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de Oliveira Laterza Ribeiro M, Correia VM, Herling de Oliveira LL, Soares PR, Scudeler TL. Evolving Diagnostic and Management Advances in Coronary Heart Disease. Life (Basel) 2023; 13:951. [PMID: 37109480 PMCID: PMC10143565 DOI: 10.3390/life13040951] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Despite considerable improvement in diagnostic modalities and therapeutic options over the last few decades, the global burden of ischemic heart disease is steadily rising, remaining a major cause of death worldwide. Thus, new strategies are needed to lessen cardiovascular events. Researchers in different areas such as biotechnology and tissue engineering have developed novel therapeutic strategies such as stem cells, nanotechnology, and robotic surgery, among others (3D printing and drugs). In addition, advances in bioengineering have led to the emergence of new diagnostic and prognostic techniques, such as quantitative flow ratio (QFR), and biomarkers for atherosclerosis. In this review, we explore novel diagnostic invasive and noninvasive modalities that allow a more detailed characterization of coronary disease. We delve into new technological revascularization procedures and pharmacological agents that target several residual cardiovascular risks, including inflammatory, thrombotic, and metabolic pathways.
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Affiliation(s)
| | | | | | | | - Thiago Luis Scudeler
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
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Liu J, Mao B, Feng Y, Li B, Liu J, Liu Y. Closed-loop geometric multi-scale heart-coronary artery model for the numerical calculation of fractional flow reserve. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 208:106266. [PMID: 34265546 DOI: 10.1016/j.cmpb.2021.106266] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/29/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Fractional flow reserve (FFR) is considered to be the "gold standard" for the clinical diagnosis of functional myocardial ischemia. With the development of medical imaging and computational fluid dynamics (CFD), noninvasive computation of FFR has been developed. The most representative calculation method is the noninvasive FFR derived from coronary CT angiography (FFRCT), but it cannot thoroughly simulate the real physiological structure of the cardiovascular system. In this study, we propose a noninvasive closed-loop FFR derived from coronary CT angiography (FFRCCT). METHODS The closed-loop multi-scale model includes three parts: the heart module, the coronary artery module with microcirculation structure and the systemic circulation module. The proposed structure was formed by coupling a lumped parameter model (0D) with a 3D model, such that the 0D model provides the boundary conditions for the 3D model. We enrolled 100 patients through a prospective multi-center clinical trial and calculated their FFRCCT. Then, we extracted the pressure and flow waveforms of the coronary stenosis vessels through closed-loop geometric multi-scale CFD calculations. We evaluated the accuracy of FFRCCT in diagnosing myocardial ischemia using the clinical measurement of FFR as the standard. RESULTS The results of FFRCCT calculation in all patients showed a good correlation between FFRCCT and FFR (r = 0.64, p < 0.05). The AUC (95% CI) of FFRCCT was 0.819 [0.72, 0.91]. The accuracy, specificity, sensitivity, positive predictive value and negative predictive value of FFRCCT were 86%, 95%, 62%, 86% and 83%, respectively. CONCLUSIONS The closed-loop multi-scale model proposed in this study can simulate the physiological cycle in a more realistic way. FFRCCT is a reliable diagnostic index for myocardial ischemia.
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Affiliation(s)
- Jincheng Liu
- Faculty of Environment and Life, Beijing University of Technology, Beijing 100124, China.
| | - Boyan Mao
- Beijing University of Chinese Medicine, Beijing 100029, China.
| | - Yue Feng
- Peking University First Hospital, Medical Equipment Dept, Beijing 100034, China.
| | - Bao Li
- Faculty of Environment and Life, Beijing University of Technology, Beijing 100124, China.
| | - Jian Liu
- People's Hospital, Peking University, Beijing 100080, China.
| | - Youjun Liu
- Faculty of Environment and Life, Beijing University of Technology, Beijing 100124, China.
