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Pradhan AM, Mut F, Cebral JR. A one-dimensional computational model for blood flow in an elastic blood vessel with a rigid catheter. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2024; 40:e3834. [PMID: 38736046 DOI: 10.1002/cnm.3834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 05/14/2024]
Abstract
Strokes are one of the leading causes of death in the United States. Stroke treatment involves removal or dissolution of the obstruction (usually a clot) in the blocked artery by catheter insertion. A computer simulation to systematically plan such patient-specific treatments needs a network of about 105 blood vessels including collaterals. The existing computational fluid dynamic (CFD) solvers are not employed for stroke treatment planning as they are incapable of providing solutions for such big arterial trees in a reasonable amount of time. This work presents a novel one-dimensional mathematical formulation for blood flow modeling in an elastic blood vessel with a centrally placed rigid catheter. The governing equations are first-order hyperbolic partial differential equations, and the hypergeometric function needs to be computed to obtain the characteristic system of these hyperbolic equations. We employed the Discontinuous Galerkin method to solve the hyperbolic system and validated the implementation by comparing it against a well-established 3D CFD solver using idealized vessels and a realistic truncated arterial network. The results showed clinically insignificant differences in steady flow cases, with overall variations between 1D and 3D models remaining below 10%. Additionally, the solver accurately captured wave reflection phenomena at domain discontinuities in unsteady cases. A primary advantage of this model over 3D solvers is its ease in obtaining a discretized geometry of complex vasculatures with multiple arterial branches. Thus, the 1D computational model offers good accuracy and applicability in simulating complex vasculatures, demonstrating promising potential for investigating patient-specific endovascular interventions in strokes.
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Affiliation(s)
| | - Fernando Mut
- Bioengineering Department, George Mason University, Fairfax, Virginia, USA
| | - Juan Raul Cebral
- Bioengineering Department, George Mason University, Fairfax, Virginia, USA
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Eerdekens R, Tonino PAL, Zimmermann FM, Teeuwen K, Vlaar PJ, de Waard GA, van Royen N, van Nunen LX. Fluid-filled versus sensor-tipped pressure guidewires for FFR and P d/P a measurement; PW-COMPARE study. Int J Cardiol 2024; 406:131998. [PMID: 38555057 DOI: 10.1016/j.ijcard.2024.131998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/22/2024] [Accepted: 03/27/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Fluid-filled pressure guidewires are unaffected by the previously inevitable hydrostatic pressure gradient (HPG). This study aimed to compare simultaneous pressure measurements with fluid-filled and sensor-tipped pressure guidewires. METHODS Fifty patients underwent fractional flow reserve (FFR) and Pd/Pa measurement with a fluid-filled and a sensor-tipped pressure guidewire simultaneously. To assess maneuverability, patients were randomized with respect to which pressure guidewire was used to cross the lesion first. Lateral fluoroscopy was used to estimate height difference between catheter tip and distal wire position (and thus HPG). Agreement between pressure measurements was studied. RESULTS Measurements were performed in LM (4% (n = 2)), LAD (44% (n = 22)), LCX (26% (n = 13)), and RCA (26% (n = 13)). Simultaneous pressure measurements showed excellent agreement (mean FFR difference - 0.01 ± 0.03 (r = 0.959, p < 0.001), mean Pd/Pa difference - 0.01 ± 0.04 (r = 0.929, p < 0.001)). FFR was ≤0.80 in 42.6% (n = 20) with fluid-filled FFR measurements versus 46.8% (n = 22) by sensor-tipped FFR measurements. Mean height difference was 15 ± 34 mm, and strongly dependent on the coronary artery (LAD 45 ± 10 mm, LCX -23 ± 16 mm, RCA -13 ± 17 mm). There was a strong correlation between height difference and difference in pressure ratios between sensor-tipped and fluid-filled pressure guidewires (FFR r = -0.850, p < 0.001; Pd/Par = -0.641, p < 0.001). Largest FFR differences were present in the LAD (-0.04 ± 0.02). After HPG correction, mean difference between HPG-corrected sensor-tipped FFR and fluid-filled FFR was 0.00 ± 0.02, mean Pd/Pa difference was 0.01 ± 0.03. CONCLUSIONS This study shows excellent overall correlation between FFR and Pd/Pa measurements with both pressure guidewires. Differences measured with fluid-filled and sensor-tipped pressure guidewires are vessel-specific and attributable to hydrostatic pressure gradients (NCT04802681).
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Affiliation(s)
- Rob Eerdekens
- Heart Center, Catharina Hospital, Eindhoven, the Netherlands
| | - Pim A L Tonino
- Heart Center, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Koen Teeuwen
- Heart Center, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Guus A de Waard
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lokien X van Nunen
- Heart Center, Catharina Hospital, Eindhoven, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
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Råmunddal T, Dworeck C, Torild P, Andréen S, Gan LM, Hirlekar G, Ioanes D, Myredal A, Odenstedt J, Petursson P, Pylova T, Töpel F, Völz S, Hilmersson M, Redfors B, Angerås O. Safety and Feasibility Using a Fluid-Filled Wire to Avoid Hydrostatic Errors in Physiological Intracoronary Measurements. Cardiol Res Pract 2024; 2024:6664482. [PMID: 38204600 PMCID: PMC10776192 DOI: 10.1155/2024/6664482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Background Using a fluid-filled wire with a pressure sensor outside the patient compared to a conventional pressure wire may avoid the systematic error introduced by the hydrostatic pressure within the coronary circulation. Aims To assess the safety and effectiveness of the novel fluid-filled wire, Wirecath (Cavis Technologies, Uppsala, Sweden), as well as its ability to avoid the hydrostatic pressure error. Methods and Results The Wirecath pressure wire was used in 45 eligible patients who underwent invasive coronary angiography and had a clinical indication for invasive coronary pressure measurement at Sahlgrenska University Hospital, Gothenburg, Sweden. In 29 patients, a simultaneous measurement was performed with a conventional coronary pressure wire (PressureWire X, Abbott Medical, Plymouth, MN, USA), and in 19 patients, the vertical height difference between the tip of the guide catheter and the wire measure point was measured in a 90-degree lateral angiographic projection. No adverse events caused by the pressure wires were reported. The mean Pd/Pa and mean FFR using the fluid-filled wire and the sensor-tipped wire differed significantly; however, after correcting for the hydrostatic effect, the sensor-tipped wire pressure correlated well with the fluid-filled wire pressure (R = 0.74 vs. R = 0.89 at rest and R = 0.89 vs. R = 0.98 at hyperemia). Conclusion Hydrostatic errors in physiologic measurements can be avoided by using the fluid-filled Wirecath wire, which was safe to use in the present study. This trial is registered with NCT04776577 and NCT04802681.
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Affiliation(s)
- Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Christian Dworeck
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Petronella Torild
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sofie Andréen
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Li-Ming Gan
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Geir Hirlekar
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Myredal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Petur Petursson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Tetiana Pylova
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Fanny Töpel
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sebastian Völz
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | | | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
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Florie NHM, Eerdekens R, Manzi MV, Heinrichs E, van 't Veer M, van Royen N, Tonino PAL, van Nunen LX. Potential effects of the hydrostatic pressure gradient on hyperemic and nonhyperemic pressure ratios. Am J Physiol Heart Circ Physiol 2023; 325:H562-H568. [PMID: 37477689 DOI: 10.1152/ajpheart.00305.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 07/22/2023]
Abstract
When measuring hyperemic and nonhyperemic pressure ratios with traditional sensor-tipped wires, the inevitable hydrostatic pressure gradient (HPG) may influence treatment decisions. This study aimed to simulate and analyze the effect of a hydrostatic pressure gradient on different indices of functional lesion severity. A hypothetical Pd-Pa height difference and subsequent hydrostatic pressure gradient based on previous literature was applied to the pressure measurements from the CONTRAST study. The effect on three indices of functional lesion severity (FFR, Pd/Pa, and dPR) was assessed and possible reclassifications in functional significance by the different indices were analyzed. In 602 pressure tracings, simulated hydrostatic pressure gradients led to an absolute change in Pd of 3.18 ± 1.30 mmHg, resulting in an overall increase in FFR, Pd/Pa, and dPR of 0.02 ± 0.04 for all indices (P = 0.69). Reclassification due to the hydrostatic pressure gradient when using dichotomous cutoff values occurred in 13.4, 22.3, and 20.6% for FFR, Pd/Pa, and dPR, respectively. The effect of hydrostatic pressure gradient correction differed among the coronary arteries and was most pronounced in the left anterior descending. When considering the gray zone for the different functional indices, the hydrostatic pressure gradient resulted in reclassification in only one patient out of the complete patient population (1/602; 0.17%). The hydrostatic pressure gradient can influence functional lesion assessment when using dichotomous cutoff values. When taking the gray zone into account, its effect is limited.NEW & NOTEWORTHY This study systematically simulated the effect of hydrostatic pressure gradients (HPG) on real-world hyperemic and nonhyperemic pressure ratios, showing correction for HPG leads to reclassification in functional significance from 13.4 to 22.3% for different functional indices. This was most pronounced in nonhyperemic pressure ratios. A new pressure guidewire (Wirecath) is unaffected by HPG. The ongoing PW-COMPARE study (NCT04802681) prospectively analyzes the magnitude and importance of HPG by simultaneous FFR measurements.
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Affiliation(s)
| | - Rob Eerdekens
- Heart Center, Catharina Hospital, Eindhoven, The Netherlands
| | | | | | | | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pim A L Tonino
- Heart Center, Catharina Hospital, Eindhoven, The Netherlands
| | - Lokien X van Nunen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
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Novel Method to Detect Pitfalls of Intracoronary Pressure Measurements by Pressure Waveform Analysis. J Pers Med 2022; 12:jpm12122035. [PMID: 36556256 PMCID: PMC9784866 DOI: 10.3390/jpm12122035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
Potential pitfalls of fractional flow reserve (FFR) measurements are well-known drawbacks of invasive physiology measurement, e.g., significant drift of the distal pressure trace may lead to the misclassification of stenoses. Thus, a simultaneous waveform analysis of the pressure traces may be of help in the quality control of these measurements by online detection of such artefacts as the drift or the wedging of the catheter. In the current study, we analysed the intracoronary pressure waveform with a dedicated program. In 130 patients, 232 FFR measurements were performed and derivative pressure curves were calculated. Local amplitude around the dicrotic notch was calculated from the distal intracoronary pressure traces (δdPn/dt). A unidimensional arterial network model of blood flow was employed to simulate the intracoronary pressure traces at different flow rates. There was a strong correlation between δdPn/dt values measured during hyperaemia and FFR (r = 0.88). Diagnostic performance of distal δdPn/dt ≤ 3.52 for the prediction of FFR ≤ 0.80 was 91%. The correlation between the pressure gradient and the corresponding δdPn/dt values obtained from all measurements independently of the physiological phase was also significant (r = 0.80). During simulation, the effect of flow rate on δdPn/dt further supported the close correlation between the pressure ratios and δdPn/dt. Discordance between the FFR and the δdPn/dt can be used as an indicator of possible technical problems of FFR measurements. Hence, an online calculation of the δdPn/dt may be helpful in avoiding some pitfalls of FFR evaluation.
