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Yoneyama S, Hoyano M, Ozaki K, Ikegami R, Kubota N, Okubo T, Yanagawa T, Kurokawa T, Akiyama T, Washiyama Y, Kashimura T, Inomata T. Pd/Pa fluctuation with continuous ATP administration indicates inaccurate FFR measurement caused by insufficient hyperemia. Heart Vessels 2024:10.1007/s00380-024-02438-x. [PMID: 38981910 DOI: 10.1007/s00380-024-02438-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] [Received: 12/11/2023] [Accepted: 07/03/2024] [Indexed: 07/11/2024]
Abstract
Continuous intravenous adenosine triphosphate (ATP) administration is the standard method for inducing maximal hyperemia in fractional flow reserve (FFR) measurements. Several cases have demonstrated fluctuations in the ratio of mean distal coronary pressure to mean arterial pressure (Pd/Pa) value during ATP infusion, which raised our suspicions of FFR value inaccuracy. This study aimed to investigate our hypothesis that Pd/Pa fluctuations may indicate inaccurate FFR measurements caused by insufficient hyperemia. We examined 57 consecutive patients with angiographically intermediate coronary lesions who underwent fractional flow reverse (FFR) measurements in our hospital between November 2016 and September 2018. Pd/Pa was measured after continuous ATP administration (150 μg/kg/min) via a peripheral forearm vein for 5 min (FFRA); and we analyzed the FFR value variation in the final 20 s of the 5 min, defining 'Fluctuation' as variation range > 0.03. Then, 2 mg of nicorandil was administered into the coronary artery during continued ATP infusion, and the Pd/Pa was remeasured (FFRA+N). Fluctuations were observed in 23 of 57 patients. The cases demonstrating discrepancies of > 0.05 between FFRA and FFRA+N were observed more frequently in the fluctuation group than in the non-fluctuation group (12/23 vs. 1/34; p < 0.0001). The discrepancy between FFRA and FFRA+N values was smaller in the non-fluctuation group (mean difference ± SD; -0.00026 ± 0.04636 vs. 0.02608 ± 0.1316). Pd/Pa fluctuation with continuous ATP administration could indicate inaccurate FFR measurements caused by incomplete hyperemia. Additional vasodilator administration may achieve further hyperemia when Pd/Pa fluctuations are observed.
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Affiliation(s)
- Shintaro Yoneyama
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan.
| | - Makoto Hoyano
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Kazuyuki Ozaki
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Ryutaro Ikegami
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Naoki Kubota
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takeshi Okubo
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takao Yanagawa
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takakuni Kurokawa
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takumi Akiyama
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Yuzo Washiyama
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takeshi Kashimura
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
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Lowe CM, Seto AH. Exploring the Impact of End-Stage Renal Disease on Fractional Flow Reserve. Am J Cardiol 2023; 207:505-506. [PMID: 37805282 DOI: 10.1016/j.amjcard.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Caleb M Lowe
- Department of Graduate Medical Education, Charles R. Drew University of Medicine and Science, Los Angeles, California
| | - Arnold H Seto
- Department of Cardiology, Tibor Rubin VA Medical Center, Long Beach, California.
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Matsumoto H, Higuchi S, Tanaka H, Masaki R, Kondo S, Tsujita H, Shinke T. Insufficient adenosine-induced hyperemia is a major determinant of discordance between non-hyperemic pressure ratio and fractional flow reserve. Sci Rep 2023; 13:729. [PMID: 36639567 PMCID: PMC9839754 DOI: 10.1038/s41598-023-27929-1] [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: 08/31/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023] Open
Abstract
Adenosine occasionally overestimates fractional flow reserve (FFR) values (i.e., insufficient adenosine-induced hyperemia), leading to low non-hyperemic pressure ratios (NHPR)-high FFR discordance. We investigated the impact of insufficient adenosine-induced hyperemia on NHPR-FFR discordance and the reclassification of functional significance. We measured resting distal-to-aortic pressure ratio (Pd/Pa) and FFR by using adenosine (FFRADN) and papaverine (FFRPAP) in 326 patients (326 vessels). FFRADN overestimation was calculated as FFRADN - FFRPAP. We explored determinants of low Pd/Pa - high FFRADN discordance (Pd/Pa ≤ 0.92 and FFRADN > 0.80) versus high Pd/Pa - low FFRADN discordance (Pd/Pa > 0.92 and FFRADN ≤ 0.80). Reclassification of functional significance was defined as FFRADN > 0.80 and FFRPAP ≤ 0.80. Multivariable analysis identified FFRADN overestimation (p = 0.002) and heart rate at baseline (p = 0.048) as independent determinants of the low Pd/Pa-high FFRADN discordance. In the low Pd/Pa-high FFRADN group (n = 26), papaverine produced a further decline in the FFR value in 21 vessels (81%) compared with FFRADN, and the reclassification was observed in 17 vessels (65%). Insufficient adenosine-induced hyperemia is a major determinant of the low resting Pd/Pa-high FFR discordance. Physicians should bear in mind that the presence of low NHPR-high FFR discordance may indicate a false-negative FFR result.