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3
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Hair J, Timmins L, El Sayed R, Samady H, Oshinski J. Effect of Patient-Specific Coronary Flow Reserve Values on the Accuracy of MRI-Based Virtual Fractional Flow Reserve. Front Cardiovasc Med 2021; 8:663767. [PMID: 34277727 PMCID: PMC8282891 DOI: 10.3389/fcvm.2021.663767] [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: 02/03/2021] [Accepted: 05/28/2021] [Indexed: 01/09/2023] Open
Abstract
The purpose of this study is to investigate the effect of varying coronary flow reserve (CFR) values on the calculation of computationally-derived fractional flow reserve (FFR). CFR reflects both vessel resistance due to an epicardial stenosis, and resistance in the distal microvascular tissue. Patients may have a wide range of CFR related to the tissue substrate that is independent of epicardial stenosis levels. Most computationally based virtual FFR values such as FFRCT do not measure patient specific CFR values but use a population-average value to create hyperemic flow conditions. In this study, a coronary arterial computational geometry was constructed using magnetic resonance angiography (MRA) data acquired in a patient with moderate CAD. Coronary flow waveforms under rest and stress conditions were acquired in 13 patients with phase-contrast magnetic resonance (PCMR) to calculate CFR, and these flow waveforms and CFR values were applied as inlet flow boundary conditions to determine FFR based on computational fluid dynamics (CFD) simulations. The stress flow waveform gave a measure of the functional significance of the vessel when evaluated with the physiologically-accurate behavior with the patient-specific CFR. The resting flow waveform was then scaled by a series of CFR values determined in the 13 patients to simulate how hyperemic flow and CFR affects FFR values. We found that FFR values calculated using non-patient-specific CFR values did not accurately predict those calculated with the true hyperemic flow waveform. This indicates that both patient-specific anatomic and flow information are required to accurately non-invasively assess the functional significance of coronary lesions.
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Affiliation(s)
- Jackson Hair
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States.,Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States
| | - Lucas Timmins
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States.,Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
| | - Retta El Sayed
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States
| | - Habib Samady
- Division of Cardiology, Department of Medicine, Emory School of Medicine, Atlanta, GA, United States
| | - John Oshinski
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States.,Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States
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4
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Cardiac hypoxic resistance and decreasing lactate during maximum apnea in elite breath hold divers. Sci Rep 2021; 11:2545. [PMID: 33510292 PMCID: PMC7844051 DOI: 10.1038/s41598-021-81797-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/06/2021] [Indexed: 01/30/2023] Open
Abstract
Breath-hold divers (BHD) enduring apnea for more than 4 min are characterized by resistance to release of reactive oxygen species, reduced sensitivity to hypoxia, and low mitochondrial oxygen consumption in their skeletal muscles similar to northern elephant seals. The muscles and myocardium of harbor seals also exhibit metabolic adaptations including increased cardiac lactate-dehydrogenase-activity, exceeding their hypoxic limit. We hypothesized that the myocardium of BHD possesses similar adaptive mechanisms. During maximum apnea 15O-H2O-PET/CT (n = 6) revealed no myocardial perfusion deficits but increased myocardial blood flow (MBF). Cardiac MRI determined blood oxygen level dependence oxygenation (n = 8) after 4 min of apnea was unaltered compared to rest, whereas cine-MRI demonstrated increased left ventricular wall thickness (LVWT). Arterial blood gases were collected after warm-up and maximum apnea in a pool. At the end of the maximum pool apnea (5 min), arterial saturation decreased to 52%, and lactate decreased 20%. Our findings contrast with previous MR studies of BHD, that reported elevated cardiac troponins and decreased myocardial perfusion after 4 min of apnea. In conclusion, we demonstrated for the first time with 15O-H2O-PET/CT and MRI in elite BHD during maximum apnea, that MBF and LVWT increases while lactate decreases, indicating anaerobic/fat-based cardiac-metabolism similar to diving mammals.