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Zhu XL, Pang ZY, Jiang W, Dong TY. Synergistic prognostic value of coronary distensibility index and fractional flow reserve based cCTA for major adverse cardiac events in patients with Coronary artery disease. BMC Cardiovasc Disord 2022; 22:220. [PMID: 35568818 PMCID: PMC9107240 DOI: 10.1186/s12872-022-02655-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Coronary distensibility index (CDI), as an early predictor of cardiovascular diseases, has the potential to complement coronary computed tomography angiography (cCTA)-derived fractional flow reserve (CT-FFR) for predicting major adverse cardiac events (MACEs). Thus, the prognostic value of CT-FFR combined with CDI for MACEs is worth exploring. METHODS Patients with a moderate or severe single left anterior descending coronary artery stenosis were included and underwent FFR and CDI analysis based on cCTA, followed up at least 1 year, and recorded MACEs. Multivariate logistic regression analysis was performed to determine independent predictors of MACEs. The area under of receiver operating characteristic (ROC) curve was used to evaluated evaluate the diagnostic performance of CT-FFR, CDI, and a combination of the two. RESULTS All the vessel-specific data were from LAD. 150 patients were analysed. 55 (37%) patients experienced MACEs during follow-up. Patients with CT-FFR ≤ 0.8 had higher percentage of MACEs compared with CT-FFR > 0.8 (56.3% vs.7.3%, p < 0.05). Patients' CDI was significantly decreased in MACEs group compared with non-MACEs group (p < 0.05). Multivariate analysis revealed that diabetes (p = 0.025), triglyceride (p = 0.015), CT-FFR ≤ 0.80 (p = 0.038), and CDI (p < 0.001) are independent predictors of MACEs. According to ROC curve analysis, CT-FFR combined CDI showed incremental diagnostic performance over CT-FFR alone for prediction of MACEs (AUC = 0.831 vs. 0.656, p = 0.0002). CONCLUSION Our study provides initial evidence that combining CDI with CT-FFR shows incremental discriminatory power for MACEs over CT-FFR alone, independent of clinical risk factors. Diabetes and triglyceride are also associated with MACEs.
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Affiliation(s)
- Xiao-Long Zhu
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, No. 12, Changqing Road, Qiaoxi District, Zhangjiakou, 075000, Hebei, China.
| | - Zhi-Ying Pang
- Graduate School of Hebei North University, Hebei, China
| | - Wei Jiang
- The Medical Engineering Office, The First Affiliated Hospital of Hebei North University, Hebei, China
| | - Ting-Yu Dong
- Graduate School of Hebei North University, Hebei, China
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7
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Banerjee RK, Ramadurai S, Manegaonkar SM, Rao MB, Rakkimuthu S, Effat MA. Comparison Between 5- and 1-Year Outcomes Using Cutoff Values of Pressure Drop Coefficient and Fractional Flow Reserve for Diagnosing Coronary Artery Diseases. Front Physiol 2021; 12:689517. [PMID: 34335296 PMCID: PMC8317064 DOI: 10.3389/fphys.2021.689517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/28/2021] [Indexed: 12/02/2022] Open
Abstract
Background The current pressure-based coronary diagnostic index, fractional flow reserve (FFR), has a limited efficacy in the presence of microvascular disease (MVD). To overcome the limitations of FFR, the objective is to assess the recently introduced pressure drop coefficient (CDP), a fundamental fluid dynamics-based combined pressure–flow index. Methods We hypothesize that CDP will result in improved clinical outcomes in comparison to FFR. To test the hypothesis, chi-square test was performed to compare the percent major adverse cardiac events (%MACE) at 5 years between (a) FFR < 0.75 and CDP > 27.9 and (b) FFR < 0.80 and CDP > 25.4 groups using a prospective cohort study. Furthermore, Kaplan–Meier survival curves were compared between the FFR and CDP groups. The results were considered statistically significant for p < 0.05. The outcomes of the CDP arm were presumptive as clinical decision was solely based on the FFR. Results For the complete patient group, the %MACE in the CDP > 27.9 group (10 out of 35, 29%) was lower in comparison to the FFR < 0.75 group (11 out of 20, 55%), and the difference was near significant (p = 0.05). The survival analysis showed a significantly higher survival rate (p = 0.01) in the CDP > 27.9 group (n = 35) when compared to the FFR < 0.75 group (n = 20). The results remained similar for the FFR = 0.80 cutoff. The comparison of the 5-year MACE outcomes with the 1-year outcomes for the complete patient group showed similar trends, with a higher statistical significance for a longer follow-up period of 5 years. Conclusion Based on the MACE and survival analysis outcomes, CDP could possibly be an alternate diagnostic index for decision-making in the cardiac catheterization laboratory. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT01719016.
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Affiliation(s)
- Rupak K Banerjee
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States.,Research Services, Veteran Affairs Medical Services, Cincinnati, OH, United States
| | - Sruthi Ramadurai
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States
| | - Shreyash M Manegaonkar
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States
| | - Marepalli B Rao
- Department of Environmental and Public Health Sciences, University of Cincinnati, Cincinnati, OH, United States
| | - Sathyaprabha Rakkimuthu
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States
| | - Mohamed A Effat
- Department of Cardiology, University of Cincinnati Medical Center, Cincinnati, OH, United States
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Gassenmaier S, Tsiflikas I, Greulich S, Kuebler J, Hagen F, Nikolaou K, Niess AM, Burgstahler C, Krumm P. Prevalence of pathological FFR CT values without coronary artery stenosis in an asymptomatic marathon runner cohort. Eur Radiol 2021; 31:8975-8982. [PMID: 34041572 PMCID: PMC8589749 DOI: 10.1007/s00330-021-08027-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/17/2021] [Accepted: 04/28/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To evaluate computed tomography fractional flow reserve (FFRCT) values in distal parts of the coronaries in an asymptomatic cohort of marathon runners without any coronary stenosis for potentially false-positive values. METHODS Ninety-eight asymptomatic male marathon runners (age 53 ± 7 years) were enrolled in a prospective monocentric study and underwent coronary computed tomography angiography (CCTA). CCTA data were analyzed for visual coronary artery stenosis. FFRCT was evaluated in 59 participants without coronary artery stenosis in proximal, mid, and distal coronary sections using an on-site software prototype. RESULTS In participants without coronary artery stenosis, abnormal FFRCT values ≤ 0.8 in distal segments were found in 22 participants (37%); in 19 participants in the LAD; in 5 participants in the LCX; and in 4 participants in the RCA. Vessel diameters in participants with FFRCT values > 0.80 compared to ≤ 0.80 were 1.6 ± 0.3 mm versus 1.5 ± 0.3 mm for distal LAD (p = 0.025), 1.8 ± 0.3 mm versus 1.6 ± 0.5 mm for distal LCX (p = 0.183), and 2.0 ± 0.4 mm versus 1.5 ± 0.2 mm for distal RCA (p < 0.001). CONCLUSIONS Abnormal FFRCT values of ≤ 0.8 frequently occurred in distal coronary segments in subjects without any anatomical coronary artery stenosis. This effect is only to some degree explainable by small distal vessel diameters. Therefore, the validity of hemodynamic relevance evaluation using FFRCT in distal coronary artery segment stenosis is reduced. KEY POINTS • Abnormal FFRCT values (≤ 0.8) occurred in over a third of the subjects in the distal LAD despite the absence of coronary artery stenosis.. • Therefore, the validity of hemodynamic relevance evaluation in distal coronary artery segment stenosis is reduced. • Decision-making based on abnormal FFRCT values in distal vessel sections should be performed with caution and only in combination with visual assessment of the grade of stenosis..
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Affiliation(s)
- Sebastian Gassenmaier
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Tübingen, Germany
| | - Ilias Tsiflikas
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Tübingen, Germany
| | - Simon Greulich
- Department of Cardiology and Angiology, University of Tuebingen, Tübingen, Germany
| | - Jens Kuebler
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Tübingen, Germany
| | - Florian Hagen
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Tübingen, Germany
| | - Andreas M Niess
- Department of Internal Medicine V, Sports Medicine, University of Tuebingen, Hoppe-Seyler-Straße 6, 72076, Tübingen, Germany
| | - Christof Burgstahler
- Department of Internal Medicine V, Sports Medicine, University of Tuebingen, Hoppe-Seyler-Straße 6, 72076, Tübingen, Germany.
| | - Patrick Krumm
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Tübingen, Germany
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Li C, Yang J, Dong S, Dong L, Chen J, Shen L, Zhang F, Li C, Liu H, Hu X, Hau WK, Qian J, Jeremias A, Wang J, Ge J. Multicenter clinical evaluation of a piezoresistive-MEMS-sensor rapid-exchange pressure microcatheter system for fractional flow reserve measurement. Catheter Cardiovasc Interv 2021; 98:E243-E253. [PMID: 33951285 PMCID: PMC8453920 DOI: 10.1002/ccd.29678] [Citation(s) in RCA: 4] [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: 01/29/2021] [Revised: 03/02/2021] [Accepted: 03/16/2021] [Indexed: 11/11/2022]
Abstract
Objectives This multicenter, prospective clinical study investigates whether the microelectromechanical‐systems‐(MEMS)‐sensor pressure microcatheter (MEMS‐PMC) is comparable to a conventional pressure wire in fractional flow reserve (FFR) measurement. Background As a conventional tool for FFR measurement, pressure wires (PWs) still have some limitations such as suboptimal handling characteristics and unable to maintain the wire position during pullback assessment. Recently, a MEMS‐PMC compatible with any 0.014″ guidewire is developed. Compared with the existing optical‐sensor PMC, this MEMS‐PMC has smaller profiles at both the lesion crossing and sensor packaging areas. Methods Two hundred and forty‐two patients with visually 30–70% coronary stenosis were enrolled at four centers. FFR was measured first with the MEMS‐PMC, and then with the PW. The primary endpoint was the Bland–Altman mean bias between the MEMS‐PMC and PW FFR. Results From the 224‐patient per‐protocol data, quantitative coronary angiography showed 17.9% and 55.9% vessels had diameter < 2.5 mm and stenosis >50%, respectively. The two systems' mean bias was −0.01 with [−0.08, 0.06] 95% limits‐of‐agreement. Using PW FFR≤0.80 as cutoff, the MEMS‐PMC per‐vessel diagnostic accuracy was 93.4% [95% confidence interval: 89.4–96.3%]. The MEMS‐PMC's success rate was similar to that of PW (97.5 vs. 96.3%, p = .43) with no serious adverse event, and its clinically‐significant (>0.03) drift rate was 43% less (9.5 vs. 16.7%, p = .014). Conclusions Our study showed the MEMS‐PMC is safe to use and has a minimal bias equal to the resolution of current FFR systems. Given the MEMS‐PMC's high measurement accuracy and rapid‐exchange nature, it may become an attractive new tool facilitating routine coronary physiology assessment.
