Metabolic Medicine; University of Leeds; Leeds UK
| | - Amedeo Chiribiri
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
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Eftekhari A, Min J, Achenbach S, Marwan M, Budoff M, Leipsic J, Gaur S, Jensen JM, Ko BS, Christiansen EH, Kaltoft A, Bøtker HE, Jensen JF, Nørgaard BL. Fractional flow reserve derived from coronary computed tomography angiography: diagnostic performance in hypertensive and diabetic patients. Eur Heart J Cardiovasc Imaging 2016; 18:1351-1360. [DOI: 10.1093/ehjci/jew209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/11/2016] [Indexed: 12/14/2022] Open
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Murai T, Lee T, Kanaji Y, Matsuda J, Usui E, Araki M, Niida T, Hishikari K, Ichijyo S, Hamaya R, Yonetsu T, Isobe M, Kakuta T. The influence of elective percutaneous coronary intervention on microvascular resistance: a serial assessment using the index of microcirculatory resistance. Am J Physiol Heart Circ Physiol 2016; 311:H520-31. [DOI: 10.1152/ajpheart.00837.2015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 06/23/2016] [Indexed: 12/31/2022]
Abstract
This study investigates whether hyperemic microvascular resistance (MR) is influenced by elective percutaneous coronary intervention (PCI) by using the index of microcirculatory resistance (IMR). Seventy-one consecutive patients with stable angina pectoris undergoing elective PCI were prospectively studied. The IMR was measured before and after PCI and at the 10-mo follow-up. The IMR significantly decreased until follow-up; the pre-PCI, post-PCI, and follow-up IMRs had a median of 19.8 (interquartile range, 14.6–28.9), 16.2 (11.8–22.1), and 14.8 (11.8–18.7), respectively ( P < 0.001). The pre-PCI IMR was significantly correlated with the change in IMR between pre- and post-PCI ( r = 0.84, P < 0.001) and between pre-PCI and follow-up ( r = 0.93, P < 0.001). Pre-PCI IMR values were significantly higher in territories with decreases in IMR than in those with increases in IMR [pre-PCI IMR: 25.4 (18.4–35.5) vs. 12.5 (9.4–16.8), P < 0.001]. At follow-up, IMR values in territories showing decreases in IMR were significantly lower than those with increases in IMR [IMR at follow-up: 13.9 (10.9–17.6) vs. 16.6 (14.0–21.4), P = 0.013]. The IMR decrease was significantly associated with a greater shortening of mean transit time, indicating increases in coronary flow ( P < 0.001). The optimal cut-off values of pre-PCI IMR to predict a decrease in IMR after PCI and at follow-up were 16.8 and 17.0, respectively. In conclusion, elective PCI affected hyperemic MR and its change was associated with pre-PCI MR, resulting in showing a wide distribution. Overall hyperemic MR significantly decreased until follow-up. The modified hyperemic MR introduced by PCI may affect post-PCI coronary flow.
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Affiliation(s)
- Tadashi Murai
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsumin Lee
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Yoshihisa Kanaji
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Junji Matsuda
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Eisuke Usui
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Makoto Araki
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Takayuki Niida
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Keiichi Hishikari
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Sadamitsu Ichijyo
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Rikuta Hamaya
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Taishi Yonetsu
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
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Murai T, Kanaji Y, Yonetsu T, Lee T, Matsuda J, Usui E, Araki M, Niida T, Isobe M, Kakuta T. Preprocedural fractional flow reserve and microvascular resistance predict increased hyperaemic coronary flow after elective percutaneous coronary intervention. Catheter Cardiovasc Interv 2016; 89:233-242. [DOI: 10.1002/ccd.26596] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/30/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Tadashi Murai
- Cardiovascular Medicine; Tsuchiura Kyodo General Hospital; Tsuchiura Ibaraki Japan
| | - Yoshihisa Kanaji
- Cardiovascular Medicine; Tsuchiura Kyodo General Hospital; Tsuchiura Ibaraki Japan
| | - Taishi Yonetsu
- Cardiovascular Medicine; Tsuchiura Kyodo General Hospital; Tsuchiura Ibaraki Japan
| | - Tetsumin Lee
- Cardiovascular Medicine; Tsuchiura Kyodo General Hospital; Tsuchiura Ibaraki Japan
| | - Junji Matsuda
- Cardiovascular Medicine; Tsuchiura Kyodo General Hospital; Tsuchiura Ibaraki Japan
| | - Eisuke Usui
- Cardiovascular Medicine; Tsuchiura Kyodo General Hospital; Tsuchiura Ibaraki Japan
| | - Makoto Araki
- Cardiovascular Medicine; Tsuchiura Kyodo General Hospital; Tsuchiura Ibaraki Japan