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Affiliation(s)
- Hidenari Matsumoto
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan.
| | - Satoshi Higuchi
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Hideaki Tanaka
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Ryota Masaki
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Seita Kondo
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Hiroaki Tsujita
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
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Matsumoto H, Masaki R, Higuchi S, Tanaka H, Kondo S, Tsujita H, Shinke T. Impact of overestimation of fractional flow reserve by adenosine on anatomical-functional mismatch. Sci Rep 2022; 12:14962. [PMID: 36056128 PMCID: PMC9440099 DOI: 10.1038/s41598-022-19330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/29/2022] [Indexed: 11/08/2022] Open
Abstract
Adenosine occasionally results in overestimation of fractional flow reserve (FFR) values, compared with other hyperemic stimuli. We aimed to elucidate the association of overestimation of FFR by adenosine with anatomically significant but functionally non-significant lesions (anatomical-functional mismatch) and its influence on reclassification of functional significance. Distal-to-aortic pressure ratio (Pd/Pa) was measured using adenosine (Pd/PaADN) and papaverine (Pd/PaPAP) in 326 patients (326 vessels). The overestimation of FFR was calculated as Pd/PaADN-Pd/PaPAP. The anatomical-functional mismatch was defined as diameter stenosis > 50% and Pd/PaADN > 0.80. Reclassification was indicated by Pd/PaADN > 0.80 and Pd/PaPAP ≤ 0.80. The mismatch (n = 72) had a greater overestimation of FFR than the non-mismatch (n = 99): median 0.02 (interquartile range 0.01-0.05) versus 0.01 (0.00-0.04), p = 0.014. Multivariable analysis identified the overestimation of FFR (p = 0.003), minimal luminal diameter (p = 0.001), and non-left anterior descending artery (LAD) location (p < 0.001) as determinants of the mismatch. Reclassification was indicated in 29% of the mismatch and was more frequent in the LAD than in the non-LAD (52% vs. 20%, p = 0.005). The overestimation of FFR is an independent determinant of anatomical-functional mismatch. Anatomical-functional mismatch, specifically in the LAD, may suggest a false-negative result.
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Affiliation(s)
- Hidenari Matsumoto
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan.