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Affiliation(s)
- Chenguang Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junqing Yang
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangzhou, Guangdong, China
| | - Shaohong Dong
- Department of Cardiology, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Liang Dong
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangzhou, Guangdong, China
| | - Li Shen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Changling Li
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Huadong Liu
- Department of Cardiology, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - William Kongto Hau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Juying Qian
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Allen Jeremias
- Department of Cardiology, St. Francis Hospital, Roslyn, New York, New York, USA.,Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
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10
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Beck S, Pereyra VM, Seitz A, McChord J, Hubert A, Bekeredjian R, Sechtem U, Ong P. Invasive Diagnosis of Coronary Functional Disorders Causing Angina Pectoris. Eur Cardiol 2021; 16:e27. [PMID: 34276812 PMCID: PMC8280748 DOI: 10.15420/ecr.2021.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/26/2021] [Indexed: 01/16/2023] Open
Abstract
Coronary vasomotion disorders represent a frequent cause of angina and/or dyspnoea in patients with non-obstructed coronary arteries. The highly sophisticated interplay of vasodilatation and vasoconstriction can be assessed in an interventional diagnostic procedure. Established parameters characterising adequate vasodilatation are coronary blood flow at rest, and, after drug-induced vasodilation, coronary flow reserve, and microvascular resistance (hyperaemic microvascular resistance, index of microcirculatory resistance). An increased vasoconstrictive potential is diagnosed by provocation testing with acetylcholine or ergonovine. This enables a diagnosis of coronary epicardial and/or microvascular spasm. Ischaemia associated with microvascular spasm can be confirmed by ischaemic ECG changes and the measurement of lactate concentrations in the coronary sinus. Although interventional diagnostic procedures are helpful for determining the mechanism of the angina, which may be the key to successful medical treatment, they are still neither widely accepted nor applied in many medical centres. This article summarises currently well-established invasive methods for the diagnosis of coronary functional disorders causing angina pectoris.
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Affiliation(s)
- Sascha Beck
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | | | - Andreas Seitz
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Johanna McChord
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Astrid Hubert
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Raffi Bekeredjian
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Peter Ong
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
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11
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Nogi K, Soeda T, Hara M, Iwama H, Toyokawa N, Sakai S, Yano H, Iwai A, Hashimoto Y, Fujimoto H, Suzuki M, Nakai T, Doi N, Saito Y. Functional assessment of intermediate coronary artery stenosis with 4-Fr catheters. Heart Vessels 2021; 36:638-645. [PMID: 33389064 DOI: 10.1007/s00380-020-01746-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
The 4-Fr catheter system is not recommended for invasive functional assessment of coronary artery stenosis, because it tends to distort the aortic waveform. This study aimed to identify the incidence of aortic waveform distortion and a feasible method for correct diagnosis of coronary artery stenosis with a 4-Fr catheter. We retrospectively investigated 178 lesions with intermediate coronary artery stenosis. Non-hyperemic distal coronary artery pressure (Pd) and aortic pressure (Pa) were measured with a 4-Fr diagnostic or 6-Fr guiding catheter before and after saline flush. The mean Pd/mean Pa (Pd/Pa) and instantaneous wave-free ratio (iFR) were calculated before and after flushing. We compared the effect of flushing on the changes in Pd/Pa and iFR between the 4-Fr diagnostic and 6-Fr guiding catheters. Using the 4-Fr diagnostic catheter, there was a significant decrease in incidence of aortic waveform distortion from 42.0% (47 lesions) before flushing to 1.8% (2 lesions) after flushing (p < 0.001); the incidence was only 3.0% before saline flush and decreased to 0% after saline flush when using the 6-Fr guiding catheter. The presence of aortic waveform distortion influenced the iFR when the 4-Fr system was used. Functional measurements with the 4-Fr diagnostic catheter require adequate saline flush to remove the influence of aortic waveform distortion.
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Affiliation(s)
- Kazutaka Nogi
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan.,Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Tsunenari Soeda
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan.
| | - Masahiko Hara
- Center for Community-Based Healthcare Research and Education, Shimane University, Izumo, Japan
| | - Hajime Iwama
- Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Nozomi Toyokawa
- Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Satoshi Sakai
- Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Hiroki Yano
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan.,Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Atsushi Iwai
- Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Yukihiro Hashimoto
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan.,Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Hajime Fujimoto
- Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Megumi Suzuki
- Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Takehito Nakai
- Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Naofumi Doi
- Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan
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12
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Jerabek S, Zemanek D, Pudil J, Bayerova K, Kral A, Kopriva K, Kawase Y, Omori H, Tanigaki T, Chen Z, Vodzinska A, Branny M, Matsuo H, Mates M, Sonka M, Kovarnik T. Endothelial dysfunction assessed by digital tonometry and discrepancy between fraction flow reserve and instantaneous wave free ratio. Acta Cardiol 2020; 75:323-328. [PMID: 30945607 DOI: 10.1080/00015385.2019.1586089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background: We tested whether the level of endothelial dysfunction assessed by digital tonometry, and expressed as reactive hyperemia index (RHI), is related to occurrences of a discrepancy between fractional flow reserve (FFR) and the instantaneous wave free ratio (iFR) (ClinicalTrials.gov identifier: NCT03033810).Methods: We examined patients with coronary stenosis in the range of 40-70%, assessed by both FFR and iFR (system Philips-Volcano) for stable angina. We included consecutive patients with FFR and iFR in one native coronary artery, and who had had no previous intervention.Results: We included 138 patients. Out of those, 24 patients (17.4%) had a negative FFR (with an FFR value >0.8) and positive iFR (with a iFR value ≤0.89) - designated the FFRn/iFRp discrepancy group, and 22 patients (15.9%) had a positive FFR (≤0.8) and negative iFR (>0.89) - designated the FFRp/iFRn discrepancy. RHI was higher in the discrepancy groups compared the group without discrepancy (1.73 ± 0.79 vs. 1.48 ± 0.50, p = 0.025). However, this finding was not confirmed in multivariant logistic regression analyses. Patients with any type of discrepancy differed from the agreement group by having a higher occurrence of diabetes mellitus [9 patients (21.4%) vs. 36 patients (39.6%), p = 0.029], active smoking (23 patients or 54.8% vs. 26 patients or 28.6%, p = 0.003) and lower use of calcium channel blockers (9 patients, 21.4%, vs. 43 patients, 46.7%, p = 0.004).Conclusion: The presence of endothelial dysfunction can be associated with a discrepancy in FFR/iFR. However, RHI correlated with risk factors of atherosclerosis, not with FFR or iFR.
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Affiliation(s)
- Stepan Jerabek
- 2nd Department of Medicine – Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - David Zemanek
- 2nd Department of Medicine – Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Jan Pudil
- 2nd Department of Medicine – Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Kristyna Bayerova
- 2nd Department of Medicine – Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Ales Kral
- 2nd Department of Medicine – Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Karel Kopriva
- Cardiology Department, Homolka Hospital, Prague, Czech Republic
| | | | | | | | - Zhi Chen
- Department of Electrical & Computer Engineering and Iowa Institute for Biomedical Imaging, The University of Iowa, Iowa City, IA, USA
| | | | - Marian Branny
- Cardiology Department, Trinec Podlesi Hospital, Trinec, Czech Republic
| | | | - Martin Mates
- Cardiology Department, Homolka Hospital, Prague, Czech Republic
| | - Milan Sonka
- Department of Electrical & Computer Engineering and Iowa Institute for Biomedical Imaging, The University of Iowa, Iowa City, IA, USA
| | - Tomas Kovarnik
- 2nd Department of Medicine – Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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13
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Vieira HCA, Ferreira MCM, Nunes LC, Cardoso CJF, Nascimento EMD, Oliveira GMMD. Evaluation of Myocardial Ischemia with iFR (Instantaneous Wave-Free Ratio in the Catheterization Laboratory: A Pilot Study. Arq Bras Cardiol 2020; 114:256-264. [PMID: 32215494 PMCID: PMC7077572 DOI: 10.36660/abc.20180298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 03/10/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The Instantaneous Wave-Free Ratio (iFR) is an invasive functional evaluation method that does not require vasoactive drugs to induce maximum hyperemia. OBJECTIVE To evaluate the contribution of the iFR to the therapeutic decision-making of coronary lesions in the absence of non-invasive diagnostic methods for ischemia, or in case of discordance between these methods and coronary angiography. METHOD We studied patients older than 18 years, of both sexes, consecutively referred for percutaneous treatment between May 2014 and March 2018. Coronary stenotic lesions were classified by visual estimation of the stenosis diameter into moderate (41-70% stenosis) or severe (71%-90%). An iFR ≤ 0.89 was considered positive for ischemia. Logistic regression was performed using the elastic net, with placement of stents as outcome variable, and age, sex, arterial hypertension, diabetes, dyslipidemia, smoking, family history, obesity and acute myocardial infarction (AMI) as independent variables. Classification trees, ROC curves, and Box Plot graphs were constructed using the R software. A p-value < 0.05 was considered statistically significant. RESULTS Fifty-two patients with 96 stenotic lesions (56 moderate, 40 severe) were evaluated. The iFR cut-off point of 0.87 showed a sensitivity of 0.57 and 1-specificity of 0.88, demonstrating high accuracy in reclassifying the lesions. Diabetes mellitus, dyslipidemia, and presence of moderate lesions with an iFR < 0.87 were predictors of stent implantation. Stents were used in 32% of lesions in patients with stable coronary artery disease and AMI with or without ST elevation (non-culprit lesions). CONCLUSION The iFR has an additional value to the therapeutic decision making in moderate and severe coronary stenotic lesions, by contributing to the reclassification of lesions and decreasing the need for stenting.