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5
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Monroy-Gonzalez AG, Juarez-Orozco LE, Han C, Vedder IR, García DV, Borra R, Slomka PJ, Nesterov SV, Knuuti J, Slart RHJA, Alexanderson-Rosas E. Software reproducibility of myocardial blood flow and flow reserve quantification in ischemic heart disease: A 13N-ammonia PET study. J Nucl Cardiol 2020; 27:1225-1233. [PMID: 30903608 DOI: 10.1007/s12350-019-01620-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/13/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND We explored agreement in the quantification of myocardial perfusion by cross-comparison of implemented software packages (SPs) in three distinguishable patient profile populations. METHODS We studied 91 scans of patients divided into 3 subgroups based on their semi-quantitative perfusion findings: patients with normal perfusion, with reversible perfusion defects, and with fixed perfusion defects. Rest myocardial blood flow (MBF), stress MBF, and myocardial flow reserve (MFR) were obtained with QPET, SyngoMBF, and Carimas. Agreement between SPs was considered adequate when a pairwise standardized difference was found to be < 0.20 and its corresponding intraclass correlation coefficient was ≥ 0.75. RESULTS In patients with normal perfusion, two out of three comparisons of global stress MBF quantifications were outside the limits of agreement. In ischemic patients, all comparisons of global stress MBF and MFR were outside the limits of established agreement. In patients with fixed perfusion defects, all SP comparisons of perfusion quantifications were within the limit of agreement. Regionally, agreement of these perfusion estimates was mostly found for the left anterior descending artery vascular territory. CONCLUSION Reversible defects demonstrated the worst agreement in global stress MBF and MFR and discrepancies showed to be regional dependent. Reproducibility between SPs should not be assumed.
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Affiliation(s)
- Andrea G Monroy-Gonzalez
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Chunlei Han
- Turku PET Centre, University of Turku, Turku, Finland
| | - Issi R Vedder
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - David Vállez García
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ronald Borra
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Piotr J Slomka
- Departments of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sergey V Nesterov
- Turku PET Centre, University of Turku, Turku, Finland
- Institute of Evolutionary Physiology and Biochemistry, RAS, St. Petersburg, Russia
| | - Juhani Knuuti
- Turku PET Centre, University of Turku, Turku, Finland
| | - Riemer H J A Slart
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Biomedical Photonic Imaging, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Erick Alexanderson-Rosas
- Department of Physiology, National Autonomous University of Mexico, Mexico City, Mexico.
- National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico.
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6
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Hashemi J, Rai S, Ghafghazi S, Berson RE. Blood residence time to assess significance of coronary artery stenosis. Sci Rep 2020; 10:11658. [PMID: 32669566 PMCID: PMC7363809 DOI: 10.1038/s41598-020-68292-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 06/15/2020] [Indexed: 01/09/2023] Open
Abstract
Coronary artery stenosis is a narrowing of coronary lumen space caused by an atherosclerotic lesion. Fractional flow reserve (FFR) is the gold standard metric to assess physiological significance of coronary stenosis, but requires an invasive procedure. Computational modeling in conjunction with patient-specific imaging demonstrates formation of regions of recirculatory flow distal to a stenosis, increasing mean blood residence time relative to uninhibited flow. A new computational parameter, mean blood residence time (BloodRT), was computed for 100 coronary artery segments for which FFR was known. A threshold for BloodRT was determined to assess the physiological significance of a stenosis, analogous to diagnostic threshold for FFR. Model sensitivity and specificity of BloodRT for diagnosis of hemodynamically significant coronary stenosis was 98% and 96% respectively, compared with FFR. When applied to clinical practice, this could potentially allow practicing cardiologists to accurately assess the severity of coronary stenosis without resorting to invasive techniques.
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Affiliation(s)
- Javad Hashemi
- Department of Chemical Engineering, University of Louisville, Louisville, KY, USA
| | - Shesh Rai
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY, USA
| | - Shahab Ghafghazi
- Department of Medicine, University of Louisville, Louisville, KY, USA.
| | - R Eric Berson
- Department of Chemical Engineering, University of Louisville, Louisville, KY, USA.