| | - Ryota Masaki
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Satoshi Higuchi
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Hideaki Tanaka
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Seita Kondo
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Hiroaki Tsujita
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
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Tanaka H, Matsumoto H, Takahashi H, Hosonuma M, Sato S, Ogura K, Oishi Y, Masaki R, Sakai K, Sekimoto T, Kondo S, Tsujita H, Tsukamoto S, Sumida A, Okada N, Inoue K, Shinke T. Linear concentration-response relationship of serum caffeine with adenosine-induced fractional flow reserve overestimation: a comparison with papaverine. EUROINTERVENTION 2021; 17:e925-e931. [PMID: 34647891 PMCID: PMC9725067 DOI: 10.4244/eij-d-21-00453] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Caffeine intake from one cup of coffee one hour before adenosine stress tests, corresponding to serum caffeine levels of 3-4 mg/L, is thought to be acceptable for non-invasive imaging. AIMS We aimed to elucidate whether serum caffeine is independently associated with adenosine-induced fractional flow reserve (FFR) overestimation and their concentration-response relationship. METHODS FFR was measured using adenosine (FFRADN) and papaverine (FFRPAP) in 209 patients. FFRADN overestimation was defined as FFRADN - FFRPAP. The locally weighted scatterplot smoothing (LOWESS) approach was applied to evaluate the relationship between serum caffeine level and FFRADN overestimation. Multiple regression analysis was used to determine independent factors associated with FFRADN overestimation. RESULTS Caffeine was ingested at <12 hours in 85 patients, at 12-24 hours in 35 patients, and at >24 hours in 89 patients. Multiple regression analysis identified serum caffeine level as the strongest factor associated with FFRADN overestimation (p<0.001). The LOWESS curve demonstrated that FFRADN overestimation started from just above the lower detection limit of serum caffeine and increased approximately 0.01 FFR unit per 1 mg/L increase in serum caffeine level with a linear relationship. The 90th percentile of serum caffeine levels for the ≤12-hour, the 12-24-hour, and the >24-hour groups corresponded to FFRADN overestimations by 0.06, 0.03, and 0.02, respectively. CONCLUSIONS Serum caffeine overestimates FFRADN values in a linear concentration-response manner. FFRADN overestimation occurs at much lower serum caffeine levels than those that were previously believed. Our results highlight that standardised caffeine control is required for reliable adenosine-induced FFR measurements.
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Affiliation(s)
- Hideaki Tanaka
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Hidenari Matsumoto
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Haruya Takahashi
- Division of Food Science and Biotechnology, Graduate School of Agriculture, Kyoto University, Uji, Kyoto, Japan
| | - Masahiro Hosonuma
- Department of Clinical Immuno Oncology, Clinical Research Institute for Clinical Pharmacology and Therapeutics, Showa University, Tokyo, Japan
| | - Shunya Sato
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Kunihiro Ogura
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Yosuke Oishi
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Ryota Masaki
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Koshiro Sakai
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Teruo Sekimoto
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Seita Kondo
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Hiroaki Tsujita
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Shigeto Tsukamoto
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Arihiro Sumida
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Natsumi Okada
- Department of Clinical Immuno Oncology, Clinical Research Institute for Clinical Pharmacology and Therapeutics, Showa University, Tokyo, Japan
| | - Kazuo Inoue
- Department of Hospital Pharmaceutics, Showa University School of Pharmacy, Tokyo, Japan
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
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6
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Feenstra RGT, van Lavieren MA, Echavarria-Pinto M, Wijntjens GW, Stegehuis VE, Meuwissen M, de Winter RJ, Beijk MAM, Lerman A, Escaned J, Piek JJ, van de Hoef TP. Respiration-related variations in Pd/Pa ratio and fractional flow reserve in resting conditions and during intravenous adenosine administration. Catheter Cardiovasc Interv 2021; 99:844-852. [PMID: 34766734 PMCID: PMC9543847 DOI: 10.1002/ccd.30012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/06/2021] [Accepted: 10/17/2021] [Indexed: 01/09/2023]
Abstract
Aims We evaluated the occurrence and physiology of respiration‐related beat‐to‐beat variations in resting Pd/Pa and FFR during intravenous adenosine administration, and its impact on clinical decision‐making. Methods and Results Coronary pressure tracings in rest and at plateau hyperemia were analyzed in a total of 39 stenosis from 37 patients, and respiratory rate was calculated with ECG‐derived respiration (EDR) in 26 stenoses from 26 patients. Beat‐to‐beat variations in FFR occurred in a cyclical fashion and were strongly correlated with respiratory rate (R2 = 0.757, p < 0.001). There was no correlation between respiratory rate and variations in resting Pd/Pa. When single‐beat averages were used to calculate FFR, mean ΔFFR was 0.04 ± 0.02. With averaging of FFR over three or five cardiac cycles, mean ΔFFR decreased to 0.02 ± 0.02, and 0.01 ± 0.01, respectively. Using a FFR ≤ 0.80 threshold, stenosis classification changed in 20.5% (8/39), 12.8% (5/39) and 5.1% (2/39) for single‐beat, three‐beat and five‐beat averaged FFR. The impact of respiration was more pronounced in patients with pulmonary disease (ΔFFR 0.05 ± 0.02 vs 0.03 ± 0.02, p = 0.021). Conclusion Beat‐to‐beat variations in FFR during plateau hyperemia related to respiration are common, of clinically relevant magnitude, and frequently lead FFR to cross treatment thresholds. A five‐beat averaged FFR, overcomes clinically relevant impact of FFR variation.