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Affiliation(s)
| | | | | | | | - Emilia Matos do Nascimento
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ - Brazil.,Fundação Centro Universitário Estadual da Zona Oeste - UEZO, Rio de Janeiro, RJ - Brazil
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14
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Abstract
PURPOSE OF REVIEW This review discusses similarities and differences between cardiac positron emission tomography (PET), absolute myocardial blood flow, and flow reserve with invasive fractional flow reserve (FFR). RECENT FINDINGS Fundamentally, cardiac PET measures absolute myocardial blood flow whereas FFR provides a relative flow reserve. Cardiac PET offers a non-invasive and therefore lower risk alternative, able to image the entire left ventricle regardless of coronary anatomy. While cardiac PET can provide unique information about the subendocardium, FFR pullbacks offer unparalleled spatial resolution. Both diagnostic tests provide a highly repeatable and technically successful index of coronary hemodynamics that accounts for the amount of distal myocardial mass, albeit only indirectly with FFR. The randomized evidence base for FFR and its associated cost effectiveness remains unsurpassed. Cardiac PET and FFR have been intertwined since the very development of FFR over 25 years ago. Recent work has emphasized the ability of both techniques to guide revascularization decisions by high-quality physiology. In the past few years, cardiac PET has expanded its evidence base regarding clinical outcomes, whereas FFR has solidified its position in randomized studies as the invasive reference standard.
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Affiliation(s)
- Nils P. Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030 USA
- Memorial Hermann Hospital, Houston, TX USA
| | - K. Lance Gould
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030 USA
- Memorial Hermann Hospital, Houston, TX USA
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15
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TOPAL S, SEZENÖZ B, CANDEMİR M, AÇIKGÖZ E, AÇIKGÖZ SK, BOYACI NB. An old friend: uric acid and its association with fractional flow reserve. Turk J Med Sci 2019; 49:1614-1619. [PMID: 31655503 PMCID: PMC7518665 DOI: 10.3906/sag-1903-91] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/22/2019] [Indexed: 11/04/2022] Open
Abstract
Background/aim The aim of this study was to investigate the importance of preprocedural uric acid (UA) level in predicting fractional flow reserve (FFR) results of intermediate coronary lesions in patients with stable coronary artery disease undergoing coronary angiography. Materials and methods We retrospectively analyzed 293 patients who underwent FFR measurement to determine the significance of intermediate coronary stenosis detected by conventional coronary angiography. Patients were divided into 2 groups: Group 1 (n = 127) included patients with FFR of <0.80 (hemodynamically significant lesions), and Group 2 (n = 169) consisted of patients with FFR of >0.80 (hemodynamically nonsignificant lesions). Uric acid levels were assessed in both groups with the enzymatic colorimetric method by clinical chemistry autoanalyzer. Results The mean UA level was significantly higher in patients whose FFR indicated hemodynamically significant coronary lesions (UA: 5.43 ± 1.29 mg/dL in Group 1 vs. 4.51 ± 1.34 mg/dL in Group 2, P < 0.001). Conclusion Elevated UA levels are associated with hemodynamically significant coronary lesions measured with FFR. Uric acid may be used as a predictor of hemodynamically compromised coronary lesions before FFR procedures.
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Affiliation(s)
- Salih TOPAL
- Department of Cardiology, Faculty of Medicine, Gazi University, AnkaraTurkey
- * To whom correspondence should be addressed. E-mail:
| | - Burak SEZENÖZ
- Department of Cardiology, Faculty of Medicine, Gazi University, AnkaraTurkey
| | | | - Eser AÇIKGÖZ
- Department of Cardiology, Abdurrahman Yurtarslan Ankara Oncology Education and Research Hospital, AnkaraTurkey
| | - Sadık Kadri AÇIKGÖZ
- Department of Cardiology, Kahraman Kazan Hamdi Eriş State Hospital, KahramankazanTurkey
| | - Nuri Bülent BOYACI
- Department of Cardiology, Faculty of Medicine, Gazi University, AnkaraTurkey
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16
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Howard JP, Cook CM, van de Hoef TP, Meuwissen M, de Waard GA, van Lavieren MA, Echavarria-Pinto M, Danad I, Piek JJ, Götberg M, Al-Lamee RK, Sen S, Nijjer SS, Seligman H, van Royen N, Knaapen P, Escaned J, Francis DP, Petraco R, Davies JE. Artificial Intelligence for Aortic Pressure Waveform Analysis During Coronary Angiography. JACC Cardiovasc Interv 2019; 12:2093-2101. [DOI: 10.1016/j.jcin.2019.06.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/12/2019] [Accepted: 06/18/2019] [Indexed: 10/26/2022]
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17
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Abstract
BACKGROUND The only indication for coronary revascularization is elimination of ischaemia. Invasive hemodynamic methods (fractional flow reserve - FFR and instantaneous wave-free ratio (iFR) are superior to coronary angiography in detection of lesions causing myocardial ischaemia. Current European guidelines for myocardial revascularization recommend using of FFR for detection of functional assessment of lesions severity in category IA and number of these procedures increases. However, routine usage of these methods requires knowledge of technical requirements and limitations. AIM The aim of the study is to summarise good clinical practice for FFR and iFR measurements with explanation of possible technical challenges, that are necessary for increasing of measurement accuracy. CONCLUSIONS Authors describe frequent technical mistakes and malpractice during invasive assessment of lesion severity in coronary arteries.
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Affiliation(s)
- Stepan Jerabek
- 2nd Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Praha, Czech Republic
| | - Tomas Kovarnik
- 2nd Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Praha, Czech Republic
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18
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Casadonte L, Piek JJ, VanBavel E, Spaan JAE, Siebes M. Discordance between pressure drift after wire pullback and intracoronary distal pressure offset affects stenosis physiology appraisal. Int J Cardiol 2018; 277:29-34. [PMID: 30173920 DOI: 10.1016/j.ijcard.2018.08.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/07/2018] [Accepted: 08/17/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Drift is a well-known issue affecting intracoronary pressure measurements. A small pressure offset at the end of the procedure is generally considered acceptable, while repeat assessment is advised for drift exceeding ±2 mmHg. This practice implies that drift assessed after wire pullback equals that at the time of stenosis appraisal, but this assumption has not been systematically investigated. Our aim was to compare intra-and post-procedural pressure sensor drift and assess benefits of correction for intra-procedural drift and its effect on diagnostic classification. METHODS In 70 patients we compared intra- and post-procedural pressure drift for 120 hemodynamic tracings obtained at baseline and throughout the hyperemic response to intracoronary adenosine. Intra-procedural drift was derived from the intercept of the stenosis pressure gradient-velocity relationship. Diagnostic reclassification after correction for intra-procedural drift was assessed for the mean distal-to-aortic pressure ratio at baseline (Pd/Pa) and hyperemia (fractional flow reserve, FFR), and corresponding stenosis resistances. RESULTS Post- and intra-procedural drift exceeding the tolerated threshold was observed in 73% and 64% of the hemodynamic tracings, respectively. Discordance in terms of acceptable drift level was present for 42% of the tracings, with avoidable repeat physiological assessment in 25% and unacceptable intra-procedural drift unrecognized at final drift check in 17% of the tracings. Correction for intra-procedural drift caused higher reclassification rates for baseline than hyperemic functional indices. CONCLUSIONS Post-procedural pressure drift frequently does not match drift during physiological assessment. Tracing-specific correction for intra-procedural drift can potentially lower the risk of inadvertent diagnostic misclassification and prevent unnecessary repeats.
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Affiliation(s)
- Lorena Casadonte
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Ed VanBavel
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jos A E Spaan
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Maria Siebes
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, the Netherlands.
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19
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Mynard JP, Penny DJ, Smolich JJ. Major influence of a 'smoke and mirrors' effect caused by wave reflection on early diastolic coronary arterial wave intensity. J Physiol 2018; 596:993-1017. [PMID: 29318640 DOI: 10.1113/jp274710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/02/2018] [Indexed: 01/25/2023] Open
Abstract
KEY POINTS Coronary wave intensity analysis (WIA) is an emerging technique for assessing upstream and downstream influences on myocardial perfusion. It is thought that a dominant backward decompression wave (BDWdia ) is generated by a distal suction effect, while early-diastolic forward decompression (FDWdia ) and compression (FCWdia ) waves originate in the aorta. We show that wave reflection also makes a substantial contribution to FDWdia , FCWdia and BDWdia , as quantified by a novel method. In 18 sheep, wave reflection accounted for ∼70% of BDWdia , whereas distal suction dominated in a computer model representing a hypertensive human. Non-linear addition/subtraction of mechanistically distinct waves (e.g. wave reflection and distal suction) obfuscates the true contribution of upstream and downstream forces on measured waves (the 'smoke and mirrors' effect). The mechanisms underlying coronary WIA are more complex than previously thought and the impact of wave reflection should be considered when interpreting clinical and experimental data. ABSTRACT Coronary arterial wave intensity analysis (WIA) is thought to provide clear insight into upstream and downstream forces on coronary flow, with a large early-diastolic surge in coronary flow accompanied by a prominent backward decompression wave (BDWdia ), as well as a forward decompression wave (FDWdia ) and forward compression wave (FCWdia ). The BDWdia is believed to arise from distal suction due to release of extravascular compression by relaxing myocardium, while FDWdia and FCWdia are thought to be transmitted from the aorta into the coronary arteries. Based on an established multi-scale computational model and high-fidelity measurements from the proximal circumflex artery (Cx) of 18 anaesthetized sheep, we present evidence that wave reflection has a major impact on each of these three waves, with a non-linear addition/subtraction of reflected waves obscuring the true influence of upstream and downstream forces through concealment and exaggeration, i.e. a 'smoke and mirrors' effect. We also describe methods, requiring additional measurement of aortic WIA, for unravelling the separate influences of wave reflection versus active upstream/downstream forces on coronary waves. Distal wave reflection accounted for ∼70% of the BDWdia in sheep, but had a lesser influence (∼25%) in the computer model representing a hypertensive human. Negative reflection of the BDWdia at the coronary-aortic junction attenuated the Cx FDWdia (by ∼40% in sheep) and augmented Cx FCWdia (∼5-fold), relative to the corresponding aortic waves. We conclude that wave reflection has a major influence on early-diastolic WIA, and thus needs to be considered when interpreting coronary WIA profiles.