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Groepenhoff F, Bots SH, Kessler EL, Sickinghe AA, Eikendal ALM, Leiner T, den Ruijter HM. Sex-Specific Aspects in the Pathophysiology and Imaging of Coronary Macro- and Microvascular Disease. J Cardiovasc Transl Res 2019; 13:39-46. [PMID: 31471830 PMCID: PMC7010630 DOI: 10.1007/s12265-019-09906-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/25/2019] [Indexed: 12/15/2022]
Abstract
Sex differences in coronary artery disease (CAD) are well established, with women presenting with non-obstructive CAD more often than men do. However, recent evidence has identified coronary microvascular dysfunction as the underlying cause for cardiac complaints, yet sex-specific prevalence numbers are inconclusive. This review summarises known sex-specific aspects in the pathophysiology of both macro- and microvascular dysfunction and identifies currently existing knowledge gaps. In addition, this review describes current diagnostic approaches and whether these should take underlying sex differences into account by, for example, using different techniques or cut-off values for women and men. Future research into both innovation of imaging techniques and perfusion-related sex differences is needed to fill evidence gaps and enable the implementation of the available knowledge in daily clinical practice.
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Affiliation(s)
- Floor Groepenhoff
- Laboratory for Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sophie H Bots
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elise L Kessler
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ariane A Sickinghe
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anouk L M Eikendal
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht University, P. O. Box 85500, 3508, GA, Utrecht, The Netherlands
| | - Hester M den Ruijter
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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8
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Rambarat CA, Elgendy IY, Handberg EM, Bairey Merz CN, Wei J, Minissian MB, Nelson MD, Thomson LEJ, Berman DS, Shaw LJ, Cook-Wiens G, Pepine CJ. Late sodium channel blockade improves angina and myocardial perfusion in patients with severe coronary microvascular dysfunction: Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction ancillary study. Int J Cardiol 2019; 276:8-13. [PMID: 30293664 PMCID: PMC6324974 DOI: 10.1016/j.ijcard.2018.09.081] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND In a prior trial of late sodium channel inhibition (ranolazine) among symptomatic subjects without obstructive coronary artery disease (CAD) and limited myocardial perfusion reserve index (MPRI), we observed no improvement in angina or MPRI, overall. Here we describe the clinical characteristics and myocardial perfusion responses of a pre-defined subgroup who had coronary flow reserve (CFR) assessed invasively. METHODS Symptomatic patients without obstructive CAD and limited MPRI in a randomized, double-blind, crossover trial of ranolazine vs. placebo were subjects of this prespecified substudy. Because we had previously observed that adverse outcomes and beneficial treatment responses occurred in those with lower CFR, patients were subgrouped by CFR <2.5 vs ≥2.5. Symptoms were assessed using the Seattle Angina Questionnaire and the SAQ-7, and left-ventricular volume and MPRI were assessed by magnetic resonance imaging (MRI). Coronary angiograms, CFR, and MRI data were analyzed by core labs masked to treatment and patient characteristics. RESULTS During qualifying coronary angiography, 81 patients (mean age 55 years, 98% women) had invasively determined CFR 2.69 ± 0.65 (mean ± SD; range 1.4-5.5); 43% (n = 35) had CFR <2.5. Demographic and symptomatic findings did not differ comparing CFR subgroups. Those with low CFR had improved angina (p = 0.04) and midventricular MPRI (p = 0.03) with ranolazine vs placebo. Among patients with low CFR, reduced left-ventricular end-diastolic volume predicted a beneficial angina response. CONCLUSIONS Symptomatic patients with CFR <2.5 and no obstructive CAD had improved angina and myocardial perfusion with ranolazine, supporting the hypothesis that the late sodium channel is important in management of coronary microvascular dysfunction. TRIAL REGISTRATION clinicaltrials.gov Identifier NCT01342029.
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Affiliation(s)
- Cecil A Rambarat
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Eileen M Handberg
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - C Noel Bairey Merz
- Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Janet Wei
- Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Margo B Minissian
- Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Michael D Nelson
- Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Louise E J Thomson
- Departments of Medicine and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Medicine and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Leslee J Shaw
- Program in Cardiovascular Outcomes Research and Epidemiology, Emory University, Atlanta, GA, USA
| | - Galen Cook-Wiens
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA.
