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Integrating Anatomical and Functional Assessment of Coronary Artery Disease: Can MDCT act as the lone Gatekeeper in the near Future? CURRENT CARDIOVASCULAR IMAGING REPORTS 2014. [DOI: 10.1007/s12410-014-9292-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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102
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103
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Schindler TH, Quercioli A, Valenta I, Ambrosio G, Wahl RL, Dilsizian V. Quantitative Assessment of Myocardial Blood Flow—Clinical and Research Applications. Semin Nucl Med 2014; 44:274-93. [DOI: 10.1053/j.semnuclmed.2014.04.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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104
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Sengottuvelu G, Chakravarthy B, Rajendran R, Ravi S. Clinical usefulness and cost effectiveness of fractional flow reserve among Indian patients (FIND study). Catheter Cardiovasc Interv 2014; 88:E139-E144. [PMID: 24740902 DOI: 10.1002/ccd.25517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 02/02/2014] [Accepted: 04/06/2014] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To study the clinical usefulness, cost benefit, and medium term outcome of fractional flow reserve (FFR) based management of coronary artery disease of intermediate severity. BACKGROUND In spite of the advantages of FFR there is paucity of data in Indian population who have frequent diffuse, small and multivessel disease where it would probably be more beneficial in terms of cost and outcome. METHODS The treating cardiologist's management decision with both FFR and angiographic data was compared with that of a reviewing cardiologist decision based on a retrospective analysis of angiogram alone. RESULTS Eighty-one vessels with intermediate lesions in 59 patients required 26 stents lesser when FFR data was added to the angiogram. The concordance of management decision was about 58% which means that >40% of intermediate lesions would be misclassified as significant based on angiography alone. There were no major events at a mean follow up of 11 ± 5 months. The net cost benefit in favor of FFR based management was INR 8,57,600 (USD 15,600) in our centre. CONCLUSION Indians with more severe form of CAD benefit from a FFR based management plan for intermediate lesions, both clinically and economically. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- G Sengottuvelu
- Senior Consultant and Interventional cardiologist, Department of cardiology, Apollo Hospitals, Greams Road, Chennai, Tamil Nadu, India
| | - Babu Chakravarthy
- Interventional cardiologist, SS Heart & Skin Care Hospital, Kallakurichi, Tamil Nadu, India
| | - Ravindran Rajendran
- Associate Consultant, Apollo Hospitals, Greams Road, Chennai, Tamil Nadu, India
| | - Sreyes Ravi
- Research Assistant, Apollo Hospitals, Greams Road, Chennai, Tamil Nadu, India
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105
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SPECT myocardial perfusion versus fractional flow reserve for evaluation of functional ischemia: A meta analysis. Eur J Radiol 2014; 83:951-956. [DOI: 10.1016/j.ejrad.2014.02.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 02/13/2014] [Accepted: 02/17/2014] [Indexed: 01/23/2023]
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106
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Invasive assessment modalities of unprotected left main stenosis. J Saudi Heart Assoc 2014; 27:109-17. [PMID: 25870504 PMCID: PMC4392349 DOI: 10.1016/j.jsha.2014.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 04/19/2014] [Accepted: 04/27/2014] [Indexed: 01/06/2023] Open
Abstract
Among all coronary lesions, the decision-making process for the treatment of unprotected left main (ULM) stem lesions is still challenging. Indeed, the optimal therapeutic strategy for patients with ULM disease remains controversial: coronary artery bypass grafting was established as the gold standard, but it is without doubt that percutaneous coronary intervention (PCI) performed by experienced operators achieves good results at long term follow up, especially in cases where the ostium and/or shaft of ULM are treated. Thanks to the widespread use of invasive assessment of atherothrombotic ULM stenosis, improved selection of PCI cases and techniques of stenting, better outcomes are now possible. This review seeks to define the place of PCI in ULM disease by describing the different modalities of ULM stenosis assessment.
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Affiliation(s)
- William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA
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108
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Diagnostic Performance of Noninvasive Fractional Flow Reserve Derived From Coronary Computed Tomography Angiography in Suspected Coronary Artery Disease. J Am Coll Cardiol 2014; 63:1145-1155. [DOI: 10.1016/j.jacc.2013.11.043] [Citation(s) in RCA: 958] [Impact Index Per Article: 95.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 11/21/2013] [Accepted: 11/27/2013] [Indexed: 11/22/2022]
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109
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Elgendy IY, Conti CR, Bavry AA. Fractional flow reserve: an updated review. Clin Cardiol 2014; 37:371-80. [PMID: 24652785 DOI: 10.1002/clc.22273] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 02/18/2014] [Indexed: 01/10/2023] Open
Abstract
Revascularization of ischemia-producing coronary lesions is widely used in the management of coronary artery disease. However, some coronary lesions appear significant on the conventional angiogram when they are truly non-flow limiting. For this reason, it is becoming increasingly important to determine the coronary physiology. Fractional flow reserve (FFR) has emerged as a useful tool to determine the lesions that require revascularization. Measurement of FFR during invasive coronary angiography now has a class IA indication from the European Society of Cardiology for identifying hemodynamically significant coronary lesions when noninvasive evidence of myocardial ischemia is unavailable. Current data on FFR can be broadly classified into studies that compare the diagnostic accuracy of FFR measurement compared with other noninvasive modalities and studies that test treatment strategies of patients with intermediate coronary stenoses using a threshold value for FFR and that have clinical outcomes as endpoints. In this review, we will discuss the concept of FFR, current evidence supporting its usage, and future perspectives.
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Affiliation(s)
- Islam Y Elgendy
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida
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Joutsiniemi E, Saraste A, Pietila M, Maki M, Kajander S, Ukkonen H, Airaksinen J, Knuuti J. Absolute flow or myocardial flow reserve for the detection of significant coronary artery disease? Eur Heart J Cardiovasc Imaging 2014; 15:659-65. [DOI: 10.1093/ehjci/jet274] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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111
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Pantos I, Katritsis D. Fractional Flow Reserve Derived from Coronary Imaging and Computational Fluid Dynamics. Interv Cardiol 2014; 9:145-150. [PMID: 29588793 DOI: 10.15420/icr.2014.9.3.145] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The assessment of functional severity of atherosclerotic stenoses in patients with coronary artery disease by invasive fractional flow reserve (FFR) measurement requires coronary artery cannulation, advancement of a wire and intravenous adenosine infusion with inherent procedure-related risk and costs. Coronary computed tomographic angiography (CCTA) and rotational coronary angiography (RA) have been recently used in conjunction with computational fluid dynamics (CFD) and image-based modelling for the determination of FFR without the need for additional imaging, modification of acquisition protocols or administration of medication. FFR derived from CCTA was demonstrated as superior to measures of CCTA stenosis severity for determination of lesion-specific ischaemia. Estimation of FFR from RA images and CFD provides a less invasive alternative to conventional FFR measurement while estimated values are in agreement with measured values. These new, combined anatomic-functional assessments have the potential to simplify the noninvasive diagnosis of coronary artery disease with a single study to identify patients with ischaemia-causing stenosis who may benefit from revascularisation.