| | - Takayuki Niida
- Cardiovascular Medicine; Tsuchiura Kyodo General Hospital; Tsuchiura Ibaraki Japan
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine; Tokyo Medical and Dental University; Tokyo Japan
| | - Tsunekazu Kakuta
- Cardiovascular Medicine; Tsuchiura Kyodo General Hospital; Tsuchiura Ibaraki Japan
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de Waard GA, Hollander MR, Teunissen PF, Jansen MF, Eerenberg ES, Beek AM, Marques KM, van de Ven PM, Garrelds IM, Danser AJ, Duncker DJ, van Royen N. Changes in Coronary Blood Flow After Acute Myocardial Infarction. JACC Cardiovasc Interv 2016; 9:602-13. [DOI: 10.1016/j.jcin.2016.01.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/30/2015] [Accepted: 01/01/2016] [Indexed: 01/10/2023]
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Ladwiniec A, Cunnington MS, Rossington J, Thackray S, Alamgir F, Hoye A. Microvascular dysfunction in the immediate aftermath of chronic total coronary occlusion recanalization. Catheter Cardiovasc Interv 2016; 87:1071-9. [PMID: 26756537 DOI: 10.1002/ccd.26392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/13/2015] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The aim of this study was to compare microvascular resistance under both baseline and hyperemic conditions immediately after percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) with an unobstructed reference vessel in the same patient BACKGROUND Microvascular dysfunction has been reported to be prevalent immediately after CTO PCI. However, previous studies have not made comparison with a reference vessel. Patients with a CTO may have global microvascular and/or endothelial dysfunction, making comparison with established normal values misleading. METHODS After successful CTO PCI in 21 consecutive patients, coronary pressure and flow velocity were measured at baseline and hyperemia in distal segments of the CTO/target vessel and an unobstructed reference vessel. Hemodynamics including hyperemic microvascular resistance (HMR), basal microvascular resistance (BMR), and instantaneous minimal microvascular resistance at baseline and hyperemia were calculated and compared between reference and target/CTO vessels. RESULTS After CTO PCI, BMR was reduced in the target/CTO vessel compared with the reference vessel: 3.58 mm Hg/cm/s vs 4.94 mm Hg/cm/s, difference -1.36 mm Hg/cm/s (-2.33 to -0.39, p = 0.008). We did not detect a difference in HMR: 1.82 mm Hg/cm/s vs 2.01 mm Hg/cm/s, difference -0.20 (-0.78 to 0.39, p = 0.49). Instantaneous minimal microvascular resistance correlated strongly with the length of stented segment at baseline (r = 0.63, p = 0.005) and hyperemia (r = 0.68, p = 0.002). CONCLUSIONS BMR is reduced in a recanalized CTO in the immediate aftermath of PCI compared to an unobstructed reference vessel; however, HMR appears to be preserved. A longer stented segment is associated with increased microvascular resistance. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Andrew Ladwiniec
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
| | - Michael S Cunnington
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
| | - Jennifer Rossington
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
| | - Simon Thackray
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
| | - Farquad Alamgir
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
| | - Angela Hoye
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
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van de Hoef TP, Meuwissen M, Piek JJ. Fractional flow reserve-guided percutaneous coronary intervention: where to after FAME 2? Vasc Health Risk Manag 2015; 11:613-22. [PMID: 26673639 PMCID: PMC4676623 DOI: 10.2147/vhrm.s68328] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Fractional flow reserve (FFR) is a well-validated clinical coronary physiological parameter derived from the measurement of coronary pressures and has drastically changed revascularization decision-making in clinical practice. Nonetheless, it is important to realize that FFR is a coronary pressure-derived estimate of coronary blood flow impairment. It is thereby not the same as direct measures of coronary flow impairment that determine the occurrence of signs and symptoms of myocardial ischemia. This consideration is important, since the FAME 2 study documented a limited discriminatory power of FFR to identify stenoses that require revascularization to prevent adverse events. The physiological difference between FFR and direct measures of coronary flow impairment may well explain the findings in FAME 2. This review aims to address the physiological background of FFR, its ambiguities, and its consequences for the application of FFR in clinical practice, as well as to reinterpret the diagnostic and prognostic characteristics of FFR in the light of the recent FAME 2 trial outcomes.