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9
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Khanmohammadi M, Engan K, Sæland C, Eftestøl T, Larsen AI. Automatic Estimation of Coronary Blood Flow Velocity Step 1 for Developing a Tool to Diagnose Patients With Micro-Vascular Angina Pectoris. Front Cardiovasc Med 2019; 6:1. [PMID: 30740396 PMCID: PMC6357931 DOI: 10.3389/fcvm.2019.00001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/03/2019] [Indexed: 11/13/2022] Open
Abstract
Aim: Our aim was to automatically estimate the blood velocity in coronary arteries using cine X-ray angiographic sequence. Estimating the coronary blood velocity is a key approach in investigating patients with angina pectoris and no significant coronary artery disease. Blood velocity estimation is central in assessing coronary flow reserve. Methods and Results: A multi-step automatic method for blood flow velocity estimation based on the information extracted solely from the cine X-ray coronary angiography sequence obtained by invasive selective coronary catheterization was developed. The method includes (1) an iterative process of segmenting coronary arteries modeling and removing the heart motion using a non-rigid registration, (2) measuring the area of the segmented arteries in each frame, (3) fitting the measured sequence of areas with a 7° polynomial to find start and stop time of dye propagation, and (4) estimating the blood flow velocity based on the time of the dye propagation and the length of the artery-tree. To evaluate the method, coronary angiography recordings from 21 patients with no obstructive coronary artery disease were used. In addition, coronary flow velocity was measured in the same patients using a modified transthoracic Doppler assessment of the left anterior descending artery. We found a moderate but statistically significant correlation between flow velocity assessed by trans thoracic Doppler and the proposed method applying both Spearman and Pearson tests. Conclusion: Measures of coronary flow velocity using a novel fully automatic method that utilizes the information from the X-ray coronary angiographic sequence were statistically significantly correlated to measurements obtained with transthoracic Doppler recordings.
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Affiliation(s)
- Mahdieh Khanmohammadi
- University of Stavanger Department of Electrical Engineering and Computer Science, Stavanger, Norway
| | - Kjersti Engan
- University of Stavanger Department of Electrical Engineering and Computer Science, Stavanger, Norway
| | - Charlotte Sæland
- Stavanger University Hospital Department of Cardiology, Stavanger, Norway
| | - Trygve Eftestøl
- University of Stavanger Department of Electrical Engineering and Computer Science, Stavanger, Norway
| | - Alf I Larsen
- Stavanger University Hospital Department of Cardiology, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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10
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Stegehuis VE, Wijntjens GW, Piek JJ, van de Hoef TP. Fractional Flow Reserve or Coronary Flow Reserve for the Assessment of Myocardial Perfusion : Implications of FFR as an Imperfect Reference Standard for Myocardial Ischemia. Curr Cardiol Rep 2018; 20:77. [PMID: 30046914 PMCID: PMC6061210 DOI: 10.1007/s11886-018-1017-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Purpose of Review Accumulating evidence exists for the value of coronary physiology for clinical decision-making in ischemic heart disease (IHD). The most frequently used pressure-derived index to assess stenosis severity, the fractional flow reserve (FFR), has long been considered the gold standard for this purpose, despite the fact that the FFR assesses solely epicardial stenosis severity and aims to estimate coronary flow impairment in the coronary circulation. The coronary flow reserve (CFR) directly assesses coronary blood flow in the coronary circulation, including both the epicardial coronary artery and the coronary microvasculature, but is nowadays less established than FFR. It is now recognized that both tools may provide insight into the pathophysiological substrate of ischemic heart disease, and that particularly combined FFR and CFR measurements provide a comprehensive insight into the multilevel involvement of IHD. This review discusses the diagnostic and prognostic characteristics, as well as future implications of combined assessment of FFR and CFR pressure and flow measurements as parameters for inducible ischemia. Recent Findings FFR and CFR disagree in up to 40% of all cases, giving rise to fundamental questions regarding the role of FFR in contemporary ischemic heart disease management, and implying a renewed approach in clinical management of these patients using combined coronary pressure and flow measurement to allow appropriate identification of patients at risk for cardiovascular events. Summary This review emphasizes the value of comprehensive coronary physiology measurements in assessing the pathophysiological substrate of IHD, and the importance of acknowledging the broad spectrum of epicardial and microcirculatory involvement in IHD. Increasing interest and large clinical trials are expected to further strengthen the potential of advanced coronary physiology in interventional cardiology, consequently inducing reconsideration of current clinical guidelines.