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Affiliation(s)
- Ioannis Pantos
- Athens Euroclinic, Athens, Greece.,University of Athens, Greece
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112
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Myocardial perfusion imaging with a cadmium zinc telluride-based gamma camera versus invasive fractional flow reserve. Eur J Nucl Med Mol Imaging 2013; 41:956-62. [DOI: 10.1007/s00259-013-2630-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 11/06/2013] [Indexed: 11/25/2022]
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113
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Phillips LM, Hachamovitch R, Berman DS, Iskandrian AE, Min JK, Picard MH, Kwong RY, Friedrich MG, Scherrer-Crosbie M, Hayes SW, Sharir T, Gosselin G, Mazzanti M, Senior R, Beanlands R, Smanio P, Goyal A, Al-Mallah M, Reynolds H, Stone GW, Maron DJ, Shaw LJ. Lessons learned from MPI and physiologic testing in randomized trials of stable ischemic heart disease: COURAGE, BARI 2D, FAME, and ISCHEMIA. J Nucl Cardiol 2013; 20:969-75. [PMID: 23963599 PMCID: PMC3954506 DOI: 10.1007/s12350-013-9773-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
There is a preponderance of evidence that, in the setting of an acute coronary syndrome, an invasive approach using coronary revascularization has a morbidity and mortality benefit. However, recent stable ischemic heart disease (SIHD) randomized clinical trials testing whether the addition of coronary revascularization to guideline-directed medical therapy (GDMT) reduces death or major cardiovascular events have been negative. Based on the evidence from these trials, the primary role of GDMT as a front line medical management approach has been clearly defined in the recent SIHD clinical practice guideline; the role of prompt revascularization is less precisely defined. Based on data from observational studies, it has been hypothesized that there is a level of ischemia above which a revascularization strategy might result in benefit regarding cardiovascular events. However, eligibility for recent negative trials in SIHD has mandated at most minimal standards for ischemia. An ongoing randomized trial evaluating the effectiveness of randomization of patients to coronary angiography and revascularization as compared to no coronary angiography and GDMT in patients with moderate-severe ischemia will formally test this hypothesis. The current review will highlight the available evidence including a review of the published and ongoing SIHD trials.
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Affiliation(s)
- Lawrence M Phillips
- New York University School of Medicine, 530 First Avenue, SKI-9U, New York, NY, 10016, USA,
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Lotfi A, Jeremias A, Fearon WF, Feldman MD, Mehran R, Messenger JC, Grines CL, Dean LS, Kern MJ, Klein LW. Expert consensus statement on the use of fractional flow reserve, intravascular ultrasound, and optical coherence tomography: a consensus statement of the Society of Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2013; 83:509-18. [PMID: 24227282 DOI: 10.1002/ccd.25222] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 09/29/2013] [Indexed: 12/15/2022]
Affiliation(s)
- Amir Lotfi
- Baystate Medical Center, Springfield, Massachusetts
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Zimarino M, Curzen N, Cicchitti V, De Caterina R. The adequacy of myocardial revascularization in patients with multivessel coronary artery disease. Int J Cardiol 2013; 168:1748-57. [DOI: 10.1016/j.ijcard.2013.05.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 04/04/2013] [Accepted: 05/03/2013] [Indexed: 02/04/2023]
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116
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Chen SL, Xu B, Chen JB, Xu T, Ye F, Zhang JJ, Kwan TW, Tian NL, Liu ZZ, Lin S. Diagnostic accuracy of quantitative angiographic and intravascular ultrasound parameters predicting the functional significance of single de novo lesions. Int J Cardiol 2013; 168:1364-9. [DOI: 10.1016/j.ijcard.2012.12.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 09/19/2012] [Accepted: 12/05/2012] [Indexed: 10/27/2022]
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117
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Affiliation(s)
- Harold L Lazar
- Department of Cardiothoracic Surgery, Boston Medical Center, and the Boston University School of Medicine, Boston, MA
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118
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Toth G, De Bruyne B, Casselman F, De Vroey F, Pyxaras S, Di Serafino L, Van Praet F, Van Mieghem C, Stockman B, Wijns W, Degrieck I, Barbato E. Fractional flow reserve-guided versus angiography-guided coronary artery bypass graft surgery. Circulation 2013; 128:1405-11. [PMID: 23985788 DOI: 10.1161/circulationaha.113.002740] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fractional flow reserve (FFR) is well established for patients undergoing percutaneous coronary intervention, yet little is known about candidates for coronary artery bypass graft surgery. METHODS AND RESULTS From 2006 to 2010, we retrospectively included in this registry 627 consecutive patients treated by coronary artery bypass graft surgery having at least 1 angiographically intermediate stenosis. In 429 patients, coronary artery bypass graft surgery was based solely on angiography (angiography-guided group). In 198 patients, at least 1 intermediate stenosis was grafted with an FFR ≤0.80 or deferred with an FFR >0.80 (FFR-guided group). The end point was major adverse cardiovascular events at 3 years, defined as the composite of overall death, myocardial infarction, and target vessel revascularization. The rate of angiographic multivessel disease was similar in the angiography-guided and FFR-guided groups (404 [94.2%] versus 186 [93.9%]; P=0.722). In the FFR-guided group, this was significantly downgraded after FFR measurements to 86.4% (P<0.001 versus before FFR) and was associated with a smaller number of anastomoses (3 [2-3] versus 3 [2-4]; P<0.001) and rate of on-pump surgery (49% versus 69%; P<0.001). At 3 years, major adverse cardiovascular events were not different between the angiography-guided and FFR-guided groups (12% versus 11%; hazard ratio, 1.030; 95% confidence interval, 0.627-1.692; P=0.908). However, the FFR-guided group compared with the angiography-guided group presented a significantly lower rate of angina (Canadian Cardiovascular Society class II-IV, 31% versus 47%; P<0.001). CONCLUSIONS FFR-guided coronary artery bypass graft surgery was associated with a lower number of graft anastomoses and a lower rate of on-pump surgery compared with angiography-guided coronary artery bypass graft surgery. This did not result in a higher event rate during up to 36 months of follow-up and was associated with a lower rate of angina.