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Affiliation(s)
- Jonathan P Mynard
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia.,Department of Cardiology, Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - Daniel J Penny
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia.,Department of Cardiology, Royal Children's Hospital, Parkville, VIC 3052, Australia.,Institute of Reproduction and Development, Monash University, Clayton, VIC, Australia
| | - Joseph J Smolich
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia.,Institute of Reproduction and Development, Monash University, Clayton, VIC, Australia
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20
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Tonino PAL, Johnson NP. Why Is Fractional Flow Reserve After Percutaneous Coronary Intervention Not Always 1.0? JACC Cardiovasc Interv 2018; 9:1032-5. [PMID: 27198683 DOI: 10.1016/j.jcin.2016.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 03/28/2016] [Accepted: 04/01/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Pim A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands.
| | - Nils P Johnson
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands; Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas
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21
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Liu X, Peng C, Xia Y, Gao Z, Xu P, Wang X, Xian Z, Yin Y, Jiao L, Wang D, Shi L, Huang W, Liu X, Zhang H. Hemodynamics analysis of the serial stenotic coronary arteries. Biomed Eng Online 2017; 16:127. [PMID: 29121932 PMCID: PMC5679505 DOI: 10.1186/s12938-017-0413-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 10/11/2017] [Indexed: 11/25/2022] Open
Abstract
Coronary arterial stenoses, particularly serial stenoses in a single branch, are responsible for complex hemodynamic properties of the coronary arterial trees, and the uncertain prognosis of invasive intervention. Critical information of the blood flow redistribution in the stenotic arterial segments is required for the adequate treatment planning. Therefore, in this study, an image based non-invasive functional assessment is performed to investigate the hemodynamic significances of serial stenoses. Twenty patient-specific coronary arterial trees with different combinations of stenoses were reconstructed from the computer tomography angiography for the evaluation of the hemodynamics. Our results showed that the computed FFR based on CTA images (FFRCT) pullback curves with wall shear stress (WSS) distribution could provide more effectively examine the physiological significance of the locations of the segmental narrowing and the curvature of the coronary arterial segments. The paper thus provides the diagnostic efficacy of FFRCT pullback curve for noninvasive quantification of the hemodynamics of stenotic coronary arteries with serial lesions, compared to the gold standard invasive FFR, to provide a reliable physiological assessment of significant amount of coronary artery stenosis. Further, we were also able to demonstrate the potential of carrying out virtual revascularization, to enable more precise PCI procedures and improve their outcomes.
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Affiliation(s)
- Xin Liu
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Science, Southern Medical University, 1023-1063 Shatai South Road, Baiyun, Guangzhou, 510515 Guangdong China
| | - Changnong Peng
- Department of Cardiology, Shenzhen Sun Yat-Sen Cardiovascular Hospital, Shenzhen, 518055 China
| | - Yufa Xia
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
| | - Zhifan Gao
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
- Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences, Shenzhen, 518055 China
| | - Pengcheng Xu
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Science, Southern Medical University, 1023-1063 Shatai South Road, Baiyun, Guangzhou, 510515 Guangdong China
| | - Xiaoqing Wang
- Department of Cardiology, Shenzhen Sun Yat-Sen Cardiovascular Hospital, Shenzhen, 518055 China
| | - Zhanchao Xian
- Department of Cardiology, Shenzhen Sun Yat-Sen Cardiovascular Hospital, Shenzhen, 518055 China
| | - Youbing Yin
- Shenzhen Keya Medical Technology, Shenzhen, China
| | - Liqun Jiao
- Xuanwu Hospital, Capital University of Medical Sciences, Beijing, China
| | - Defeng Wang
- Department of Imaging and Interventional Radiology, Prince Of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Lin Shi
- Department of Imaging and Interventional Radiology, Prince Of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Wenhua Huang
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Science, Southern Medical University, 1023-1063 Shatai South Road, Baiyun, Guangzhou, 510515 Guangdong China
| | - Xin Liu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
| | - Heye Zhang
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
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22
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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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23
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de Waard G, Di Mario C, Lerman A, Serruys P, van Royen N. Instantaneous wave-free ratio to guide coronary revascularisation: physiological framework, validation and differences from fractional flow reserve. EUROINTERVENTION 2017; 13:450-458. [DOI: 10.4244/eij-d-16-00456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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24
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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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25
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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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26
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Achenbach S, Rudolph T, Rieber J, Eggebrecht H, Richardt G, Schmitz T, Werner N, Boenner F, Möllmann H. Performing and Interpreting Fractional Flow Reserve Measurements in Clinical Practice: An Expert Consensus Document. Interv Cardiol 2017; 12:97-109. [PMID: 29588737 DOI: 10.15420/icr.2017:13:2] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Fractional flow reserve (FFR) measurements can determine the haemodynamic relevance of coronary artery stenoses. Current guidelines recommend their use in lesions in the absence of non-invasive proof of ischaemia. The prognostic impact of FFR has been evaluated in randomised trials, and it has been shown that revascularisation can be safely deferred if FFR is >0.80, while revascularisation of stenoses with FFR values ≤0.80 results in significantly lower event rates compared to medical treatment. Left main stenoses, aorto-ostial lesions, as well as patients with left ventricular hypertrophy and severely-impaired ejection fraction, have been excluded from large, randomised trials. While FFR measurements are relatively straightforward to perform, uncertainty about procedural logistics, as well as data acquisition and interpretation in specific situations, could explain why they are not widely used in clinical practice. We summarise the clinical data in support of FFR measurements, and provide recommendations for performing and interpreting the procedure.
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Affiliation(s)
- Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander University (FAU) Erlangen-Nuremberg, Germany
| | - Tanja Rudolph
- Department of Internal Medicine 3, University Hospital, Cologne, Germany
| | - Johannes Rieber
- Heart Centre, Municipal Hospitals of Munich, Munich, Germany
| | | | | | | | - Nikos Werner
- Department of Internal Medicine 2, University Hospital, Bonn, Germany
| | - Florian Boenner
- Department of Internal Medicine, University Hospital, Düsseldorf, Germany
| | - Helge Möllmann
- Department of Cardiology, St Johannes Hospital, Dortmund, Germany
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27
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Rotman OM, Zaretsky U, Shitzer A, Einav S. Pressure drop and arterial compliance – Two arterial parameters in one measurement. J Biomech 2017; 50:130-137. [DOI: 10.1016/j.jbiomech.2016.11.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 11/15/2022]
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28
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Cook CM, Ahmad Y, Shun-Shin MJ, Nijjer S, Petraco R, Al-Lamee R, Mayet J, Francis DP, Sen S, Davies JE. Quantification of the Effect of Pressure Wire Drift on the Diagnostic Performance of Fractional Flow Reserve, Instantaneous Wave-Free Ratio, and Whole-Cycle Pd/Pa. Circ Cardiovasc Interv 2016; 9:e002988. [PMID: 27076571 PMCID: PMC4836560 DOI: 10.1161/circinterventions.115.002988] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 02/22/2016] [Indexed: 01/10/2023]
Abstract
Background— Small drifts in intracoronary pressure measurements (±2 mm Hg) can affect stenosis categorization using pressure indices. This has not previously been assessed for fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), and whole-cycle distal pressure/proximal pressure (Pd/Pa) indices. Methods and Results—Four hundred forty-seven stenoses were assessed with FFR, iFR, and whole-cycle Pd/Pa. Cut point values for significance were predefined as ≤0.8, <0.90, and <0.93, respectively. Pressure wire drift was simulated by offsetting the distal coronary pressure trace by ±2 mm Hg. FFR, iFR, and whole-cycle Pd/Pa indices were recalculated and stenosis misclassification quantified. Median (±median absolute deviation) values for FFR, iFR, and whole-cycle Pd/Pa were 0.81 (±0.11), 0.90 (±0.07), and 0.93 (±0.06), respectively. For the cut point of FFR, iFR, and whole-cycle Pd/Pa, 34.6% (155), 50.1% (224), and 62.2% (278) of values, respectively, lay within ±0.05 U. With ±2 mm Hg pressure wire drift, 21% (94), 25% (110), and 33% (148) of the study population were misclassified with FFR, iFR, and whole-cycle Pd/Pa, respectively. Both FFR and iFR had significantly lower misclassification than whole-cycle Pd/Pa (P<0.001). There was no statistically significant difference between the diagnostic performance of FFR and iFR (P=0.125). Conclusions— In a substantial proportion of cases, small amounts of pressure wire drift are enough to cause stenoses to change classification. Whole-cycle Pd/Pa is more vulnerable to such reclassification than FFR and iFR.
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Affiliation(s)
- Christopher M Cook
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom.
| | - Yousif Ahmad
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Matthew J Shun-Shin
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Sukhjinder Nijjer
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Ricardo Petraco
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Rasha Al-Lamee
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Jamil Mayet
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Darrel P Francis
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Sayan Sen
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Justin E Davies
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
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29
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A head-to-head comparison between CT- and IVUS-derived coronary blood flow models. J Biomech 2016; 51:65-76. [PMID: 27939753 DOI: 10.1016/j.jbiomech.2016.11.070] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/29/2016] [Accepted: 11/29/2016] [Indexed: 01/05/2023]
Abstract
The goal of this work is to compare coronary hemodynamics as predicted by computational blood flow models derived from two imaging modalities: coronary computed tomography angiography (CCTA) and intravascular ultrasound integrated with angiography (IVUS). Criteria to define boundary conditions are proposed to overcome the dissimilar anatomical definition delivered by both modalities. The strategy to define boundary conditions is novel in the present context, and naturally accounts for the flow redistribution induced by the resistance of coronary vessels. Hyperemic conditions are assumed to assess model predictions under stressed hemodynamic environments similar to those encountered in Fractional Flow Reserve (FFR) calculations. As results, it was found that CCTA models predict larger pressure drops, higher average blood velocity and smaller FFR. Concerning the flow rate at distal locations in the major vessels of interest, it was found that CCTA predicted smaller flow than IVUS, which is a consequence of a larger sensitivity of CCTA models to coronary steal phenomena. Comparisons to in-vivo measurements of FFR are shown.
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30
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van Nunen LX, Lenders GD, Schampaert S, van 't Veer M, Wijnbergen I, Brueren GRG, Tonino PAL, Pijls NHJ. Single bolus intravenous regadenoson injection versus central venous infusion of adenosine for maximum coronary hyperaemia in fractional flow reserve measurement. EUROINTERVENTION 2016; 11:905-13. [PMID: 25136887 DOI: 10.4244/eijy14m08_10] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIMS The aim of this study was to compare the hyperaemic effect of a single bolus regadenoson injection to a central venous adenosine infusion for inducing hyperaemia in the measurement of fractional flow reserve (FFR). METHODS AND RESULTS One hundred patients scheduled for FFR measurement were enrolled. FFR was first measured by IV adenosine (140 µg/kg/min), thereafter by IV bolus regadenoson injection (400 µg), followed by another measurement by IV adenosine and bolus injection of regadenoson. The regadenoson injections were randomised to central or peripheral intravenous. Hyperaemic response and duration of steady state maximum hyperaemia were studied, central versus peripheral venous regadenoson injections were compared, and safety and reproducibility of repeated injections were investigated. Mean age was 66±8 years, 75% of the patients were male. The target stenosis was located in the LM, LAD, LCX, and RCA in 7%, 54%, 20% and 19%, respectively. There was no difference in FFR measured by adenosine or by regadenoson (ΔFFR=0.00±0.01, r=0.994, p<0.001). Duration of maximum hyperaemia after regadenoson was variable (10-600 s). No serious side effects of either drug were observed. CONCLUSIONS Maximum coronary hyperaemia can be achieved easily, rapidly, and safely by one single intravenous bolus of regadenoson administered either centrally or peripherally. Repeated regadenoson injections are safe. The hyperaemic plateau is variable. Clinical Trial Registration: http://clinicaltrials.gov/ct2/ show/study/NCT01809743?term=NCT01809743&rank=1 (ClinicalTrials.gov Identifier: NCT01809743).