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Affiliation(s)
- Valérie E Stegehuis
- Amsterdam UMC, University of Amsterdam, Department of Cardiology, Heart Centre, Meibergdreef 9, Amsterdam, The Netherlands
| | - Gilbert W Wijntjens
- Amsterdam UMC, University of Amsterdam, Department of Cardiology, Heart Centre, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jan J Piek
- Amsterdam UMC, University of Amsterdam, Department of Cardiology, Heart Centre, Meibergdreef 9, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- Amsterdam UMC, University of Amsterdam, Department of Cardiology, Heart Centre, Meibergdreef 9, Amsterdam, The Netherlands.
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11
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Erre GL, Buscetta G, Paliogiannis P, Mangoni AA, Carru C, Passiu G, Zinellu A. Coronary flow reserve in systemic rheumatic diseases: a systematic review and meta-analysis. Rheumatol Int 2018; 38:1179-1190. [DOI: 10.1007/s00296-018-4039-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 04/30/2018] [Indexed: 12/11/2022]
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12
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Kawaguchi N, Okayama H, Kawamura G, Shigematsu T, Takahashi T, Kawada Y, Hiasa G, Yamada T, Matsuoka H, Kazatani Y, Miyagawa M, Mochizuki T. Clinical Usefulness of Coronary Flow Reserve Ratio for the Detection of Significant Coronary Artery Disease on 13N-Ammonia Positron Emission Tomography. Circ J 2018; 82:486-493. [DOI: 10.1253/circj.cj-17-0745] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Naoto Kawaguchi
- Department of Radiology, Ehime University Graduate School of Medicine
| | - Hideki Okayama
- Department of Cardiology, Ehime Prefectural Central Hospital
| | - Go Kawamura
- Department of Cardiology, Ehime Prefectural Central Hospital
| | | | | | | | - Go Hiasa
- Department of Cardiology, Ehime Prefectural Central Hospital
| | | | | | - Yukio Kazatani
- Department of Cardiology, Ehime Prefectural Central Hospital
| | - Masao Miyagawa
- Department of Radiology, Ehime University Graduate School of Medicine
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13
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Alrifai A, Kabach M, Nieves J, Pino J, Chait R. Microvascular Coronary Artery Disease: Review Article. US CARDIOLOGY REVIEW 2017. [DOI: 10.15420/usc.2017:27:1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Recently it has become more apparent that microvascular dysfunction is responsible for morbidity and mortality in many different cardiovascular diseases. It is no longer felt to be benign, and besides accounting for angina symptoms, it likely plays a role in heart failure with preserved ejection fraction, as well as in Takotsubo syndrome and various inflammatory diseases associated with ischemia and atherosclerosis. Coronary microvascular disease can be diagnosed by means of invasive coronary reactivity testing and noninvasively by echocardiography, computerized tomography, magnetic resonance, and positron emission tomography. Unfortunately, treatment has been more empiric, and not as well evaluated by randomized trials as in other disease states. Beta blockers, nitrates, and calcium channel blockers have all been used with varying degrees of success. Given its prevalence, particularly among women, its increased recognition and importance mandates further research into prompt diagnosis and more robust studies of its treatment.