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Affiliation(s)
- Gabor Toth
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
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119
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Abstract
Coronary artery disease (CAD) remains the leading cause of death and morbidity worldwide. To date, diagnostic evaluation of patients with suspected CAD has relied upon the use of physiologic non-invasive testing by stress electrocardiography, echocardiography, myocardial perfusion imaging (MPI) and magnetic resonance imaging. Indeed, the importance of physiologic evaluation of CAD has been highlighted by large-scale randomized trials that demonstrate the propitious benefit of an integrated anatomic-physiologic evaluation method by performing lesion-specific ischemia assessment by fractional flow reserve (FFR)-widely considered the "gold" standard for ischemia assessment-at the time of invasive angiography. Coronary CT angiography (CCTA) has emerged as an attractive non-invasive test for anatomic illustration of the coronary arteries and atherosclerotic plaque. In a series of prospective multicenter trials, CCTA has been proven as having high diagnostic performance for stenosis detection as compared to invasive angiography. Nevertheless, CCTA evaluation of obstructive stenoses is prone to overestimation of severity and further, detection of stenoses by CCTA does not reliably determine the hemodynamic significance of the visualized lesions. Recently, a series of technological innovations have advanced the possibility of CCTA to enable physiologic evaluation of CAD, thereby creating the potential of this test to provide an integrated anatomic-physiologic assessment of CAD. These advances include rest-stress MPI by CCTA as well as the use of computational fluid dynamics to non-invasively calculate FFR from a typically acquired CCTA. The purpose of this review is to summarize the most recent data addressing these 2 physiologic methods of CAD evaluation by CCTA.
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Affiliation(s)
- Minisha Kochar
- Division of Cardiology, Kaiser Permanente, Panorama City, CA, USA
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120
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Di Serafino L, De Bruyne B, Mangiacapra F, Bartunek J, Agostoni P, Vanderheyden M, Scognamiglio G, Heyndrickx GR, Wijns W, Barbato E. Long-term clinical outcome after fractional flow reserve- versus angio-guided percutaneous coronary intervention in patients with intermediate stenosis of coronary artery bypass grafts. Am Heart J 2013; 166:110-8. [PMID: 23816029 DOI: 10.1016/j.ahj.2013.04.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 04/17/2013] [Indexed: 01/17/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR)-guided percutaneous revascularization (percutaneous coronary intervention [PCI]) of intermediate stenosis in native coronary artery is safe and associated with better clinical outcomes as compared with an angiography-guided PCI. It is unknown whether this applies to coronary artery bypass grafts (CABGs). METHODS We included 223 patients with CABG and with stable or unstable angina and an intermediate stenosis involving an arterial or a venous graft. Patients were divided into 2 groups: FFR guided (n = 65, PCI performed in case of FFR ≤0.80) and angio guided (n = 158, PCI performed based on angiographic evaluation). Primary end point was major adverse cardiac and cerebrovascular event, defined as death, myocardial infarction, target vessel failure, and cerebrovascular accident (CVA). RESULTS The 2 groups were similar in terms of demographic and clinical characteristics. Percutaneous coronary intervention was performed in 23 patients (35%) of the FFR-guided group and 90 patients (57%) of the angio-guided group (P < .01). In the FFR-guided group, PCI was more often performed in arterial grafts as compared with the angio-guided group (16 [70%] vs 12 [13%], respectively; P < .01). Follow-up was obtained in 96% of patients at a median of 3.8 years (1.6-4.0 years). At multivariate analysis, major adverse cardiac and cerebrovascular event rate was significantly lower in the FFR-guided group as compared with the angio-guided group (18 [28%] vs 77 [51%], hazard ratio 0.33 [0.11-0.96], P = .043]. Procedure costs were overall reduced in the FFR-guided group (€2240 ± €652 vs €2416 ± €522, P = .03). CONCLUSIONS An FFR-guided PCI of intermediate stenosis in bypass grafts is safe and results in better clinical outcomes as compared with an angio-guided PCI. This clinical benefit is achieved with a significant overall reduction in procedural costs.
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121
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Qi X, Lv H, Zhou F, Zhao J, Xu J, Xiang L, Wang F, Zhan Q, Jiang J, Xiao J. A novel noninvasive method for measuring fractional flow reserve through three-dimensional modeling. Arch Med Sci 2013; 9:581-3. [PMID: 23847686 PMCID: PMC3701973 DOI: 10.5114/aoms.2013.35020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 09/10/2012] [Accepted: 09/16/2012] [Indexed: 11/17/2022] Open
Affiliation(s)
- Xiaolong Qi
- Experimental Center of Life Sciences and Regeneration Lab, School of Life Science, Shanghai University, Shanghai, China
- Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Huijie Lv
- Division of Mathematics, Tongji University, Shanghai, China
| | - Fangyu Zhou
- Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiangmin Zhao
- Department of Radiology, Shanghai Third People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiahong Xu
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Li Xiang
- Department of General Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Fei Wang
- Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qing Zhan
- Department of Neurology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jinfa Jiang
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Junjie Xiao
- Experimental Center of Life Sciences and Regeneration Lab, School of Life Science, Shanghai University, Shanghai, China
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Wasilewski J, Mirota K, Hawranek M, Poloński L. Invasive and non-invasive fractional flow reserve index in validation of hemodynamic severity of intracoronary lesions. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2013; 9:160-9. [PMID: 24570710 PMCID: PMC3915971 DOI: 10.5114/pwki.2013.35452] [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] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Revised: 03/25/2013] [Accepted: 04/22/2013] [Indexed: 01/17/2023] Open
Abstract
This review discusses visual and functional evaluation of the hemodynamic significance of the degree of stenosis in coronary angiography, with respect to the indications for revascularization. The concept of the coronary flow reserve is defined, and the theoretical assumptions of the invasive measurement of the fractional flow reserve (FFR) are presented. In the following part, the publication describes the basic steps of numerical stimulations in terms of computational fluid dynamics (CFD) in calculating the fractional flow reserve based on computed tomography (CT) coronary angiography (FFRCT). The numerical FFRCT estimation in correlation with invasive measurements, as well as benefits deriving from FFRCT in the diagnosis of coronary artery disease, is presented in the example of the multicentre prospective DISCOVER-FLOW trial and the DeFACTO project. The CDF method enables to obtain hemodynamic significance of stenosis solely from the coronary anatomy vizualized by CT angiography. The calculation of FFRCT increases the diagnostic reliability of coronary flow reserve estimations. It contributes to the improvement in patients' qualification for contrast coronarography. If the accuracy of FFRCT is confirmed in clinical practice, and the time required for computational processing is shortened, it may turn out that the algorithms of coronary heart disease diagnosis will be verified and it will be to a greater extent based on the CT results.