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Affiliation(s)
- Lokien X van Nunen
- Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
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31
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Badoz M, Chatot M, Hechema R, Chopard R, Meneveau N, Schiele F. Effect of Fractional Flow Reserve (≤0.90 vs >0.90) on Long-Term Outcome (>10 Years) in Patients With Nonsignificant Coronary Arterial Narrowings. Am J Cardiol 2016; 118:465-72. [PMID: 27448943 DOI: 10.1016/j.amjcard.2016.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/23/2016] [Accepted: 05/23/2016] [Indexed: 11/30/2022]
Abstract
We assessed the long-term (>10 years) clinical course of patients with documented coronary lesions deemed nonsignificant according to fractional flow reserve (FFR) assessment and investigated whether the initial FFR value impacted on prognosis. From January 2000 to October 2003, all patients submitted to coronary angiography with FFR measurement were included in a single-center, prospective registry. Patients with an FFR value >0.80 were treated medically without revascularization. Major adverse cardiac events (MACE) (death, acute coronary syndrome (ACS), or coronary revascularization) were compared according to initial FFR value (absolute value and by category, ≤0.90 vs >0.90). Analyses were performed using a multivariable Cox model and propensity score matching. Among 257 patients (332 lesions) treated medically initially, 131 (51%, 143 lesions) had FFR ≤0.90 and 126 (49%, 189 lesions) >0.90. During follow-up (median duration, 11.6 years), 82 (31.9%) had a MACE, 38 (14.8%) died, 17 (6.6%) had ACS, 93 (36.2%) had repeat coronary angiography, and 27 (10.5%) had revascularization. There was no clinical, biologic or angiographic difference between patients with initial FFR value ≤0.90 versus >0.90. Adjusted Cox model showed no difference in relative risk of MACE, death, ACS, or revascularization. Coronary angiographies were numerically more frequent in patients with FFR ≤0.90, versus FFR >0.90. These findings were confirmed by propensity score-matched comparison. In patients with coronary narrowings left unrevascularized based on FFR, an FFR value between 0.80 and 0.90 has no impact on long-term outcome compared with those with FFR >0.90. In conclusion, patients with high FFR values should not be considered as having a lower risk of coronary event.
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Affiliation(s)
- Marc Badoz
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, Besançon, France
| | - Marion Chatot
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, Besançon, France
| | - Rémy Hechema
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, Besançon, France
| | - Romain Chopard
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, Besançon, France
| | - Nicolas Meneveau
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, Besançon, France
| | - François Schiele
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, Besançon, France.
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32
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Kolli KK, Min JK, Ha S, Soohoo H, Xiong G. Effect of Varying Hemodynamic and Vascular Conditions on Fractional Flow Reserve: An In Vitro Study. J Am Heart Assoc 2016; 5:JAHA.116.003634. [PMID: 27364988 PMCID: PMC5015400 DOI: 10.1161/jaha.116.003634] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background The aim of this study was to investigate the impact of varying hemodynamic conditions on fractional flow reserve (ratio of pressure distal [Pd] and proximal [Pa] to stenosis under hyperemia) in an in vitro setting. Failure to achieve maximal hyperemia and the choice of hyperemic agents may have differential effects on coronary hemodynamics and, consequently, on the determination of fractional flow reserve. Methods and Results An in vitro flow system was developed to experimentally model the physiological coronary circulation as flow‐dependent stenosis resistance in series with variable downstream resistance. Five idealized models with 30% to 70% diameter stenosis severity were fabricated using VeroClear rigid material in an Objet260 Connex printer. Mean aortic pressure was maintained at 7 levels (60–140 mm Hg) from hypotension to hypertension using a needle valve that mimicked adjustable microcirculatory resistance. A range of physiological flow rates was applied by a steady flow pump and titrated by a flow sensor. The pressure drop and the pressure ratio (Pd/Pa) were assessed for the 7 levels of aortic pressure and differing flow rates. The in vitro experimental data were coupled with pressure–flow relationships from clinical data for populations with and without myocardial infarction, respectively, to evaluate fractional flow reserve. The curve for pressure ratio and flow rate demonstrated a quadratic relationship with a decreasing slope. The absolute decrease in fractional flow reserve in the group without myocardial infarction (with myocardial infarction) was on the order of 0.03 (0.02), 0.05 (0.02), 0.07 (0.05), 0.17 (0.13) and 0.20 (0.24), respectively, for 30%, 40%, 50%, 60%, and 70% diameter stenosis, for an increase in aortic pressure from 60 to 140 mm Hg. Conclusions The fractional flow reserve value, an index of physiological stenosis significance, was observed to decrease with increasing aortic pressure for a given stenosis in this idealized in vitro experiment for vascular groups with and without myocardial infarction.
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Affiliation(s)
- Kranthi K Kolli
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College, New York, NY
| | - James K Min
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College, New York, NY Departments of Radiology and Medicine, Weill Cornell Medical College, New York, NY
| | - Seongmin Ha
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College, New York, NY
| | - Hilary Soohoo
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College, New York, NY
| | - Guanglei Xiong
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College, New York, NY
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33
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Fraktionelle Flussreserve in der Diagnostik der koronaren Herzerkrankung. DER KARDIOLOGE 2016. [DOI: 10.1007/s12181-016-0049-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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34
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Tesche C, De Cecco CN, Caruso D, Baumann S, Renker M, Mangold S, Dyer KT, Varga-Szemes A, Baquet M, Jochheim D, Ebersberger U, Bayer RR, Hoffmann E, Steinberg DH, Schoepf UJ. Coronary CT angiography derived morphological and functional quantitative plaque markers correlated with invasive fractional flow reserve for detecting hemodynamically significant stenosis. J Cardiovasc Comput Tomogr 2016; 10:199-206. [PMID: 26993434 DOI: 10.1016/j.jcct.2016.03.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 02/26/2016] [Accepted: 03/05/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Compare morphological and functional coronary plaque markers derived from coronary CT angiography (CCTA) for their ability to detect lesion-specific ischemia. MATERIALS AND METHODS Data of patients who had undergone both dual-source CCTA and invasive fractional flow reserve (FFR) measurement within 3 months were retrospectively analyzed. Various quantitative stenosis markers were derived from CCTA: Corrected coronary opacification (CCO), transluminal attenuation gradient (TAG), remodeling index (RI), computational FFR (cFFR), lesion length (LL), vessel volume (VV), total plaque volume (TPV), and calcified and non-calcified plaque volume (CPV and NCPV). Discriminatory power of these markers for flow-limiting versus non-significant coronary stenosis was assessed against invasive FFR as the reference standard. RESULTS The cohort included 37 patients (61 ± 12 years, 68% male). Among 37 lesions, 11 were hemodynamically significant by FFR. On a per-lesion level, sensitivity and specificity of TPV, CPV, and NCPV for hemodynamically significant stenosis detection were 88% and 74%, 67% and 53%, and 92% and 81%, respectively. For CCO, TAG, RI, and cFFR these were 64% and 86%, 35% and 56%, 82% and 54%, and 100% and 90%, respectively. At ROC analysis, only TPV (0.78, p = 0.013), NCPV (0.79, p = 0.009), cFFR (0.85, p = 0.003), and CCO (0.82, p = 0.0003) showed discriminatory power for detecting hemodynamically significant stenosis. CONCLUSION TPV, NCPV, CCO, and cFFR derived from CCTA can aid detecting hemodynamically significant coronary lesions with cFFR showing the greatest discriminatory ability.
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Affiliation(s)
- Christian Tesche
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany
| | - Carlo N De Cecco
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Department of Radiological Sciences, Oncology and Pathology, University of Rome "Sapienza", Rome, Italy
| | - Damiano Caruso
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Department of Radiological Sciences, Oncology and Pathology, University of Rome "Sapienza", Rome, Italy
| | - Stefan Baumann
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany
| | - Matthias Renker
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Department of Internal Medicine I, Cardiology/Angiology, Giessen University, Giessen, Germany
| | - Stefanie Mangold
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Department of Diagnostic and Interventional Radiology, Eberhard-Karls University, Tuebingen, Tuebingen, Germany
| | - Kevin T Dyer
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Moritz Baquet
- Department of Cardiology, Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - David Jochheim
- Department of Cardiology, Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Ullrich Ebersberger
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany
| | - Richard R Bayer
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ellen Hoffmann
- Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany
| | - Daniel H Steinberg
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
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35
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Nijjer SS, Petraco R, van de Hoef TP, Sen S, van Lavieren MA, Foale RA, Meuwissen M, Broyd C, Echavarria-Pinto M, Al-Lamee R, Foin N, Sethi A, Malik IS, Mikhail GW, Hughes AD, Mayet J, Francis DP, Di Mario C, Escaned J, Piek JJ, Davies JE. Change in coronary blood flow after percutaneous coronary intervention in relation to baseline lesion physiology: results of the JUSTIFY-PCI study. Circ Cardiovasc Interv 2016; 8:e001715. [PMID: 26025217 DOI: 10.1161/circinterventions.114.001715] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) aims to increase coronary blood flow by relieving epicardial obstruction. However, no study has objectively confirmed this and assessed changes in flow over different phases of the cardiac cycle. We quantified the change in resting and hyperemic flow velocity after PCI in stenoses defined physiologically by fractional flow reserve and other parameters. METHODS AND RESULTS Seventy-five stenoses (67 patients) underwent paired flow velocity assessment before and after PCI. Flow velocity was measured over the whole cardiac cycle and the wave-free period. Mean fractional flow reserve was 0.68±0.02. Pre-PCI, hyperemic flow velocity is diminished in stenoses classed as physiologically significant compared with those classed nonsignificant (P<0.001). In significant stenoses, flow velocity over the resting wave-free period and hyperemic flow velocity did not differ statistically. After PCI, resting flow velocity over the wave-free period increased little (5.6±1.6 cm/s) and significantly less than hyperemic flow velocity (21.2±3 cm/s; P<0.01). The greatest increase in hyperemic flow velocity was observed when treating stenoses below physiological cut points; treating stenoses with fractional flow reserve ≤0.80 gained Δ28.5±3.8 cm/s, whereas those fractional flow reserve >0.80 had a significantly smaller gain (Δ4.6±2.3 cm/s; P<0.001). The change in pressure-only physiological indices demonstrated a curvilinear relationship to the change in hyperemic flow velocity but was flat for resting flow velocity. CONCLUSIONS Pre-PCI physiology is strongly associated with post-PCI increase in hyperemic coronary flow velocity. Hyperemic flow velocity increases 6-fold more when stenoses classed as physiologically significant undergo PCI than when nonsignificant stenoses are treated. Resting flow velocity measured over the wave-free period changes at least 4-fold less than hyperemic flow velocity after PCI.