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14
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Hsu B, Hu LH, Yang BH, Chen LC, Chen YK, Ting CH, Hung GU, Huang WS, Wu TC. SPECT myocardial blood flow quantitation toward clinical use: a comparative study with 13N-Ammonia PET myocardial blood flow quantitation. Eur J Nucl Med Mol Imaging 2016; 44:117-128. [PMID: 27585576 DOI: 10.1007/s00259-016-3491-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/07/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the accuracy of myocardial blood flow (MBF) quantitation of 99mTc-Sestamibi (MIBI) single photon emission computed tomography (SPECT) compared with 13N-Ammonia (NH3) position emission tomography (PET) on the same cohorts. BACKGROUND Recent advances of SPECT technologies have been applied to develop MBF quantitation as a promising tool to diagnose coronary artery disease (CAD) for areas where PET MBF quantitation is not available. However, whether the SPECT approach can achieve the same level of accuracy as the PET approach for clinical use still needs further investigations. METHODS Twelve healthy volunteers (HVT) and 16 clinical patients with CAD received both MIBI SPECT and NH3 PET flow scans. Dynamic SPECT images acquired with high temporary resolution were fully corrected for physical factors and processed to quantify K1 using the standard compartmental modeling. Human MIBI tracer extraction fraction (EF) was determined by comparing MIBI K1 and NH3 flow on the HVT group and then used to convert flow values from K1 for all subjects. MIBI and NH3 flow values were systematically compared to validate the SPECT approach. RESULTS The human MIBI EF was determined as [1.0-0.816*exp(-0.267/MBF)]. Global and regional MBF and myocardial flow reserve (MFR) of MIBI SPECT and NH3 PET were highly correlated for all subjects (global R2: MBF = 0.92, MFR = 0.78; regional R2: MBF ≥ 0.88, MFR ≥ 0.71). No significant differences for rest flow, stress flow, and MFR between these two approaches were observed (All p ≥ 0.088). Bland-Altman plots overall revealed small bias between MIBI SPECT and NH3 PET (global: ΔMBF = -0.03Lml/min/g, ΔMFR = 0.07; regional: ΔMBF = -0.07 - 0.06 , ΔMFR = -0.02 - 0.22). CONCLUSIONS Quantitation with SPECT technologies can be accurate to measure myocardial blood flow as PET quantitation while comprehensive imaging factors of SPECT to derive the variability between these two approaches were fully addressed and corrected.
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Affiliation(s)
- Bailing Hsu
- Nuclear Science and Engineering Institute, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Lien-Hsin Hu
- Department of Nuclear Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Bang-Hung Yang
- Department of Nuclear Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Lung-Ching Chen
- Division of Cardiology, Shin Kong Wu-Ho Su Memorial Hospital, Taipei, Taiwan
| | - Yen-Kung Chen
- Department of Nuclear Medicine, Shin Kong Wu-Ho Su Memorial Hospital, Taipei, Taiwan
| | - Chien-Hsin Ting
- Department of Nuclear Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Guang-Uei Hung
- Department of Nuclear Medicine, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Wen-Sheng Huang
- Department of Nuclear Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Tao-Cheng Wu
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
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Kim HY, Choi JH. How to Utilize Coronary Computed Tomography Angiography in the Treatment of Coronary Artery Disease. J Cardiovasc Ultrasound 2015; 23:204-8. [PMID: 26755927 PMCID: PMC4707304 DOI: 10.4250/jcu.2015.23.4.204] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/06/2015] [Accepted: 12/07/2015] [Indexed: 12/25/2022] Open
Abstract
Coronary computed tomography angiography (CCTA) has high negative predictive power for detecting coronary artery disease. However CCTA is limited by moderate positive predictive power in the detection of myocardial ischemia. This is not unexpected because the diameter of a stenosis is a poor indicator of myocardial ischemia and discrepancy between the severity of stenosis and noninvasive tests is not uncommon. The value of stenosis for predicting future development of acute coronary syndrome represented by plaque rupture has been questioned. CCTA identifies the characteristics of high-risk plaque including positive remodeling, low density plaque and spotty or micro-calcification. Also, additional evaluation of myocardial ischemia using computational flow dynamics, and luminal attenuation gradient are expected to increase both diagnostic performance for hemodynamically significant stenosis and the predictive power for future cardiovascular risk. Technical advances in CCTA would enable evaluation of both coronary artery stenosis and myocardial ischemia simultaneously with high predictive performance, and would improve vastly the clinical value of CCTA.
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Affiliation(s)
- Hyung-Yoon Kim
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.; Department of Emergency Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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