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Affiliation(s)
- Jarosław Wasilewski
- 3 Department of Cardiology, Silesian Center for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | | | - Michał Hawranek
- 3 Department of Cardiology, Silesian Center for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Lech Poloński
- 3 Department of Cardiology, Silesian Center for Heart Diseases, Medical University of Silesia, Zabrze, Poland
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123
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Gaemperli O, Lüscher TF, Bax JJ. View point: what should the future design of clinical imaging studies be? Eur Heart J 2013; 34:2432-5. [PMID: 23708489 DOI: 10.1093/eurheartj/eht170] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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124
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Muller O, Ntalianis A, Wijns W, Delrue L, Dierickx K, Auer R, Rodondi N, Mangiacapra F, Trana C, Hamilos M, Valentin E, De Bruyne B, Barbato E, Bartunek J. Association of biomarkers of lipid modification with functional and morphological indices of coronary stenosis severity in stable coronary artery disease. J Cardiovasc Transl Res 2013; 6:536-44. [PMID: 23670230 DOI: 10.1007/s12265-013-9468-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 04/25/2013] [Indexed: 12/12/2022]
Abstract
Biomarkers of blood lipid modification and oxidative stress have been associated with increased cardiovascular morbidity. We sought to determine whether these biomarkers were related to functional indices of stenosis severity among patients with stable coronary artery disease. We studied 197 consecutive patients with stable coronary artery disease due to single vessel disease. Fractional flow reserve (FFR) ≤ 0.80 was assessed as index of a functionally significant lesion. Serum levels of secretory phospholipase A2 (sPLA2) activity, secretory phospholipase A2 type IIA (sPLA2-IIA), myeloperoxydase (MPO), lipoprotein-associated phospholipase A2 (Lp-PLA2), and oxidized low-density lipoprotein (OxLDL) were assessed using commercially available assays. Patients with FFR > 0.8 had higher sPLA2 activity, sPLA2 IIA, and OxLDL levels than patients with FFR ≤ 0.8 (21.25 [16.03-27.28] vs 25.85 [20.58-34.63] U/mL, p < 0.001, 2.0 [1.5-3.4] vs 2.6 [2.0-3.4] ng/mL, p < 0.01; and 53.0 [36.0-71.0] vs 64.5 [50-89.25], p < 0.001 respectively). Patients with FFR > 0.80 had similar Lp-PLA2 and MPO levels versus those with FFR ≤ 0.8. sPLA2 activity, sPLA2 IIA significantly increased area under the curve over baseline characteristics to predict FFR ≤ 0.8 (0.67 to 0.77 (95 % confidence interval [CI]: 0.69-0.85) p < 0.01 and 0.67 to 0.77 (95 % CI: 0.69-0.84) p < 0.01, respectively). Serum sPLA2 activity as well as sPLA2-IIA level is related to functional characteristics of coronary stenoses in patients with stable coronary artery disease.
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Affiliation(s)
- Olivier Muller
- Cardiovascular Center and Translational Cardiology Unit, Aalst, Belgium
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Ko BS, Cameron JD, Leung M, Meredith IT, Leong DP, Antonis PR, Crossett M, Troupis J, Harper R, Malaiapan Y, Seneviratne SK. Combined CT coronary angiography and stress myocardial perfusion imaging for hemodynamically significant stenoses in patients with suspected coronary artery disease: a comparison with fractional flow reserve. JACC Cardiovasc Imaging 2013; 5:1097-111. [PMID: 23153909 DOI: 10.1016/j.jcmg.2012.09.004] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/20/2012] [Accepted: 09/24/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We sought to determine the accuracy of combined coronary computed tomography angiography (CTA) and computed tomography stress myocardial perfusion imaging (CTP) in the detection of hemodynamically significant stenoses using fractional flow reserve (FFR) as a reference standard in patients with suspected coronary artery disease. BACKGROUND CTP can be qualitatively assessed by visual interpretation or quantified by the transmural perfusion ratio determined as the ratio of subendocardial to subepicardial contrast attenuation. The incremental value of each technique in addition to coronary CTA to detect hemodynamically significant stenoses is not known. METHODS Forty symptomatic patients underwent FFR and 320-detector computed tomography assessment including coronary CTA and CTP. Myocardial perfusion was assessed using the transmural perfusion ratio and visual perfusion assessment. Computed tomography images were assessed by consensus of 2 observers. Transmural perfusion ratio <0.99 was used as the threshold for abnormal perfusion. FFR ≤0.8 indicated hemodynamically significant stenoses. RESULTS Coronary CTA detected FFR-significant stenoses with 95% sensitivity and 78% specificity. The additional use of visual perfusion assessment and the transmural perfusion ratio both increased the specificity to 95%, with sensitivity of 87% and 71%, respectively. The area under the receiver-operating characteristic curve for coronary CTA + visual perfusion assessment was significantly higher than both coronary CTA (0.93 vs. 0.85, p = 0.0003) and coronary CTA + the transmural perfusion ratio (0.93 vs. 0.79, p = 0.0003). Per-vessel and per-patient accuracy for coronary CTA, coronary CTA + the transmural perfusion ratio, and coronary CTA + visual perfusion assessment was 83% and 83%, 87% and 92%, and 92% and 95%, respectively. CONCLUSIONS In suspected coronary artery disease, combined coronary CTA + CTP identifies patients with hemodynamically significant stenoses with >90% accuracy compared with FFR. When interpreted with coronary CTA, visual perfusion assessment provided superior incremental value in the detection of FFR-significant stenoses compared with the quantitative transmural perfusion ratio assessment.