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Affiliation(s)
- Sukhjinder S Nijjer
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Ricardo Petraco
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Tim P van de Hoef
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Sayan Sen
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Martijn A van Lavieren
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Rodney A Foale
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Martijn Meuwissen
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Christopher Broyd
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Mauro Echavarria-Pinto
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Rasha Al-Lamee
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Nicolas Foin
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Amarjit Sethi
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Iqbal S Malik
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Ghada W Mikhail
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Alun D Hughes
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Jamil Mayet
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Darrel P Francis
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Carlo Di Mario
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Javier Escaned
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Jan J Piek
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Justin E Davies
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.).
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Parikh V, Agnihotri K, Kadavath S, Patel NJ, Abbott JD. Clinical Application of Fractional Flow Reserve-Guided Percutaneous Coronary Intervention for Stable Coronary Artery Disease. Curr Cardiol Rep 2016; 18:32. [PMID: 26915010 DOI: 10.1007/s11886-016-0711-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Revascularization in stable ischemic heart disease (SIHD) is indicated in patients on optimal medical therapy with angina and/or demonstrable ischemia and a significant stenosis in one or more epicardial coronary arteries. Angiography alone, however, cannot accurately determine the hemodynamic significance of coronary lesions, particularly those of intermediate stenosis severity. A lesion may appear significant on coronary angiogram but may not have functional significance. Percutaneous coronary intervention (PCI) of functionally insignificant coronary artery lesions may have serious consequences; therefore, judicious decision-making in the cardiac catheterization laboratory is indicated. For this reason, it is becoming increasingly important to show that a stenosis is capable to induce myocardial ischemia prior to intervention. Fractional flow reserve (FFR) has emerged as a useful tool for this purpose. In this review, we will briefly discuss the principle of FFR, current evidence and rationale supporting its use, and comparison with other modalities.
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Affiliation(s)
- Valay Parikh
- Staten Island University Hospital, 475 Seaview Ave, Staten Island, NY, 10305, USA.
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Wakasa N, Kuramochi T, Mihashi N, Terada N, Kanaji Y, Murai T, Lee T, Yonetsu T, Kobashi K, Miyamoto K, Tobata H, Kakuta T. Impact of Pressure Signal Drift on Fractional Flow Reserve-Based Decision-Making for Patients With Intermediate Coronary Artery Stenosis. Circ J 2016; 80:1812-9. [DOI: 10.1253/circj.cj-15-1195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Nobutaka Wakasa
- Department of Clinical Laboratory, Tsuchiura Kyodo General Hospital
| | | | - Naoto Mihashi
- Department of Clinical Laboratory, Tsuchiura Kyodo General Hospital
| | - Noriko Terada
- Department of Clinical Laboratory, Tsuchiura Kyodo General Hospital
| | - Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Tadashi Murai
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Tetsumin Lee
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Kazuhiko Kobashi
- Department of Clinical Laboratory, Tsuchiura Kyodo General Hospital
| | | | - Hiroshi Tobata
- The Graduate School of Health Sciences (Division of Distance Education), Kyushu University of Health and Welfare
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
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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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Percutaneous Coronary Intervention Enhances Accelerative Wave Intensity in Coronary Arteries. PLoS One 2015; 10:e0142998. [PMID: 26658896 PMCID: PMC4676634 DOI: 10.1371/journal.pone.0142998] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 10/29/2015] [Indexed: 01/17/2023] Open
Abstract
Background The systolic forward travelling compression wave (sFCW) and diastolic backward travelling decompression waves (dBEW) predominantly accelerate coronary blood flow. The effect of a coronary stenosis on the intensity of these waves in the distal vessel is unknown. We investigated the relationship between established physiological indices of hyperemic coronary flow and the intensity of the two major accelerative coronary waves identified by Coronary Wave Intensity analysis (CWIA). Methodology / Principal Findings Simultaneous intracoronary pressure and velocity measurement was performed during adenosine induced hyperemia in 17 patients with pressure / Doppler flow wires positioned distal to the target lesion. CWI profiles were generated from this data. Fractional Flow Reserve (FFR) and Coronary Flow Velocity Reserve (CFVR) were calculated concurrently. The intensity of the dBEW was significantly correlated with FFR (R = -0.70, P = 0.003) and CFVR (R = -0.73, P = 0.001). The intensity of the sFCW was also significantly correlated with baseline FFR (R = 0.71, p = 0.002) and CFVR (R = 0.59, P = 0.01). Stenting of the target lesion resulted in a median 178% (interquartile range 55–280%) (P<0.0001) increase in sFCW intensity and a median 117% (interquartile range 27–509%) (P = 0.001) increase in dBEW intensity. The increase in accelerative wave intensity following PCI was proportionate to the baseline FFR and CFVR, such that stenting of lesions associated with the greatest flow limitation (lowest FFR and CFVR) resulted in the largest increases in wave intensity. Conclusions Increasing ischemia severity is associated with proportionate reductions in cumulative intensity of both major accelerative coronary waves. Impaired diastolic microvascular decompression may represent a novel, important pathophysiologic mechanism driving the reduction in coronary blood flow in the setting of an epicardial stenosis.
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van de Hoef TP, Meuwissen M, Escaned J, Sen S, Petraco R, van Lavieren MA, Echavarria-Pinto M, Nolte F, Nijjer S, Chamuleau SA, Voskuil M, van Eck-Smit BL, Verberne HJ, Henriques JP, Koch KT, de Winter RJ, Spaan JA, Siebes M, Tijssen JG, Davies JE, Piek JJ. Head-to-head comparison of basal stenosis resistance index, instantaneous wave-free ratio, and fractional flow reserve: diagnostic accuracy for stenosis-specific myocardial ischaemia. EUROINTERVENTION 2015; 11:914-25. [DOI: 10.4244/eijy14m08_17] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Seto AH, Tehrani D, Kern MJ. Limitations and Pitfalls of Fractional Flow Reserve Measurements and Adenosine-Induced Hyperemia. Interv Cardiol Clin 2015; 4:419-434. [PMID: 28581929 DOI: 10.1016/j.iccl.2015.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Coronary hemodynamic measurements provide a critical tool to assess the ischemic potential of coronary stenoses. Fractional flow reserve (FFR) is a reliable method to relate translesional coronary pressures to hyperemic myocardial blood flow. Although a basic understanding in FFR can be quickly achieved, many of the nuances and potential pitfalls require special attention. The authors discuss the practical setup of coronary pressure measurement, the most common pitfalls in technique and ways to avoid them, and the limitations of available pharmacologic hyperemic methods.
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Affiliation(s)
- Arnold H Seto
- Department of Medicine, Long Beach Veterans Affairs Medical Center, 5901 East 7th Street 111C, Long Beach, CA 90822, USA.
| | - David Tehrani
- Department of Medicine, Long Beach Veterans Affairs Medical Center, 5901 East 7th Street 111C, Long Beach, CA 90822, USA
| | - Morton J Kern
- Department of Medicine, Long Beach Veterans Affairs Medical Center, 5901 East 7th Street 111C, Long Beach, CA 90822, USA
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Johnson NP, Kirkeeide RL, Gould KL. History and Development of Coronary Flow Reserve and Fractional Flow Reserve for Clinical Applications. Interv Cardiol Clin 2015; 4:397-410. [PMID: 28581927 DOI: 10.1016/j.iccl.2015.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We discuss the historical development of clinical coronary physiology, emphasizing coronary flow reserve (CFR) and fractional flow reserve (FFR). Our analysis focuses on the clinical motivations and technologic advances that prompted and enabled the application of physiology for patient diagnosis. CFR grew from the general concepts of physiologic and coronary reserve, linking the anatomic severity of a lesion to its impact on hyperemic flow. FFR developed from existing models relating pressure measurements to the potential for flow to increase after removing a stenosis. Because pressure measurements have proved easier and more robust than flow measurements, FFR has become the dominant metric.
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Affiliation(s)
- Nils P Johnson
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA.
| | - Richard L Kirkeeide
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA
| | - K Lance Gould
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA
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Kolli KK, van de Hoef TP, Effat MA, Banerjee RK, Peelukhana SV, Succop P, Leesar MA, Imran A, Piek JJ, Helmy TA. Diagnostic cutoff for pressure drop coefficient in relation to fractional flow reserve and coronary flow reserve: A patient-level analysis. Catheter Cardiovasc Interv 2015; 87:273-82. [PMID: 26424295 DOI: 10.1002/ccd.26063] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 03/31/2015] [Accepted: 05/19/2015] [Indexed: 12/28/2022]
Abstract
OBJECTIVES AND BACKGROUND Functional assessment of intermediate coronary stenosis during cardiac catheterization is conducted using diagnostic parameters like fractional flow reserve (FFR), coronary flow reserve (CFR), hyperemic stenosis resistance index (HSR), and hyperemic microvascular resistance (HMR). CDP (ratio of pressure drop across a stenosis to distal dynamic pressure), a nondimensional index derived from fundamental fluid dynamic principles, based on a combination of intracoronary pressure, and flow measurements may improve the functional assessment of coronary lesion severity. METHODS Patient-level data pertaining to 350 intracoronary pressure and flow measurements across coronary stenoses was assessed to evaluate CFR, FFR, HSR, HMR, and CDP. CDP was calculated as (ΔP)/(0.5 × ρ × APV(2)). The density of blood (ρ) was assumed to be 1.05 g/cm(3). The correlation of current diagnostic parameters (CFR, FFR, HSR, and HMR) with CDP was evaluated. The receiver operating characteristic (ROC) curve was used to identify the optimal cut-off point of CDP, corresponding to the clinically used cut-off values (FFR = 0.80 and CFR = 2.0). RESULTS CDP correlated significantly with FFR (r = 0.81, P < 0.05) and had significant diagnostic efficiency (ROC-area under curve of 86%), specificity (72%) and sensitivity (85%) at FFR < 0.8. The corresponding cut-off value for CDP to detect FFR < 0.8 was at CDP>25.4. CDP also correlated significantly (r = 0.98, P < 0.05) with epicardial-specific parameter, HSR. CONCLUSIONS CDP, a functional parameter based on both intracoronary pressure and flow measurements, has close agreement (area under ROC curve = 86%) with FFR, the frequently used method of evaluating stenosis severity.
