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Han Y, Ahmed AI, Schwemmer C, Cocker M, Alnabelsi TS, Saad JM, Ramirez Giraldo JC, Al-Mallah MH. Interoperator reliability of an on-site machine learning-based prototype to estimate CT angiography-derived fractional flow reserve. Open Heart 2022; 9:openhrt-2021-001951. [PMID: 35314508 PMCID: PMC8938695 DOI: 10.1136/openhrt-2021-001951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/07/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Advances in CT and machine learning have enabled on-site non-invasive assessment of fractional flow reserve (FFRCT). PURPOSE To assess the interoperator and intraoperator variability of coronary CT angiography-derived FFRCT using a machine learning-based postprocessing prototype. MATERIALS AND METHODS We included 60 symptomatic patients who underwent coronary CT angiography. FFRCT was calculated by two independent operators after training using a machine learning-based on-site prototype. FFRCT was measured 1 cm distal to the coronary plaque or in the middle of the segments if no coronary lesions were present. Intraclass correlation coefficient (ICC) and Bland-Altman analysis were used to evaluate interoperator variability effect in FFRCT estimates. Sensitivity analysis was done by cardiac risk factors, degree of stenosis and image quality. RESULTS A total of 535 coronary segments in 60 patients were assessed. The overall ICC was 0.986 per patient (95% CI 0.977 to 0.992) and 0.972 per segment (95% CI 0.967 to 0.977). The absolute mean difference in FFRCT estimates was 0.012 per patient (95% CI for limits of agreement: -0.035 to 0.039) and 0.02 per segment (95% CI for limits of agreement: -0.077 to 0.080). Tight limits of agreement were seen on Bland-Altman analysis. Distal segments had greater variability compared with proximal/mid segments (absolute mean difference 0.011 vs 0.025, p<0.001). Results were similar on sensitivity analysis. CONCLUSION A high degree of interoperator and intraoperator reproducibility can be achieved by on-site machine learning-based FFRCT assessment. Future research is required to evaluate the physiological relevance and prognostic value of FFRCT.
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Affiliation(s)
- Yushui Han
- Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Ahmed Ibrahim Ahmed
- Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Chris Schwemmer
- Computed Tomography-Research & Development, Siemens Healthcare GmbH, Erlangen, Bayern, Germany
| | - Myra Cocker
- Computed Tomography-Research Collaborations, Siemens Healthcare USA, Malvern, Pennsylvania, USA
| | - Talal S Alnabelsi
- Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Jean Michel Saad
- Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Juan C Ramirez Giraldo
- Computed Tomography-Research Collaborations, Siemens Healthcare USA, Malvern, Pennsylvania, USA
| | - Mouaz H Al-Mallah
- Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
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Ahmed AI, Han Y, Al Rifai M, Alnabelsi T, Nabi F, Chang SM, Cocker M, Schwemmer C, Ramirez-Giraldo JC, Kleiman NS, Zoghbi WA, Mahmarian JJ, Al-Mallah MH. Prognostic Value of Computed Tomography-Derived Fractional Flow Reserve Comparison With Myocardial Perfusion Imaging. JACC Cardiovasc Imaging 2021; 15:284-295. [PMID: 34656489 DOI: 10.1016/j.jcmg.2021.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The aim of this study was to compare the incremental prognostic value of coronary computed tomography (CT) angiography (CCTA)-derived machine learning fractional flow reserve CT (ML-FFRct) versus that of ischemia detected on single-photon emission-computed tomography (SPECT) myocardial perfusion imaging (MPI) on incident cardiovascular outcomes. BACKGROUND SPECT MPI and ML-FFRct are noninvasive tools that can assess the hemodynamic significance of coronary atherosclerotic disease. METHODS We studied a retrospective cohort of consecutive patients who underwent clinically indicated CCTA and SPECT MPI. ML-FFRct was computed using a ML prototype. The primary outcome was all-cause mortality and nonfatal myocardial infarction (D/MI), and the secondary outcome was D/MI and unplanned revascularization, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) occurring more than 90 days postimaging. Multiple nested multivariate cox regression was used to model a scenario wherein an initial anatomical assessment was followed by a functional assessment. RESULTS A total of 471 patients (mean age: 64 ± 13 year; 53% males) were included. Comorbidities were prevalent (78% hypertension, 66% diabetes, 81% dyslipidemia). ML-FFRct was <0.8 in at least 1 proximal/midsegment was present in 41.6% of patients, and ischemia on MPI was present in 13.8%. After a median follow-up of 18 months, 7% of patients (n = 33) experienced D/MI. On multivariate Cox proportional analysis, the presence of ischemia on MPI but not ML-FFRct significantly predicted D/MI (HR: 2.3; 95% CI: 1.0-5.0; P = 0.047; or HR: 0.7; 95% CI: 0.3-1.4; P = 0.306 respectively) when added to CCTA obstructive stenosis. Furthermore, the model with SPECT ischemia had higher global chi-square result and significantly improved reclassification. Results were similar using the secondary outcome and on several sensitivity analyses. CONCLUSIONS In a high-risk patient cohort, SPECT MPI but not ML-FFRct adds independent and incremental prognostic information to CCTA-based anatomical assessment and clinical risk factors in predicting incident outcomes.