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Affiliation(s)
- Brian S Ko
- Monash Cardiovascular Research Centre, MonashHeart, Department of Medicine, Monash Medical Centre, Southern Health and Monash University, Melbourne, Victoria, Australia
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Taylor CA, Fonte TA, Min JK. Computational fluid dynamics applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve: scientific basis. J Am Coll Cardiol 2013; 61:2233-41. [PMID: 23562923 DOI: 10.1016/j.jacc.2012.11.083] [Citation(s) in RCA: 778] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 10/19/2012] [Accepted: 11/20/2012] [Indexed: 12/12/2022]
Abstract
Coronary computed tomography angiography (CTA) has emerged as a noninvasive method for direct visualization of coronary artery disease, with previous studies demonstrating high diagnostic performance of CTA compared with invasive coronary angiography. However, CTA assessment of coronary stenoses tends toward overestimation, and even among CTA-identified severe stenosis confirmed at the time of invasive coronary angiography, only a minority are found to be ischemia causing. Recent advances in computational fluid dynamics and image-based modeling now permit determination of rest and hyperemic coronary flow and pressure from CTA scans, without the need for additional imaging, modification of acquisition protocols, or administration of medications. These techniques have been used to noninvasively compute fractional flow reserve (FFR), which is the ratio of maximal coronary blood flow through a stenotic artery to the blood flow in the hypothetical case that the artery was normal, using CTA images. In the recently reported prospective multicenter DISCOVER-FLOW (Diagnosis of Ischemia-Causing Stenoses Obtained Via Noninvasive Fractional Flow Reserve) study and the DeFACTO (Determination of Fractional Flow Reserve by Anatomic Computed Tomographic Angiography) trial, FFR derived from CTA was demonstrated as superior to measures of CTA stenosis severity for determination of lesion-specific ischemia. Given the significant interest in this novel method for determining the physiological significance of coronary artery disease, we herein present a review on the scientific principles that underlie this technology.
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127
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Accuracy of stress myocardial perfusion imaging to diagnose coronary artery disease in end stage liver disease patients. Am J Cardiol 2013; 111:1057-61. [PMID: 23337839 DOI: 10.1016/j.amjcard.2012.12.023] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 12/05/2012] [Accepted: 12/05/2012] [Indexed: 02/08/2023]
Abstract
Patients with end-stage liver disease (ESLD) who also have underlying coronary artery disease (CAD) may be at increased risk for undergoing hemodynamically challenging orthotopic liver transplantation. Noninvasive single-photon emission computed tomographic (SPECT) imaging is often used to determine whether a patient with ESLD has unsuspected CAD. The objective of this study was to determine the accuracy of SPECT imaging for detection of CAD in patients with ESLD. Patients with ESLD who underwent coronary angiography and SPECT imaging before orthotopic liver transplantation were analyzed retrospectively. The predictive accuracy of clinical risk factors was calculated and compared to the results of SPECT imaging. There were 473 SPECT imaging studies. Adenosine SPECT imaging had a sensitivity of 62%, specificity of 82%, positive predictive value of 30%, and negative predictive value of 95% for diagnosing severe CAD. Regadenoson SPECT imaging had a sensitivity of 35%, specificity of 88%, positive predictive value of 23%, and negative predictive value of 93% for diagnosing severe CAD. The accuracy of a standard risk factor analysis showed no statistical difference in predicting CAD compared with adenosine (sensitivity McNemar's p = 0.48, specificity McNemar's p = 1.00) or regadenoson (sensitivity McNemar's p = 0.77, specificity McNemar's p = 1.00) SPECT studies. In conclusion, the 2 pharmaceutical agents had low sensitivity but high specificity for diagnosing CAD. However, because the sensitivity of the test is low, the chances of missing patients with ESLD with CAD is high, making SPECT imaging an inaccurate screening test. A standard risk factor analysis as a predictor for CAD in patients with ESLD is less expensive, has no radiation exposure, and is as accurate as SPECT imaging.
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128
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Kereiakes DJ, Stone GW. In mildly symptomatic patients, should an invasive strategy with catheterization and revascularization be routinely undertaken?: in mildly symptomatic patients, an invasive strategy with catheterization and revascularization should be routinely undertaken. Circ Cardiovasc Interv 2013; 6:107-13; discussion 113. [PMID: 23424270 DOI: 10.1161/circinterventions.112.000112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dean J Kereiakes
- The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, Ohio 45219, USA.
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129
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Abstract
The haemodynamic effect of a coronary artery stenosis is a better predictor of prognosis than anatomical lumen obstruction. Until recently, no individual non-invasive test could provide both accurate coronary anatomy and lesion-specific myocardial ischaemia. However, computer tomography (CT) fractional flow reserve, which can be calculated from a standard CT coronary angiogram, was recently demonstrated to accurately detect and rule out the haemodynamic significance of individual coronary artery stenoses.
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Blankenship JC, Gigliotti OS, Feldman DN, Mixon TA, Patel RA, Sorajja P, Yakubov SJ, Chambers CE. Ad Hoc percutaneous coronary intervention: A consensus statement from the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv 2012. [DOI: 10.1002/ccd.24701] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Dmitriy N. Feldman
- Division of Cardiology; Weill Cornell Medical College; New York; New York
| | - Timothy A. Mixon
- Department of Cardiology; Texas A&M College of Medicine; Temple; Texas
| | - Rajan A.G. Patel
- Department of Cardiology; Ochsner Clinic Foundation; New Orleans; Los Angeles
| | - Paul Sorajja
- Department of Cardiology; Mayo Clinic; Rochester; Minnesota
| | - Steven J. Yakubov
- Ohio Health Research Institute; Riverside Methodist Hospital; Columbus; Ohio
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131
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Kakouros N, Rybicki FJ, Mitsouras D, Miller JM. Coronary pressure-derived fractional flow reserve in the assessment of coronary artery stenoses. Eur Radiol 2012. [PMID: 23179519 DOI: 10.1007/s00330-012-2670-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Catheter-based angiography is the reference-standard to establish coronary anatomy. While routinely employed clinically, lumen assessment correlates poorly with physiological measures of ischaemia. Moreover, functional studies to identify and localise ischaemia before elective angiography are often not available. This article reviews fractional flow reserve (FFR) and its role in guiding patient management for patients with a potentially haemodynamic significant coronary lesion. METHODS This review discusses the theory, evidence, indications, and limitations of FFR. Also included are emerging non-invasive imaging FFR surrogates currently under evaluation for accuracy with respect to standard FFR. RESULTS Coronary pressure-derived fractional flow reserve (FFR) rapidly assesses the haemodynamic significance of individual coronary artery lesions and can readily be performed in the catheterisation laboratory. The use of FFR has been shown to effectively guide coronary revascularization procedures leading to improved patient outcomes. CONCLUSIONS FFR is an invaluable modality in guiding coronary disease treatment decisions. It is safe, cost-effective and leads to improved patient outcomes. Non-invasive imaging modalities to assess the physiologic significance of CAD are currently being developed and evaluated.