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Affiliation(s)
- Rutger G T Feenstra
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Martijn A van Lavieren
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Mauro Echavarria-Pinto
- Hospital General ISSSTE - Facultad de Medicina, Universidad Autónoma De Querétaro, Querétaro, Mexico
| | - Gilbert W Wijntjens
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Valerie E Stegehuis
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | | | - Robbert J de Winter
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Amir Lerman
- Division of Cardiovascular Diseases, and Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos, IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Jan J Piek
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Hirata T, Tanigaki T, Kawase Y, Hirakawa A, Omori H, Okamoto S, Ota H, Sobue Y, Kikuchi J, Okubo M, Kamiya H, Kawasaki M, Suzuki T, Pijls NHJ, Matsuo H. Post-occlusional hyperemia for fractional flow reserve assessment and pull-back curve analysis. Cardiovasc Interv Ther 2019; 35:142-149. [PMID: 30788697 DOI: 10.1007/s12928-019-00579-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/12/2019] [Indexed: 11/25/2022]
Abstract
Balloon occlusion is a potential method for inducing hyperemia to measure post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR). The objective of this study was to determine the clinical usefulness of post-occlusional hyperemia. FFRs measured using post-occlusional hyperemia caused by 30 (FFRoccl30) and 60 s (FFRoccl60) of balloon occlusion after PCI were compared in 60 lesions from 60 patients. The duration of hyperemia was also measured. There was a strong correlation between FFRoccl30 and FFRoccl60 (r = 0.969, p < 0.01). The duration of hyperemia was significantly longer with FFRoccl60 than with FFRoccl30 (68 ± 23 vs. 37 ± 15 s, p < 0.01). The time required for pullback curve analysis was around 45 s. However, in 7 (12%) cases, the duration of hyperemia with FFRoccl60 was < 45 s, which was not enough for pull-back curve analysis. To predict the duration of hyperemia with FFRoccl60 ≥ 45 s, the receiver operating characteristic curve analysis revealed a cut-off value of 25 s of hyperemia with FFRoccl30. FFRoccl30 is sufficient for diagnostic purposes. FFRoccl60 is suitable for pull-back curve analysis in select cases based on predictions made using the duration of hyperemia with FFRoccl30.
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Affiliation(s)
- T Hirata
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan
| | - T Tanigaki
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan
| | - Y Kawase
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan.
| | - A Hirakawa
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - H Omori
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan
| | - S Okamoto
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan
| | - H Ota
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan
| | - Y Sobue
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan
| | - J Kikuchi
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan
| | - M Okubo
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan
| | - H Kamiya
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan
| | - M Kawasaki
- Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - T Suzuki
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan
| | - N H J Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | - H Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabutaminami, Gifu city, 5008384, Gifu, Japan
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Cesaro A, Gragnano F, Di Girolamo D, Moscarella E, Diana V, Pariggiano I, Alfieri A, Perrotta R, Golino P, Cesaro F, Mercone G, Campo G, Calabrò P. Functional assessment of coronary stenosis: an overview of available techniques. Is quantitative flow ratio a step to the future? Expert Rev Cardiovasc Ther 2018; 16:951-962. [DOI: 10.1080/14779072.2018.1540303] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Arturo Cesaro
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Felice Gragnano
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Domenico Di Girolamo
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Elisabetta Moscarella
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Vincenzo Diana
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Ivana Pariggiano
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Alfonso Alfieri
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Rocco Perrotta
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Pasquale Golino
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Francesco Cesaro
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Giuseppe Mercone
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Paolo Calabrò