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Affiliation(s)
| | - Yushui Han
- Houston Methodist Debakey Heart and Vascular Center, Houston, Texas, USA
| | | | - Talal Alnabelsi
- Houston Methodist Debakey Heart and Vascular Center, Houston, Texas, USA
| | - Faisal Nabi
- Houston Methodist Debakey Heart and Vascular Center, Houston, Texas, USA
| | - Su Min Chang
- Houston Methodist Debakey Heart and Vascular Center, Houston, Texas, USA
| | - Myra Cocker
- Houston Methodist Debakey Heart and Vascular Center, Houston, Texas, USA; Computed Tomography-Research Collaborations, Siemens Healthineers, Malvern, Pennsylvania, USA
| | - Chris Schwemmer
- Computed Tomography-Research and Development, Siemens Healthcare GmbH, Forchheim, Germany
| | - Juan C Ramirez-Giraldo
- Computed Tomography-Research Collaborations, Siemens Healthineers, Malvern, Pennsylvania, USA
| | - Neal S Kleiman
- Houston Methodist Debakey Heart and Vascular Center, Houston, Texas, USA
| | - William A Zoghbi
- Houston Methodist Debakey Heart and Vascular Center, Houston, Texas, USA
| | - John J Mahmarian
- Houston Methodist Debakey Heart and Vascular Center, Houston, Texas, USA
| | - Mouaz H Al-Mallah
- Houston Methodist Debakey Heart and Vascular Center, Houston, Texas, USA.
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Lin L, Zhou X, Dekkers IA, Lamb HJ. Cardiorenal Syndrome: Emerging Role of Medical Imaging for Clinical Diagnosis and Management. J Pers Med 2021; 11:734. [PMID: 34442378 PMCID: PMC8400880 DOI: 10.3390/jpm11080734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/24/2021] [Accepted: 07/24/2021] [Indexed: 12/16/2022] Open
Abstract
Cardiorenal syndrome (CRS) concerns the interconnection between heart and kidneys in which the dysfunction of one organ leads to abnormalities of the other. The main clinical challenges associated with cardiorenal syndrome are the lack of tools for early diagnosis, prognosis, and evaluation of therapeutic effects. Ultrasound, computed tomography, nuclear medicine, and magnetic resonance imaging are increasingly used for clinical management of cardiovascular and renal diseases. In the last decade, rapid development of imaging techniques provides a number of promising biomarkers for functional evaluation and tissue characterization. This review summarizes the applicability as well as the future technological potential of each imaging modality in the assessment of CRS. Furthermore, opportunities for a comprehensive imaging approach for the evaluation of CRS are defined.
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Affiliation(s)
- Ling Lin
- Cardiovascular Imaging Group (CVIG), Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.L.); (I.A.D.); (H.J.L.)
| | - Xuhui Zhou
- Department of Radiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 510833, China
| | - Ilona A. Dekkers
- Cardiovascular Imaging Group (CVIG), Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.L.); (I.A.D.); (H.J.L.)
| | - Hildo J. Lamb
- Cardiovascular Imaging Group (CVIG), Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.L.); (I.A.D.); (H.J.L.)