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Affiliation(s)
- Nikolaos Kakouros
- Division of Cardiology, Johns Hopkins Hospital and Johns Hopkins University, 600 N. Wolfe Street, Blalock 536, Baltimore, MD 21287, USA
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Sahiner I, Akdemir UO, Kocaman SA, Sahinarslan A, Timurkaynak T, Unlu M. Quantitative evaluation improves specificity of myocardial perfusion SPECT in the assessment of functionally significant intermediate coronary artery stenoses: a comparative study with fractional flow reserve measurements. Ann Nucl Med 2012. [DOI: 10.1007/s12149-012-0666-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Should we be using fractional flow reserve more routinely to select stable coronary patients for percutaneous coronary intervention? Curr Opin Cardiol 2012; 27:675-81. [DOI: 10.1097/hco.0b013e328358f587] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Park SJ, Kang SJ, Ahn JM, Shim EB, Kim YT, Yun SC, Song H, Lee JY, Kim WJ, Park DW, Lee SW, Kim YH, Lee CW, Mintz GS, Park SW. Visual-Functional Mismatch Between Coronary Angiography and Fractional Flow Reserve. JACC Cardiovasc Interv 2012; 5:1029-36. [DOI: 10.1016/j.jcin.2012.07.007] [Citation(s) in RCA: 229] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 07/10/2012] [Accepted: 07/19/2012] [Indexed: 10/27/2022]
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Saraste A, Kajander S, Han C, Nesterov SV, Knuuti J. PET: Is myocardial flow quantification a clinical reality? J Nucl Cardiol 2012; 19:1044-59. [PMID: 22733534 DOI: 10.1007/s12350-012-9588-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Positron emission tomography (PET) enables quantitative measurements of myocardial blood flow (MBF) and myocardial flow reserve (MFR). Recent developments and improved availability of PET technology have resulted in growing interest in translation of quantitative flow analysis from mainly a research tool to routine clinical practice. Quantitative PET measurements of absolute MBF and MFR have potential to improve accuracy of myocardial perfusion imaging in diagnosis of multivessel coronary artery disease as well as definition of the extent and functional importance of stenoses. This article reviews recent advances and experience in the quantitative myocardial perfusion imaging together with issues that need to be resolved for quantitative analysis to become clinical reality.
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Affiliation(s)
- Antti Saraste
- Turku PET Centre, University of Turku, Kiinamyllynkatu 4-8, 20520 Turku, Finland.
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136
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Godoy GK, Vavere A, Miller JM, Chahal H, Niinuma H, Lemos P, Hoe J, Paul N, Clouse ME, Ramos CD, Lima JA, Arbab-Zadeh A. Quantitative coronary arterial stenosis assessment by multidetector CT and invasive coronary angiography for identifying patients with myocardial perfusion abnormalities. J Nucl Cardiol 2012; 19:922-30. [PMID: 22814771 DOI: 10.1007/s12350-012-9598-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 07/05/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Semi-quantitative stenosis assessment by coronary CT angiography only modestly predicts stress-induced myocardial perfusion abnormalities. The performance of quantitative CT angiography (QCTA) for identifying patients with myocardial perfusion defects remains unclear. METHODS CorE-64 is a multicenter, international study to assess the accuracy of 64-slice QCTA for detecting ≥50% coronary arterial stenoses by quantitative coronary angiography (QCA). Patients referred for cardiac catheterization with suspected or known coronary artery disease were enrolled. Area under the receiver-operating-characteristic curve (AUC) was used to evaluate the diagnostic accuracy of the most severe coronary artery stenosis in a subset of 63 patients assessed by QCTA and QCA for detecting myocardial perfusion abnormalities on exercise or pharmacologic stress SPECT. RESULTS Diagnostic accuracy of QCTA for identifying patients with myocardial perfusion abnormalities by SPECT revealed an AUC of 0.71, compared to 0.72 by QCA (P = .75). AUC did not improve after excluding studies with fixed myocardial perfusion abnormalities and total coronary arterial occlusions. Optimal stenosis threshold for QCTA was 43% yielding a sensitivity of 0.81 and specificity of 0.50, respectively, compared to 0.75 and 0.69 by QCA at a threshold of 59%. Sensitivity and specificity of QCTA to identify patients with both obstructive lesions and myocardial perfusion defects were 0.94 and 0.77, respectively. CONCLUSIONS Coronary artery stenosis assessment by QCTA or QCA only modestly predicts the presence and the absence of myocardial perfusion abnormalities by SPECT. Confounding variables affecting the relationship between coronary anatomy and myocardial perfusion likely account for some of the observed discrepancies between coronary angiography and SPECT results.
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Affiliation(s)
- G K Godoy
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, 21287, USA
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137
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Impact of ischemia-guided revascularization with myocardial perfusion imaging for patients with multivessel coronary disease. J Am Coll Cardiol 2012; 60:181-90. [PMID: 22789882 DOI: 10.1016/j.jacc.2012.02.061] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 02/06/2012] [Accepted: 02/24/2012] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the impact of ischemia-guided (IG) revascularization. BACKGROUND The importance of IG revascularization has not been well-determined. METHODS The outcomes of IG revascularization, in which revascularization was performed in the matched coronary artery with the perfusion abnormality on myocardial perfusion image (MPI), were retrospectively compared with those of non-IG revascularization in a registry of 5,340 patients with multivessel coronary disease comprising 2,587 percutaneous coronary interventions (PCIs) with drug-eluting stents and 2,753 coronary artery bypass graft (CABG) surgeries after adjustment with inverse-probability-of-treatment weighting. RESULTS The MPI was performed in 42.3% of patients, and IG revascularization was performed in 17.3%, including 12.4% in PCI and 21.8% in CABG patients (p < 0.001). The incidence of major adverse cardiac and cerebrovascular events (MACCE) including death, myocardial infarction, stroke, or repeat revascularization was significantly lower in the IG than in the non-IG group (16.2% vs. 20.7%; adjusted hazard ratio [aHR]: 0.73; 95% confidence interval [CI]: 0.60 to 0.88; p = 0.001), primarily driven by the lower repeat revascularization rate (9.9% vs. 22.8%; aHR: 0.66; 95% CI: 0.49 to 0.90; p = 0.009). Subgroup analysis showed that IG reduced the risk of MACCE in PCI (17.4% vs. 22.8%; aHR: 0.59; 95% CI: 0.43 to 0.81; p = 0.001) but not in CABG (16.0% vs. 18.5%; aHR: 0.87; 95% CI: 0.67 to 1.14; p = 0.31) patients. CONCLUSIONS Ischemia-guided revascularization with MPI, particularly in PCI-treated patients, seems to decrease the risk of repeat revascularization and MACCE for patients with multivessel disease.