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
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Sciola MI, Morris PD, Gosling R, Lawford PV, Hose DR, Gunn JP. The impact of Objective Mathematical Analysis during Fractional Flow Reserve measurement: results from the OMA-FFR study. EUROINTERVENTION 2018; 14:935-941. [PMID: 29437033 DOI: 10.4244/eij-d-17-00826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIMS Fractional flow reserve (FFR), the reference standard for guiding coronary revascularisation, is most commonly acquired during intravenous adenosine infusion. Results may be sensitive to system- and operator-dependent variability in how pressure data are analysed and interpreted. To quantify FFR objectively, we developed a computational protocol to process the recorded pressure signals in a consistent manner. We studied the impact on lesion (re)classification and compared this with the operator-selected FFR obtained during cardiac catheterisation. METHODS AND RESULTS The algorithm used a moving average and Fourier transformation to identify the Pd/Pa ratio at its nadir (FFRmin) and during the stable hyperaemic period (FFRstable) in <2 s with 100% repeatability, in 163 coronary stenoses (93 patients). The mean operator-selected FFR (FFRCL) was higher than FFRmin and lower than FFRstable (0.779 vs. 0.762 vs. 0.806, p=<0.01). Compared with FFRmin, FFRstable resulted in 16.5% of all lesions being reclassified, all from significant to non-significant (p<0.01). FFRCL classified lesion significance differently from both FFRstable and FFRmin (11.7% and 6.1% lesions reclassified, respectively, p<0.01). CONCLUSIONS Subtle differences in how pressure data are analysed and interpreted by the operator during adenosine infusion result in significant differences in the classification of physiological lesion significance. An algorithmic analysis may be helpful in standardising FFR analysis, providing an objective and repeatable result.
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Affiliation(s)
- Martina I Sciola
- Mathematical Modelling in Medicine Group, Department of Infection, Immunity and Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom
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Casadonte L, Marques KM, Spaan JAE, Siebes M. Temporal dissociation between the minimal distal-to-aortic pressure ratio and peak hyperemia during intravenous adenosine infusion. Am J Physiol Heart Circ Physiol 2017; 312:H992-H1001. [DOI: 10.1152/ajpheart.00632.2016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 01/30/2017] [Accepted: 02/11/2017] [Indexed: 01/09/2023]
Abstract
The present study sought to compare the temporal relation between maximal coronary flow (peak hyperemia) and minimal coronary-to-aortic pressure ratio (Pd/Pa) for intracoronary (IC) and intravenous (IV) adenosine administration. Peak hyperemia is assumed to coincide with the minimal Pd/Pa value. However, this has not been confirmed for systemic hemodynamic variations during IV adenosine infusion. Hemodynamic responses to IV and IC adenosine administration were obtained in 12 patients (14 lesions) using combined IC pressure and flow velocity measurements. A fluid dynamic model was used to predict the change in Pd/Pa for different stenosis severities and varying Pa. Hemodynamic variability during IV adenosine hyperemia was greater than during IC adenosine, as assessed by the coefficient of variation. During IV adenosine, flow velocity peaked 28 ± 4 (SE) s after the onset of hyperemia, while Pd/Pa reached a minimum (0.82 ± 0.01) 22 ± 7 s later ( P < 0.05), when Pa had declined by 6.1% and hyperemic velocity by 4.5% ( P < 0.01). Model outcomes corroborated the role of variable Pa in this dissociation. In contrast, maximal flow and minimal Pd/Pa coincided for IC adenosine, with IV-equivalent peak velocities and a higher Pd/Pa ratio (0.86 ± 0.01, P < 0.01). Hemodynamic variability during continuous IV adenosine infusion can lead to temporal dissociation of minimal Pd/Pa and peak hyperemia, in contrast to IC adenosine injection, where maximal velocity and minimal Pd/Pa coincide. Despite this variability, stenosis hemodynamics remained stable with both ways of adenosine administration. Our findings suggest advantages of IC over IV adenosine to identify maximal hyperemia from pressure-only measurements. NEW & NOTEWORTHY Systemic hemodynamic variability during intravenous adenosine infusion produces substantial temporal dissociation between peak hyperemia appraised by coronary flow velocity and the minimal distal-to-aortic pressure ratio commonly used to determine functional stenosis severity. This dissociation was absent for intracoronary adenosine administration and tended to be mitigated in patients receiving Ca2+ antagonists.