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Beg F, Rehman H, Chamsi-Pasha MA, Nabi F, Chang SM, Mahmarian JJ, Al-Mallah MH. Association Between FFR CT and Instantaneous Wave-Free Ratio (iFR) of Intermediate Lesions on Coronary Computed Tomography Angiography. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 31:57-60. [PMID: 33272881 DOI: 10.1016/j.carrev.2020.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND New data suggests long term outcomes of coronary revascularization based on instantaneous wave free ratio (iFR) are equivalent to invasive fractional flow reserve (FFR). We aimed to evaluate the correlation between non-invasive FFR derived from cardiac CT (FFRCT) and iFR. METHODS Data from 21 patients with 26 vessels, who underwent both FFRCT computation and invasive iFR measurement, were analysed. We evaluated diagnostic performance of FFRCT according to two cut-off values of ≤0.80 and ≤0.70 with iFR ≤0.89 as the reference standard. RESULTS In a per vessel analysis, the average diameter stenosis was 59%, mean FFRCT was 0.81 while mean iFR was 0.90. Using an FFRCT cut-off of 0.80, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy for FFRCT were 86%, 84%, 67%, 94%, and 85% respectively. When the cut-off was lowered to 0.70, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy for FFRCT were 57%, 100%, 100%, 86% and 88% respectively. CONCLUSION FFRCT correlates well with iFR in this small retrospective study. Larger studies are required to confirm this finding.
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Affiliation(s)
- Faheemullah Beg
- Section of Interventional & Structural Cardiology, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Hasan Rehman
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America
| | - Mohammed A Chamsi-Pasha
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America
| | - Faisal Nabi
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America
| | - Su-Min Chang
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America
| | - John J Mahmarian
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America
| | - Mouaz H Al-Mallah
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America.
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Dilsizian V, Gewirtz H, Marwick TH, Kwong RY, Raggi P, Al-Mallah MH, Herzog CA. Cardiac Imaging for Coronary Heart Disease Risk Stratification in Chronic Kidney Disease. JACC Cardiovasc Imaging 2020; 14:669-682. [PMID: 32828780 DOI: 10.1016/j.jcmg.2020.05.035] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/22/2020] [Accepted: 05/13/2020] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease (CKD), defined as dysfunction of the glomerular filtration apparatus, is an independent risk factor for the development of coronary artery disease (CAD). Patients with CKD are at a substantially higher risk of cardiovascular mortality compared with the age- and sex-adjusted general population with normal kidney function. The risk of CAD and mortality in patients with CKD is correlated with the degree of renal dysfunction including presence of microalbuminuria. A greater cardiovascular risk, albeit lower than for patients receiving dialysis, persists even after kidney transplantation. Congestive heart failure, commonly caused by CAD, also accounts for a significant portion of the cardiovascular-related events observed in CKD. The optimal strategy for the evaluation of CAD in patients with CKD, particularly before renal transplantation, remains a topic of contention spanning over several decades. Although the evaluation of coexisting cardiac disease in patients with CKD is desirable, severe renal dysfunction limits the use of radiographic and magnetic resonance contrast agents due to concerns regarding contrast-induced nephropathy and nephrogenic systemic sclerosis, respectively. In addition, many patients with CKD have extensive and premature (often medial) calcification disproportionate to the severity of obstructive CAD, thereby limiting the diagnostic value of computed tomography angiography. As such, echocardiography, non-contrast-enhanced magnetic resonance, nuclear myocardial perfusion, and metabolic imaging offer a variety of approaches to assess obstructive CAD and cardiomyopathy of advanced CKD without the need for nephrotoxic contrast agents.
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Affiliation(s)
- Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA.
| | - Henry Gewirtz
- Department of Medicine (Cardiology Division), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Mouaz H Al-Mallah
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Charles A Herzog
- Department of Medicine (Cardiology Division) and Chronic Disease Research Group, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
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Al-Mallah MH, Aljizeeri A. Finding a gatekeeper to coronary angiography: a step in the right direction. Eur Heart J Cardiovasc Imaging 2017; 18:978-979. [PMID: 28575403 DOI: 10.1093/ehjci/jex100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mouaz H Al-Mallah
- King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard-Health PO Box 22490, Riyadh 11426, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences-Riyadh Ministry of National Guard - Health Affairs, PO Box 22490, Riyadh 11426, Saudi Arabia.,King Abdullah International Medical Research Center-PO Box 22490, Riyadh 11426, Saudi Arabia
| | - Ahmed Aljizeeri
- King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard-Health PO Box 22490, Riyadh 11426, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences-Riyadh Ministry of National Guard - Health Affairs, PO Box 22490, Riyadh 11426, Saudi Arabia.,King Abdullah International Medical Research Center-PO Box 22490, Riyadh 11426, Saudi Arabia
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