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138
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Pakkal M, Raj V, McCann GP. Non-invasive imaging in coronary artery disease including anatomical and functional evaluation of ischaemia and viability assessment. Br J Radiol 2012; 84 Spec No 3:S280-95. [PMID: 22723535 DOI: 10.1259/bjr/50903757] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Coronary artery disease has an important impact on the morbidity and mortality statistics and health economics worldwide. Diagnosis of coronary artery disease is important in risk stratification and guides further management. Invasive coronary angiography is the traditional method of imaging the coronary arteries and remains the gold standard. It detects luminal stenosis but provides little information about the vessel wall or plaques. Besides, not all anatomical lesions are functionally significant. This has lent itself to a wide variety of imaging techniques to identify and assess a flow-limiting stenosis. The approach to diagnosis of coronary artery disease is broadly based on anatomical and functional imaging. Coronary CT and MRI of coronary arteries provide an anatomical assessment of coronary stenosis. Coronary calcium score and coronary CT assess subclinical atherosclerosis by assessing the atherosclerotic plaque burden. The haemodynamic significance of a coronary artery stenosis can be assessed by stress radioisotope studies, stress echocardiography and stress MRI. The more recent literature also focuses on plaque assessment and identification of plaques that are likely to give rise to an acute coronary syndrome. There is an explosion of literature on the merits and limitations of the different imaging modalities. This review article will provide an overview of all the imaging modalities in the diagnosis of coronary artery disease.
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Affiliation(s)
- M Pakkal
- Departments of Radiology, University Hospitals of Leicester NHS Trust, Groby Road, Leicester, UK.
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139
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Tashakkor AY, Nicolaou S, Leipsic J, Mancini GJ. The Emerging Role of Cardiac Computed Tomography for the Assessment of Coronary Perfusion: A Systematic Review and Meta-analysis. Can J Cardiol 2012; 28:413-22. [DOI: 10.1016/j.cjca.2012.02.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 02/13/2012] [Accepted: 02/13/2012] [Indexed: 12/12/2022] Open
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Puri R, Kapadia SR, Nicholls SJ, Harvey JE, Kataoka Y, Tuzcu EM. Optimizing Outcomes During Left Main Percutaneous Coronary Intervention With Intravascular Ultrasound and Fractional Flow Reserve. JACC Cardiovasc Interv 2012; 5:697-707. [DOI: 10.1016/j.jcin.2012.02.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 02/10/2012] [Accepted: 02/18/2012] [Indexed: 10/28/2022]
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Hulten EA, Bittencourt MS, Ghoshhajra B, Blankstein R. Stress CT perfusion: coupling coronary anatomy with physiology. J Nucl Cardiol 2012; 19:588-600. [PMID: 22456969 DOI: 10.1007/s12350-012-9546-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
While multiple different imaging tests can be used to evaluate patients with known or suspected coronary artery disease (CAD), each of them is designed to evaluate either coronary anatomy or physiology. Recently, it has been recognized that cardiac CT can be used to evaluate stress and rest myocardial perfusion in addition to its capabilities to image the coronary arteries, thus allowing for the simultaneous evaluation of the anatomical burden and physiological significance of CAD in a single exam. In this review, the strengths and the limitations of imaging coronary anatomy and myocardial perfusion will be discussed. Next, key technical aspects of how to perform and interpret CT perfusion imaging will be summarized while providing an update of the most recent data in this emerging field. Finally, future directions and opportunities for further research will be discussed.
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Affiliation(s)
- Edward A Hulten
- Non-Invasive Cardiovascular Imaging Program, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA 02115, USA
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Min JK, Koo BK, Erglis A, Doh JH, Daniels DV, Jegere S, Kim HS, Dunning A, Defrance T, Leipsic J. Effect of image quality on diagnostic accuracy of noninvasive fractional flow reserve: Results from the prospective multicenter international DISCOVER-FLOW study. J Cardiovasc Comput Tomogr 2012; 6:191-9. [DOI: 10.1016/j.jcct.2012.04.010] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 03/15/2012] [Accepted: 04/23/2012] [Indexed: 11/30/2022]
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Gonzalo N, Gonzalo N, Escaned J, Alfonso F, Nolte C, Rodriguez V, Jimenez-Quevedo P, Bañuelos C, Fernández-Ortiz A, Fernández-Ortiz A, Garcia E, Hernandez-Antolin R, Macaya C. Morphometric assessment of coronary stenosis relevance with optical coherence tomography: a comparison with fractional flow reserve and intravascular ultrasound. J Am Coll Cardiol 2012; 59:1080-9. [PMID: 22421301 DOI: 10.1016/j.jacc.2011.09.078] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 09/22/2011] [Accepted: 09/27/2011] [Indexed: 10/28/2022]
Abstract
OBJECTIVES The study sought to assess the diagnostic efficiency of optical coherence tomography (OCT) in identifying hemodynamically severe coronary stenoses as determined by fractional flow reserve (FFR). Concomitant OCT and intravascular ultrasound (IVUS) area measurements were performed in a subgroup of patients to compare the diagnostic efficiency of both techniques. BACKGROUND The value of OCT to determine stenosis severity remains unsettled. METHODS Sixty-one stenoses with intermediate angiographic severity were studied in 56 patients. Stenoses were labeled as severe if FFR ≤0.80. OCT interrogation was performed in all cases, with concomitant IVUS imaging in 47 cases. RESULTS Angiographic stenosis severity was 50.9 ± 8% diameter stenosis with 1.28 ± 0.3 mm minimal lumen diameter. FFR was ≤0.80 in 28 (45.9%) stenoses. An overall moderate diagnostic efficiency of OCT was found (area under the curve [AUC]: 0.74; 95% confidence interval [CI]: 0.61 to 0.84), with sensitivity/specificity of 82%/63% associated with an optimal cutoff value of 1.95 mm(2). Comparison of the results in patients with simultaneous IVUS and OCT imaging revealed no significant differences in the diagnostic efficiency of OCT (AUC: 0.70; 95% CI: 0.55 to 0.83) and IVUS (AUC. 0.63; 95% CI: 0.47 to 0.77; p = 0.19). Sensitivity/specificity for IVUS was 67%/65% for an optimal cutoff value of 2.36 mm(2). In the subgroup of small vessels (reference diameter <3 mm) OCT showed a significantly better diagnostic efficiency (AUC: 0.77; 95% CI: 0.60 to 0.89) than IVUS (AUC: 0.63; 95% CI: 0.46 to 0.78) to identify functionally significant stenoses (p = 0.04). CONCLUSIONS OCT has a moderate diagnostic efficiency in identifying hemodynamically severe coronary stenoses. Although OCT seems slightly superior to IVUS for this purpose (particularly in vessels <3 mm), its low specificity precludes its use as a substitute of FFR for functional stenosis assessment.