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Affiliation(s)
- Tim P van de Hoef
- AMC Heartcentre, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Jan J Piek
- AMC Heartcentre, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Berry C, Corcoran D, Hennigan B, Watkins S, Layland J, Oldroyd KG. Fractional flow reserve-guided management in stable coronary disease and acute myocardial infarction: recent developments. Eur Heart J 2015; 36:3155-64. [PMID: 26038588 PMCID: PMC4816759 DOI: 10.1093/eurheartj/ehv206] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/09/2015] [Accepted: 05/03/2015] [Indexed: 01/10/2023] Open
Abstract
Coronary artery disease (CAD) is a leading global cause of morbidity and mortality, and improvements in the diagnosis and treatment of CAD can reduce the health and economic burden of this condition. Fractional flow reserve (FFR) is an evidence-based diagnostic test of the physiological significance of a coronary artery stenosis. Fractional flow reserve is a pressure-derived index of the maximal achievable myocardial blood flow in the presence of an epicardial coronary stenosis as a ratio to maximum achievable flow if that artery were normal. When compared with standard angiography-guided management, FFR disclosure is impactful on the decision for revascularization and clinical outcomes. In this article, we review recent developments with FFR in patients with stable CAD and recent myocardial infarction. Specifically, we review novel developments in our understanding of CAD pathophysiology, diagnostic applications, prognostic studies, clinical trials, and clinical guidelines.
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Affiliation(s)
- Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - David Corcoran
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Barry Hennigan
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | - Stuart Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | | | - Keith G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
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Nijjer SS, de Waard GA, Sen S, van de Hoef TP, Petraco R, Echavarría-Pinto M, van Lavieren MA, Meuwissen M, Danad I, Knaapen P, Escaned J, Piek JJ, Davies JE, van Royen N. Coronary pressure and flow relationships in humans: phasic analysis of normal and pathological vessels and the implications for stenosis assessment: a report from the Iberian-Dutch-English (IDEAL) collaborators. Eur Heart J 2015; 37:2069-80. [PMID: 26612582 PMCID: PMC4940452 DOI: 10.1093/eurheartj/ehv626] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 10/27/2015] [Indexed: 01/10/2023] Open
Abstract
Background Our understanding of human coronary physiological behaviour is derived from animal models. We sought to describe physiological behaviour across a large collection of invasive pressure and flow velocity measurements, to provide a better understanding of the relationships between these physiological parameters and to evaluate the rationale for resting stenosis assessment. Methods and results Five hundred and sixty-seven simultaneous intracoronary pressure and flow velocity assessments from 301 patients were analysed for coronary flow velocity, trans-stenotic pressure gradient (TG), and microvascular resistance (MVR). Measurements were made during baseline and hyperaemic conditions. The whole cardiac cycle and the diastolic wave-free period were assessed. Stenoses were assessed according to fractional flow reserve (FFR) and quantitative coronary angiography DS%. With progressive worsening of stenoses, from unobstructed angiographic normal vessels to those with FFR ≤ 0.50, hyperaemic flow falls significantly from 45 to 19 cm/s, Ptrend < 0.001 in a curvilinear pattern. Resting flow was unaffected by stenosis severity and was consistent across all strata of stenosis ( Ptrend > 0.05 for all). Trans-stenotic pressure gradient rose with stenosis severity for both rest and hyperaemic measures ( Ptrend < 0.001 for both). Microvascular resistance declines with stenosis severity under resting conditions ( Ptrend < 0.001), but was unchanged at hyperaemia (2.3 ± 1.1 mmHg/cm/s; Ptrend = 0.19). Conclusions With progressive stenosis severity, TG rises. However, while hyperaemic flow falls significantly, resting coronary flow is maintained by compensatory reduction of MVR, demonstrating coronary auto-regulation. These data support the translation of coronary physiological concepts derived from animals to patients with coronary artery disease and furthermore, suggest that resting pressure indices can be used to detect the haemodynamic significance of coronary artery stenoses.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ibrahim Danad