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Affiliation(s)
- Lorena Casadonte
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and
| | - Koen M. Marques
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Jos A. E. Spaan
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and
| | - Maria Siebes
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and
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Use of fractional flow reserve in patients with coronary artery disease: The right choice for the right outcome. Trends Cardiovasc Med 2017; 27:106-120. [DOI: 10.1016/j.tcm.2016.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/21/2016] [Accepted: 06/23/2016] [Indexed: 01/15/2023]
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13
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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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14
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Alexopoulos D, Xanthopoulou I, Tsigkas G, Koutsogiannis N, Salata P, Armylagos S, Moulias A, Davlouros P. Effect of High (200 μg/kg per Minute) Adenosine Dose Infusion on Fractional Flow Reserve Variability. J Am Heart Assoc 2016; 5:e004323. [PMID: 27930357 PMCID: PMC5210360 DOI: 10.1161/jaha.116.004323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/07/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Variations in distal coronary pressure (Pd)/aortic pressure (Pa) ratio during steady-state hyperemia with standard (140 μg/kg per minute) adenosine dose may hamper accurate fractional flow reserve assessment. This study investigated to what extent an increased adenosine dose can overcome Pd/Pa variation. METHODS AND RESULTS In a prospective, single-arm study, out of 95 prospectively screened patients, 38 (40.0%) exhibited significant (≥0.05 difference of max Pd/Pa minus min Pd/Pa) variations in Pd/Pa from 15 s post Pd/Pa dip and until the end of a 3-minute adenosine (140 μg/kg per minute) infusion. Thirty patients agreed to participate in a post 5-minute repeat fractional flow reserve assessment using 200 μg/kg per minute 3-minute adenosine infusion. The study's co-primary end point of Pd/Pa coefficient of dispersion was lower for the high versus standard adenosine dose: 1.31 (1.13-2.72) versus 2.76 (2.38-5.60), P=0.002. The study's co-primary end point of ΔPd/Pa was also lower for the high versus standard adenosine dose: 0.065 (0.038-0.10) versus 0.08 (0.06-0.11), P=0.002. This difference was mainly driven by the lowering effect of the high adenosine dose on the maximum Pd/Pa compared to the standard dose: 0.84 (0.81-0.93) versus 0.90 (0.83-0.95), P=0.007, while minimum Pd/Pa remained unaffected. High adenosine dose was adequately tolerated by all patients, without requiring infusion discontinuation in any case. CONCLUSIONS Pd/Pa variability is frequently observed during standard adenosine infusion and is significantly decreased following a high (200 μg/kg per minute) adenosine dose. This is achieved without a significant difference in the minimum Pd/Pa. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02350439.
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Affiliation(s)
| | | | - Grigorios Tsigkas
- Department of Cardiology, Patras University Hospital, Rion Patras, Greece
| | | | - Paraskevi Salata
- Department of Cardiology, Patras University Hospital, Rion Patras, Greece
| | | | - Athanasios Moulias
- Department of Cardiology, Patras University Hospital, Rion Patras, Greece
| | - Periklis Davlouros
- Department of Cardiology, Patras University Hospital, Rion Patras, Greece
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15
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Matsuo H, Kawase Y. FFR and iFR guided percutaneous coronary intervention. Cardiovasc Interv Ther 2016; 31:183-95. [DOI: 10.1007/s12928-016-0404-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/14/2016] [Indexed: 01/15/2023]
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16
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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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17
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Berry C, Corcoran D, Hennigan B, Watkins S, Layland J, Oldroyd KG. Fractional flow reserve-guided management in stable coronary disease and acute myocardial infarction: recent developments. Eur Heart J 2015; 36:3155-64. [PMID: 26038588 PMCID: PMC4816759 DOI: 10.1093/eurheartj/ehv206] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/09/2015] [Accepted: 05/03/2015] [Indexed: 01/10/2023] Open
Abstract
Coronary artery disease (CAD) is a leading global cause of morbidity and mortality, and improvements in the diagnosis and treatment of CAD can reduce the health and economic burden of this condition. Fractional flow reserve (FFR) is an evidence-based diagnostic test of the physiological significance of a coronary artery stenosis. Fractional flow reserve is a pressure-derived index of the maximal achievable myocardial blood flow in the presence of an epicardial coronary stenosis as a ratio to maximum achievable flow if that artery were normal. When compared with standard angiography-guided management, FFR disclosure is impactful on the decision for revascularization and clinical outcomes. In this article, we review recent developments with FFR in patients with stable CAD and recent myocardial infarction. Specifically, we review novel developments in our understanding of CAD pathophysiology, diagnostic applications, prognostic studies, clinical trials, and clinical guidelines.