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Affiliation(s)
- Nieves Gonzalo
- Department of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain.
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Gewirtz H. PET measurement of adenosine stimulated absolute myocardial blood flow for physiological assessment of the coronary circulation. J Nucl Cardiol 2012; 19:347-54. [PMID: 22231036 DOI: 10.1007/s12350-011-9510-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Considerable awareness has been raised of late of the need to reduce radiation exposure and control costs of x-ray and radionuclide imaging procedures. PET/CT cameras are now widely available and in conjunction with appropriate radionuclides and commercially available software make quantitative measurement of absolute MBF feasible for routine clinical practice. Quantitative measurement of absolute MBF under condition of coronary vasodilation permits independent assessment of the functional status of each of the three major coronary perfusion zones and so obviates the need for rest MBF determination in the great majority of cases. Coronary microvascular function also may be assessed in this same way. Thus, the stress-only protocol with quantitative PET measurement of MBF provides essential information required for clinical decision making related to need for catheterization and intervention for patients with known or suspected ischemic heart disease. Moreover, the single PET determination of maximal MBF in contrast to the usual rest/stress procedure addresses both safety and cost concerns. The present review focuses on: (1) quantitative PET measurements of myocardial blood flow for physiological assessment of the coronary circulation and (2) the value and potential limitations of performing stress only imaging in the clinical context.
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Affiliation(s)
- Henry Gewirtz
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Cardiac Unit/Yawkey 5E, Boston, MA 02114, USA.
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Diagnostic value of myocardial SPECT to detect in-stent restenosis after drug-eluting stent implantation. Int J Cardiovasc Imaging 2012; 28:2125-34. [PMID: 22395666 DOI: 10.1007/s10554-012-0036-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
Abstract
Different angiographic patterns and restenosis rate may affect diagnostic value of single-photon emission computed tomography (SPECT) in the era of drug-eluting stents (DES). We aimed to determine the ability of myocardial SPECT to detect in-stent restenosis (ISR) in patients treated with DES compared to that of patients treated with bare metal stent (BMS). We evaluated 228 consecutive patients who underwent 6 months follow-up SPECT and coronary angiography (CAG) after stent implantation. In 228 patients, 354 vessels were treated with stent implantation (BMS, n = 105; DES, n = 249) and 65 (18.4%) vessels showed ISR (angiographic % diameter stenosis ≥ 50%) at the 6-month follow-up CAG. In patients with BMS-ISR (n = 37), restenosis was primarily diffuse (70.3%), whereas patients with DES-ISR (n = 28) exhibited more focal restenosis (53.6%, p = 0.028). The sensitivity and specificity of myocardial SPECT did not differ significantly between patients with BMS and those with DES (BMS vs. DES: sensitivity 56.8 vs. 39.3%, p = 0.163; specificity 72.1 vs. 76.5%, p = 0.460). Evaluation of 71 false positive and 33 false negative lesions showed that the most common cause of false-positive results in SPECT was the perfusion decrease which improved but not disappeared compared with the baseline (46 among 71 vascular territories). Despite different patterns of restenosis and ISR rates, the diagnostic value of SPECT did not differ between BMS and DES. Further study looking at ISR in larger number of patients and using other protocol such as Fleming-Harrington Redistribution Wash-in Washout may give additional information.
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Hakeem A, Mouhamad A, Leesar MA. Fractional flow reserve: a new paradigm for diagnosis and management of coronary artery disease. Interv Cardiol 2012. [DOI: 10.2217/ica.11.82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Schelbert HR. FFR and Coronary Flow Reserve. JACC Cardiovasc Imaging 2012; 5:203-6. [DOI: 10.1016/j.jcmg.2011.12.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 12/09/2011] [Indexed: 01/30/2023]
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Lindstaedt M, Mügge A. Myocardial fractional flow reserve. Its role in guiding PCI in stable coronary artery disease. Herz 2012; 36:410-6. [PMID: 21755348 DOI: 10.1007/s00059-011-3486-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Revascularization of coronary artery lesions should be based on objective evidence of ischemia, as recommended by the guidelines of the European Society of Cardiology. However, even in the case of stable coronary artery disease and elective percutaneous coronary intervention (PCI), pre-procedural noninvasive stress test results are available in a minority of patients only. It is common practice for physicians to make decisions on revascularization in the catheterization laboratory after a cursory review of the angiogram, despite the well-recognized inaccuracy of such an approach. Myocardial fractional flow reserve (FFR) measured by a coronary pressure wire is a specific index of the functional significance of a coronary lesion, with superior diagnostic accuracy for the detection of ischemia than any noninvasive stress test. FFR trials on patients with single and multivessel disease, such as the DEFER and FAME studies, have demonstrated that the clinical benefit of PCI with respect to patient outcome is greatest when revascularization is limited to lesions inducing ischemia, whereas lesions not inducing ischemia should be treated medically.
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Affiliation(s)
- M Lindstaedt
- Medizinische Klinik II-Kardiologie und Angiologie, BG Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, Bochum,Germany.
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