- VU University Medical Centre, Amsterdam, The Netherlands
| | - Paul Knaapen
- VU University Medical Centre, Amsterdam, The Netherlands
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Jan J Piek
- Academic Medical Centre, Amsterdam, The Netherlands
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van de Hoef TP, Echavarría-Pinto M, van Lavieren MA, Meuwissen M, Serruys PW, Tijssen JG, Pocock SJ, Escaned J, Piek JJ. Diagnostic and Prognostic Implications of Coronary Flow Capacity. JACC Cardiovasc Interv 2015; 8:1670-80. [DOI: 10.1016/j.jcin.2015.05.032] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/27/2015] [Accepted: 05/07/2015] [Indexed: 11/25/2022]
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Piek JJ, Claessen BE, Davies JE, Escaned J. Physiology-guided myocardial revascularisation in complex multivessel coronary artery disease: beyond the 2014 ESC/EACTS guidelines on myocardial revascularisation. Open Heart 2015; 2:e000308. [PMID: 26512329 PMCID: PMC4620228 DOI: 10.1136/openhrt-2015-000308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/25/2015] [Accepted: 09/01/2015] [Indexed: 11/29/2022] Open
Abstract
For patients with multivessel coronary artery disease there are two options for revascularisation: Percutaneous coronary intervention (PCI) or Coronary Artery Bypass Graft Surgery (CABG). In daily clinical practice, a heart team consisting of an interventional cardiologist and a cardiothoracic surgeon decide on the most appropriate mode of revascularization. The current European guidelines on myocardial revascularisation include updated recommendations for patients with multivessel coronary artery disease. In patients with stable angina, three-vessel disease and a SYNTAX score of 23–32 or >32 a class I level of evidence A recommendation for CABG was issued as compared to PCI which received a class III recommendation. Although the authors of this viewpoint greatly appreciate the efforts of the guideline committee, we believe that it was an oversight not to include recommendations on physiology-guided PCI in multivessel disease (MVD). In this viewpoint, it is argued that physiology-guided revascularization using current-generation drug-eluting stents is a reasonable alternative for complex multivessel disease.
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Affiliation(s)
- Jan J Piek
- AMC Heart Center, Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Bimmer E Claessen
- AMC Heart Center, Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Justin E Davies
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust , London , UK
| | - Javier Escaned
- Hospital Clinico San Carlos and Faculty of Medicine, Complutense University of Madrid , Madrid , Spain
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80
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Wijntjens GWM, van Lavieren MA, van de Hoef TP, Piek JJ. Physiological assessment of coronary stenosis: a view from the coronary microcirculation. Interv Cardiol 2015. [DOI: 10.2217/ica.15.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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van de Hoef TP, Siebes M, Spaan JAE, Piek JJ. Fundamentals in clinical coronary physiology: why coronary flow is more important than coronary pressure. Eur Heart J 2015; 36:3312-9a. [PMID: 26033981 DOI: 10.1093/eurheartj/ehv235] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 05/10/2015] [Indexed: 11/13/2022] Open
Abstract
Wide attention for the appropriateness of coronary stenting in stable ischaemic heart disease (IHD) has increased interest in coronary physiology to guide decision making. For many, coronary physiology equals the measurement of coronary pressure to calculate the fractional flow reserve (FFR). While accumulating evidence supports the contention that FFR-guided revascularization is superior to revascularization based on coronary angiography, it is frequently overlooked that FFR is a coronary pressure-derived estimate of coronary flow impairment. It is not the same as the direct measures of coronary flow from which it was derived, and which are critical determinants of myocardial ischaemia. This review describes why coronary flow is physiologically and clinically more important than coronary pressure, details the resulting limitations and clinical consequences of FFR-guided clinical decision making, describes the scientific consequences of using FFR as a gold standard reference test, and discusses the potential of coronary flow to improve risk stratification and decision making in IHD.