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Affiliation(s)
- Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - David Corcoran
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Barry Hennigan
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | - Stuart Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | | | - Keith G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
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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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Can Resting Indices Obviate the Need for Hyperemia and Promote the Routine Use of Physiologically Guided Revascularization? Interv Cardiol Clin 2015; 4:459-469. [PMID: 28581932 DOI: 10.1016/j.iccl.2015.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This article assesses the data from contemporary human studies to address some of the common assumptions regarding hyperemic and baseline physiology in the context of the baseline pressure-derived index of instant wave-free ratio and the hyperemic index of fractional flow reserve. The article aims to determine if the available evidence supports the continued investigation, development, and use of baseline indices.
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20
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Affiliation(s)
- William F Fearon
- From the Division of Cardiovascular Medicine, Stanford University Medical Center, CA.
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23
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Johnson NP, Johnson DT, Kirkeeide RL, Berry C, De Bruyne B, Fearon WF, Oldroyd KG, Pijls NH, Gould KL. Repeatability of Fractional Flow Reserve Despite Variations in Systemic and Coronary Hemodynamics. JACC Cardiovasc Interv 2015. [DOI: 10.1016/j.jcin.2015.01.039] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
Pressure-wire technology, most typically fractional flow reserve (FFR), has provided interventional cardiologists with a means of determining the physiological importance of a stenosis during angiography. There has been renewed interest in coronary physiology in the light of guideline recognition, ongoing clinical research and new technologies changing the paradigm of how assessment is performed in the catheter laboratory. We reflect on FFR, with regards the potential effects of changing hemodynamics on FFR and the latest evidence with regards to outcomes. We also review the instantaneous wave-free ratio (iFR), a new pressure-only index, measured at rest, that is under active evaluation in several international randomized controlled trials. We review the accumulated evidence and discuss the important physiological concepts between pressure and flow that underlie the approach to using resting indices. Finally we investigate future developments, including physiological mapping with iFR-Pullback and the potential to predict the hemodynamic effect of stenting.
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25
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Scott P, Sirker A, Dworakowski R, Paul G, Candilio L, Jahagirdar N, Melikian N, Byrne J. Fractional Flow Reserve in the Transradial Era: Will Hand Vein Adenosine Infusion Suffice? JACC Cardiovasc Interv 2015; 8:527-35. [DOI: 10.1016/j.jcin.2014.10.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/26/2014] [Accepted: 10/23/2014] [Indexed: 10/23/2022]
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26
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Jeremias A, Stone GW. Fractional Flow Reserve for the Evaluation of Coronary Stenoses. Catheter Cardiovasc Interv 2015; 85:602-3. [DOI: 10.1002/ccd.25851] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 01/16/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Allen Jeremias
- Stony Brook University Medical Center; Stony Brook New York
- Cardiovascular Research Foundation; New York New York
| | - Gregg W. Stone
- Cardiovascular Research Foundation; New York New York
- Columbia University Medical Center and New York Presbyterian Hospital; New York New York
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27