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Affiliation(s)
- Kranthi K Kolli
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, Ohio.,Veteran Affairs Medical Center, Cincinnati, Ohio
| | - Tim P van de Hoef
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Mohamed A Effat
- Veteran Affairs Medical Center, Cincinnati, Ohio.,Division of Cardiovascular Disease, University of Cincinnati, Cincinnati, Ohio
| | - Rupak K Banerjee
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, Ohio.,Veteran Affairs Medical Center, Cincinnati, Ohio
| | - Srikara V Peelukhana
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, Ohio.,Veteran Affairs Medical Center, Cincinnati, Ohio
| | - Paul Succop
- Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio
| | - Massoud A Leesar
- Division of Cardiovascular Disease, University of Alabama-Birmingham, Alabama
| | - Arif Imran
- Veteran Affairs Medical Center, Cincinnati, Ohio.,Division of Cardiovascular Disease, University of Cincinnati, Cincinnati, Ohio
| | - Jan J Piek
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Tarek A Helmy
- Division of Cardiology, Saint Louis University School of Medicine, St. Louis, Missouri
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45
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Affiliation(s)
- William F Fearon
- From the Division of Cardiovascular Medicine, Stanford University Medical Center, CA.
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46
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Kobayashi N, Hirano K, Nakano M, Ito Y, Sakai T, Ishimori H, Yamawaki M, Araki M, Tsukahara R, Muramatsu T. Measuring Procedure and Maximal Hyperemia in the Assessment of Fractional Flow Reserve for Superficial Femoral Artery Disease. J Atheroscler Thromb 2015; 23:56-66. [PMID: 26310494 DOI: 10.5551/jat.30957] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
AIM The optimal fractional flow reserve (FFR) measurement method for superficial femoral artery (SFA) lesions remains to be established. We clarified the optimal measuring procedure for FFR for SFA lesions and investigated the necessary dose of papaverine for inducing maximal hyperemia in SFA lesions. METHODS Forty-eight patients with SFA lesions who underwent measurement of peripheral FFR (pFFR: distal mean pressure divided by proximal mean pressure) after endovascular treatment by the contralateral femoral crossover approach were prospectively enrolled. In the pFFR measurement, a guide sheath was placed on top of the common iliac bifurcation and pressure equalization was performed. After advancing the pressure wire distal to the SFA lesion, sequential papaverine administration selectively to the affected common iliac artery was performed. RESULTS There were no symptoms, electrocardiogram changes, and significant pressure drops at the guide sheath tip with increasing papaverine dose. pFFR changes following 20, 30, and 40 mg of papaverine were 0.87±0.10, 0.84±0.10, and 0.84±0.10, respectively (P<0.001). Although not significantly different, pFFR decreased more in several patients at 30 mg of papaverine than at 20 mg. The pFFR at 40 mg of papaverine was almost similar to that at 30 mg of papaverine. The necessary papaverine dose was not changed according to sex and number of run-off vessels. CONCLUSIONS The contralateral femoral crossover approach is useful in FFR measurement for SFA lesions, and maximal hyperemia is induced by 30 mg of papaverine.
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Abstract
Coronary angiography is the gold standard for the diagnosis of coronary artery disease and guides revascularization strategies. The emergence of new diagnostic modalities has provided clinicians with adjunctive physiologic and image-based data to help formulate treatment strategies. Fractional flow reserve can predict whether percutaneous intervention will benefit a patient. Intravascular ultrasonography and optical coherence tomography are intracoronary imaging modalities that facilitate the anatomic visualization of the vessel lumen and characterize plaques. Near-infrared spectroscopy can characterize plaque composition and potentially provide valuable prognostic information. This article reviews the indications, basic technology, and supporting clinical studies for these modalities.
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Affiliation(s)
- Elliott M Groves
- Division of Cardiology, Department of Internal Medicine, University of California, 333 City Blvd West, Suite 400, Orange, CA 92868-3298, USA; Department of Biomedical Engineering, University of California, 3120 Natural Sciences II, Irvine, CA 92697-2715, USA
| | - Arnold H Seto
- Division of Cardiology, Department of Internal Medicine, University of California, 333 City Blvd West, Suite 400, Orange, CA 92868-3298, USA; Division of Cardiology, Department of Internal Medicine, Long Beach Veterans Administration Hospital, 5901 East Seventh Street, Long Beach, CA 90822, USA.
| | - Morton J Kern
- Division of Cardiology, Department of Internal Medicine, University of California, 333 City Blvd West, Suite 400, Orange, CA 92868-3298, USA; Division of Cardiology, Department of Internal Medicine, Long Beach Veterans Administration Hospital, 5901 East Seventh Street, Long Beach, CA 90822, USA
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48
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Rajabi-Jagahrgh E, Banerjee RK. Functional diagnostic parameters for arteriovenous fistula. Artif Organs 2015; 39:492-501. [PMID: 25865141 DOI: 10.1111/aor.12410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The inability to detect the arteriovenous fistula (AVF) dysfunction in a timely manner under the current surveillance programs, which are based on either diameter (d), flow rate (Q), or pressure (p) measurements, is one of the major challenges of dialysis treatment. Thus, our aim is to introduce new functional diagnostic parameters that can better predict AVF functionality status. Six AVFs were created between the femoral arteries and veins of three pigs, each pig having two AVFs on either limb. Flow fields and pressure drop (Δp) in AVFs were obtained via numerical analysis utilizing the CT scan and Doppler ultrasound data at 2D (D: days), 7D, and 28D postsurgery. The dataset included 16 (two pigs [four AVFs] for three time points, and one pig [two AVFs] for two time points) repeated measurements over time, and the statistical analysis was done using a mixed model. To evaluate the nature of pressure drop-flow relationships in AVFs, the Δp was correlated with the average velocity at proximal artery (v) and also the corresponding scaled velocity (v*) by the curvature ratio of anastomotic segment. Based on these relationships, two new functional diagnostic parameters, including the nonlinear pressure drop coefficient (Cp ; pressure drop divided by dynamic pressure at proximal artery) and the linear resistance index (R; pressure drop divided by velocity at proximal artery), were introduced. The diagnostic parameters that were calculated based on scaled velocity are represented as R* and Cp *. A marginal (P = 0.1) increase in d from 2D (5.4 ± 0.7 mm) to 7D (6.8 ± 0.7 mm), along with a significant increase in Q (2D: 967 ± 273 mL/min; 7D: 1943 ± 273 mL/min), was accompanied by an almost unchanged Δp over this time period (2D: 16.42 ± 4.6 mm Hg; 7D: 16.40 ± 4.6 mm Hg). However, the insignificant increase in d and Q from 7D to 28D (d = 7.8 ± 0.8 mm; Q = 2181 ± 378 mL/min) was accompanied by the elevation in Δp (24.6 ± 6.5 mm Hg). The functional diagnostic parameters, R and Cp , decreased from 2D (R = 22.4 ± 2.8 mm Hg/m/s; Cp = 12.0 ± 2.6) to 7D (R = 20.8 ± 2.8 mm Hg/m/s; Cp = 8.1 ± 2.6), and then increased from 7D to 28D (R = 35.5 ± 5.7 mm Hg/m/s; Cp = 17.5 ± 3.6) with a marginal significance. However, when the scaled velocity was used to calculate R* and Cp *, the increase in diagnostic parameters from 7D to 28D achieved statistical significance (P < 0.05). In summary, although the differences in the hemodynamic parameters (d, Q, and Δp) from 7D to 28D were insignificant, changes in their combined effects in the form of diagnostic parameters were significant. Therefore, the functional diagnostic parameters are capable of better distinguishing changes in the hemodynamic variations, and thus, could be promising endpoints to diagnose the functionality of AVFs over time.
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Affiliation(s)
- Ehsan Rajabi-Jagahrgh
- Mechanical Engineering Program, Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, USA
| | - Rupak K Banerjee
- Mechanical Engineering Program, Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, USA.,Biomedical Engineering Program, Department of Biomedical, Chemical, and Environmental Engineering, University of Cincinnati, Cincinnati, OH, USA.,Cincinnati Veterans Administration Medical Center, Cincinnati, OH, USA
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de Vecchi A, Clough RE, Gaddum NR, Rutten MC, Lamata P, Schaeffter T, Nordsletten DA, Smith NP. Catheter-induced errors in pressure measurements in vessels: an in-vitro and numerical study. IEEE Trans Biomed Eng 2015; 61:1844-50. [PMID: 24845294 PMCID: PMC6217912 DOI: 10.1109/tbme.2014.2308594] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Accurate measurement of blood pressure is important because it is a biomarker for cardiovascular disease. Diagnostic catheterization is routinely used for pressure acquisition in vessels despite being subject to significant measurement errors. To investigate these errors, this study compares pressure measurement using two different techniques in vitro and numerical simulations. Pressure was acquired in a pulsatile flow phantom using a 6F fluid-filled catheter and a 0.014” pressure wire, which is considered the current gold standard. Numerical simulations of the experimental set-up with and without a catheter were also performed. Despite the low catheter-to-vessel radius ratio, the catheter traces showed a 24% peak systolic pressure overestimation compared to the wire. The numerical models replicated this difference and indicated the cause for overestimation was the increased flow resistance due to the presence of the catheter. Further, the higher frequency pressure oscillations observed in the wire and numerical data were absent in the catheter, resulting in an overestimation of the pulse wave velocity with the latter modality. These results show that catheter geometry produces significant measurement bias in both the peak pressure and the waveform shape even with radius ratios considered acceptable in clinical practice. The wire allows for more accurate pressure quantification, in agreement with the numerical model without a catheter.
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Affiliation(s)
- Adelaide de Vecchi
- King’s College London, Department of Biomedical Engineering and Imaging Sciences Division, St Thomas’ Hospital, London SE1 7EH, UK
| | - Rachel E. Clough
- King’s College London, Department of Biomedical Engineering and Imaging Sciences Division, St Thomas’ Hospital, London SE1 7EH, UK
| | - Nicholas R. Gaddum
- King’s College London, Department of Biomedical Engineering and Imaging Sciences Division, St Thomas’ Hospital, London SE1 7EH, UK
| | - Marcel C.M. Rutten
- Eindhoven University of Technology, Department of Biomedical Engineering, PO Box 513, 5600 MB Eindhoven, The Netherlands
| | - Pablo Lamata
- King’s College London, Department of Biomedical Engineering and Imaging Sciences Division, St Thomas’ Hospital, London SE1 7EH, UK
| | - Tobias Schaeffter
- King’s College London, Department of Biomedical Engineering and Imaging Sciences Division, St Thomas’ Hospital, London SE1 7EH, UK
| | - David A. Nordsletten
- King’s College London, Department of Biomedical Engineering and Imaging Sciences Division, St Thomas’ Hospital, London SE1 7EH, UK
| | - Nicolas P. Smith
- King’s College London, Department of Biomedical Engineering and Imaging Sciences Division, St Thomas’ Hospital, London SE1 7EH, UK
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Corcoran D, Berry C, Oldroyd K. Current frontiers in the clinical research of coronary physiology. Interv Cardiol 2015. [DOI: 10.2217/ica.14.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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