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Affiliation(s)
- Tim P van de Hoef
- AMC Heart Centre, Academic Medical Center, University of Amsterdam, Room B2-213, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Maria Siebes
- AMC Heart Centre, Academic Medical Center, University of Amsterdam, Room B2-213, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jos A E Spaan
- AMC Heart Centre, Academic Medical Center, University of Amsterdam, Room B2-213, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan J Piek
- AMC Heart Centre, Academic Medical Center, University of Amsterdam, Room B2-213, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Stuijfzand WJ, Uusitalo V, Kero T, Danad I, Rijnierse MT, Saraste A, Raijmakers PG, Lammertsma AA, Harms HJ, Heymans MW, Huisman MC, Marques KM, Kajander SA, Pietilä M, Sörensen J, Royen NV, Knuuti J, Knaapen P. Relative Flow Reserve Derived From Quantitative Perfusion Imaging May Not Outperform Stress Myocardial Blood Flow for Identification of Hemodynamically Significant Coronary Artery Disease. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.114.002400. [DOI: 10.1161/circimaging.114.002400] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Wijnand J. Stuijfzand
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Valtteri Uusitalo
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Tanja Kero
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Ibrahim Danad
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Mischa T. Rijnierse
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Antti Saraste
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Pieter G. Raijmakers
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Adriaan A. Lammertsma
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Hans J. Harms
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Martijn W. Heymans
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Marc C. Huisman
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Koen M. Marques
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Sami A. Kajander
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Mikko Pietilä
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Jens Sörensen
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Niels van Royen
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Juhani Knuuti
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Paul Knaapen
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
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Niccoli G, Scalone G, Crea F. Coronary Functional Tests in the Catheterization Laboratory – Pathophysiological and Clinical Relevance –. Circ J 2015; 79:676-84. [DOI: 10.1253/circj.cj-15-0201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | | | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart
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85
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Lim WH, Koo BK, Nam CW, Doh JH, Park JJ, Yang HM, Park KW, Kim HS, Takashima H, Waseda K, Amano T, Kato D, Kurita A, Oi M, Toyofuku M, van Nunen L, Pijls NHJ. Variability of fractional flow reserve according to the methods of hyperemia induction. Catheter Cardiovasc Interv 2014; 85:970-6. [PMID: 25413590 DOI: 10.1002/ccd.25752] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 11/15/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We performed this study to evaluate the variability of fractional flow reserve (FFR) values which were measured from various methods of hyperemia induction. BACKGROUND Concerns have been raised regarding the variability of FFR due to different routes for hyperemic agent administration and different hyperemic agents targeting different receptors to induce maximal hyperemia. METHODS A total of 656 intermediate coronary lesions from 628 patients with coronary artery disease were analyzed. Among them, 238 lesions underwent FFR measurement with hyperemia induced by both intravenous (IV) and intracoronary (IC) adenosine administration, 318 by IV adenosine/adenosine triphosphate (ATP) and IC nicorandil injection, and 100 by IV adenosine and regadenoson infusion. RESULTS Excellent correlation and close classification agreement (FFR ≤ 0.80) were observed between IV vs. IC adenosine (r = 0.980, CA = 92.9%, Cohen's Kappa = 0.887, P < 0.001), between IV adenosine/ATP vs. IC nicorandil (r = 0.962, CA = 91.2%, Cohen's Kappa = 0.817, P < 0.001), and between IV adenosine vs. regadenoson (r = 0.990, CA = 100%, Cohen's Kappa = 1.000, P < 0.001). When changes in blood pressure (ΔBP) or heart rate (ΔHR) were compared with changes in FFR (ΔFFR) between IV adenosine/ATP and IC nicorandil administration, there were no significant correlations between ΔBP and ΔFFR nor between ΔHR and ΔFFR (r = -0.122, P = 0.076; r = 0.036, P = 0.605, respectively). CONCLUSIONS This study suggests that the measurement of FFR is reproducible regardless of the hemodynamic changes, hyperemic agents used, or the route of administration.
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Affiliation(s)
- Woo-Hyun Lim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
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Piek JJ, van de Hoef TP. Pre-Angioplasty Instantaneous Wave-Free Ratio Pullback and Virtual Revascularization. JACC Cardiovasc Interv 2014; 7:1397-9. [DOI: 10.1016/j.jcin.2014.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 07/30/2014] [Indexed: 01/10/2023]
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87
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Physiological assessment of nonculprit stenoses during acute coronary syndromes. Am J Cardiol 2014; 114:496. [PMID: 25017659 DOI: 10.1016/j.amjcard.2014.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/06/2014] [Indexed: 11/20/2022]
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