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Nijjer SS, Sen S, Petraco R, Escaned J, Echavarria-Pinto M, Broyd C, Al-Lamee R, Foin N, Foale RA, Malik IS, Mikhail GW, Sethi AS, Al-Bustami M, Kaprielian RR, Khan MA, Baker CS, Bellamy MF, Hughes AD, Mayet J, Francis DP, Di Mario C, Davies JER. Pre-angioplasty instantaneous wave-free ratio pullback provides virtual intervention and predicts hemodynamic outcome for serial lesions and diffuse coronary artery disease. JACC Cardiovasc Interv 2014; 7:1386-96. [PMID: 25459526 DOI: 10.1016/j.jcin.2014.06.015] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/15/2014] [Accepted: 06/19/2014] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The aim of this study was to perform hemodynamic mapping of the entire vessel using motorized pullback of a pressure guidewire with continuous instantaneous wave-free ratio (iFR) measurement. BACKGROUND Serial stenoses or diffuse vessel narrowing hamper pressure wire-guided management of coronary stenoses. Characterization of functional relevance of individual stenoses or narrowed segments constitutes an unmet need in ischemia-driven percutaneous revascularization. METHODS The study was performed in 32 coronary arteries with tandem and/or diffusely diseased vessels. An automated iFR physiological map, integrating pullback speed and physiological information, was built using dedicated software to calculate physiological stenosis severity, length, and intensity (ΔiFR/mm). This map was used to predict the best-case post-percutaneous coronary intervention (PCI) iFR (iFRexp) according to the stented location, and this was compared with the observed iFR post-PCI (iFRobs). RESULTS After successful PCI, the mean difference between iFRexp and iFRobs was small (mean difference: 0.016 ± 0.004) with a strong relationship between ΔiFRexp and ΔiFRobs (r = 0.97, p < 0.001). By identifying differing iFR intensities, it was possible to identify functional stenosis length and quantify the contribution of each individual stenosis or narrowed segment to overall vessel stenotic burden. Physiological lesion length was shorter than anatomic length (12.6 ± 1.5 vs. 23.3 ± 1.3, p < 0.001), and targeting regions with the highest iFR intensity predicted significant improvement post-PCI (r = 0.86, p < 0.001). CONCLUSIONS iFR measurements during continuous resting pressure wire pullback provide a physiological map of the entire coronary vessel. Before a PCI, the iFR pullback can predict the hemodynamic consequences of stenting specific stenoses and thereby may facilitate the intervention and stenting strategy.
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Affiliation(s)
| | - Sayan Sen
- Imperial College London, London, United Kingdom
| | | | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Alun D Hughes
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Jamil Mayet
- Imperial College London, London, United Kingdom
| | | | - Carlo Di Mario
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Imperial College, London, United Kingdom
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Wave speed in human coronary arteries is not influenced by microvascular vasodilation: implications for wave intensity analysis. Basic Res Cardiol 2014; 109:405. [PMID: 24515727 DOI: 10.1007/s00395-014-0405-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 01/07/2014] [Accepted: 01/29/2014] [Indexed: 01/10/2023]
Abstract
Wave intensity analysis and wave separation are powerful tools for interrogating coronary, myocardial and microvascular physiology. Wave speed is integral to these calculations and is usually estimated by the single-point technique (SPc), a feasible but as yet unvalidated approach in coronary vessels. We aimed to directly measure wave speed in human coronary arteries and assess the impact of adenosine and nitrate administration. In 14 patients, the transit time Δt between two pressure signals was measured in angiographically normal coronary arteries using a microcatheter equipped with two high-fidelity pressure sensors located Δs = 5 cm apart. Simultaneously, intracoronary pressure and flow velocity were measured with a dual-sensor wire to derive SPc. Actual wave speed was calculated as DNc = Δs/Δt. Hemodynamic signals were recorded at baseline and during adenosine-induced hyperemia, before and after nitroglycerin administration. The energy of separated wave intensity components was assessed using SPc and DNc. At baseline, DNc equaled SPc (15.9 ± 1.8 vs. 16.6 ± 1.5 m/s). Adenosine-induced hyperemia lowered SPc by 40 % (p < 0.005), while DNc remained unchanged, leading to marked differences in respective separated wave energies. Nitroglycerin did not affect DNc, whereas SPc transiently fell to 12.0 ± 1.2 m/s (p < 0.02). Human coronary wave speed is reliably estimated by SPc under resting conditions but not during adenosine-induced vasodilation. Since coronary wave speed is unaffected by microvascular dilation, the SPc estimate at rest can serve as surrogate for separating wave intensity signals obtained during hyperemia, thus greatly extending the scope of WIA to study coronary physiology in humans.
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