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Clinical use of physiological lesion assessment using pressure guidewires: an expert consensus document of the Japanese association of cardiovascular intervention and therapeutics-update 2022. Cardiovasc Interv Ther 2022; 37:425-439. [PMID: 35543896 DOI: 10.1007/s12928-022-00863-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 04/16/2022] [Indexed: 01/10/2023]
Abstract
Fractional flow reserve and instantaneous wave-free ratio are widely accepted and recommended in Western and Japanese guidelines for appropriate percutaneous coronary intervention. There are, however, many differences in clinical situations between Japan and Western countries. Therefore, the Task Force on coronary physiology of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has proposed an expert consensus document to summarize current evidence and suggest the practical use of physiological lesion assessment in Japan.
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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Hokama Y, Tanaka N, Takashima H, Kadota K, Fujita H, Tan M, Yamada R, Naruse H, Kawamura A, Suzuki N, Takeuchi T, Tazaki J, Yamaki M, Takamisawa I, Abe S, Terai H, Makiguchi N, Matsumoto C, Chikamori T. Insufficient recovery of fractional flow reserve even after optimal implantation of drug-eluting stents: 3-year outcomes from the FUJI study. J Cardiol 2021; 77:532-538. [PMID: 33353779 DOI: 10.1016/j.jjcc.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Adequate improvement in fractional flow reserve (FFR) is not necessarily achieved in some cases of drug-eluting stent (DES) implantation, even when imaging confirms successful placement. We hypothesized that post-stent FFR may be associated with advanced diffuse atherosclerotic condition. We explored the relationships between FFR values after DES implantation (post-stent FFR). METHODS A total of 218 patients were included in this prospective, multicenter study and were divided into two groups: adequate FFR group (post-stent FFR >0.80, n=176) and inadequate FFR group (post-stent FFR ≤0.80, n=42). The primary endpoint was a major adverse cardiovascular event (MACE) including cardiac death, non-fatal myocardial infarction (MI), unplanned coronary revascularization, and hospitalization for heart failure. The secondary endpoints were event rate of all-cause death, non-fatal MI, unplanned coronary revascularization, non-fatal stroke, and hospitalization for heart failure. RESULTS During follow-up of 31.4±8.7 months, 34 patients (16%) had cardiovascular events. Inadequate FFR group was significantly associated with higher risk of MACE (hazard ratio: 3.86; 95% confidence interval: 1.17-12.76, p=0.026; log-rank p=0.027). In particular, the incidence of unplanned coronary revascularization on non-target lesions was significantly higher in the inadequate FFR group (log-rank p=0.031). CONCLUSIONS Post-stent FFR ≤0.80 was associated with a high incidence of non-target lesion revascularization and could be a surrogate marker for advanced atherosclerotic condition in the vessels of the entire coronary artery.
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Affiliation(s)
- Yohei Hokama
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0944, Japan.
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0944, Japan
| | | | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hiroshi Fujita
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Michinao Tan
- Department of Cardiology, Tokeidai Memorial Hospital, Sapporo, Japan
| | - Ryotaro Yamada
- Department of Cardiology, Kawasaki Medical University Hospital, Kurashiki, Japan
| | - Hiroyuki Naruse
- Department of Cardiology, Fujita Health University Hospital, Toyoake, Japan
| | - Akio Kawamura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Nobuaki Suzuki
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaru Yamaki
- Department of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan
| | - Itaru Takamisawa
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Shichiro Abe
- Department of Cardiovascular Medicine, Dokkyo Medical University, Tochigi, Japan
| | - Hidenobu Terai
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | | | - Chisa Matsumoto
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
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Hennigan B, Berry C, Collison D, Corcoran D, Eteiba H, Good R, McEntegart M, Watkins S, McClure JD, Mangion K, Ford TJ, Petrie MC, Hood S, Rocchiccioli P, Shaukat A, Lindsay M, Oldroyd KG. Percutaneous coronary intervention versus medical therapy in patients with angina and grey-zone fractional flow reserve values: a randomised clinical trial. Heart 2020; 106:758-764. [PMID: 32114516 PMCID: PMC7229900 DOI: 10.1136/heartjnl-2019-316075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/27/2019] [Accepted: 01/03/2020] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION There is conflicting evidence regarding the benefits of percutaneous coronary intervention (PCI) in patients with grey zone fractional flow reserve (GZFFR artery) values (0.75-0.80). The prevalence of ischaemia is unknown. We wished to define the prevalence of ischaemia in GZFFR artery and assess whether PCI is superior to optimal medical therapy (OMT) for angina control. METHODS We enrolled 104 patients with angina with 1:1 randomisation to PCI or OMT. The artery was interrogated with a Doppler flow/pressure wire. Patients underwent Magnetic Resonance Imaging (MRI) with follow-up at 3 and 12 months. The primary outcome was angina status at 3 months using the Seattle Angina Questionnaire (SAQ). RESULTS 104 patients (age 60±9 years), 79 (76%) males and 79 (76%) Left Anterior Descending (LAD) stenoses were randomised. Coronary physiology and SAQ were similar. Of 98 patients with stress perfusion MRI data, 17 (17%) had abnormal perfusion (≥2 segments with ≥25% ischaemia or ≥1 segment with ≥50% ischaemia) in the target GZFFR artery. Of 89 patients with invasive physiology data, 26 (28%) had coronary flow velocity reserve <2.0 in the target GZFFR artery. After 3 months of follow-up, compared with patients treated with OMT only, patients treated by PCI and OMT had greater improvements in SAQ angina frequency (21 (28) vs 10 (23); p=0.026) and quality of life (24 (26) vs 11 (24); p=0.008) though these differences were no longer significant at 12 months. CONCLUSIONS Non-invasive evidence of major ischaemia is uncommon in patients with GZFFR artery. Compared with OMT alone, patients randomised to undergo PCI reported improved symptoms after 3 months but these differences were no longer significant after 12 months. TRIAL REGISTRATION NUMBER NCT02425969.
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Affiliation(s)
- Barry Hennigan
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom .,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK.,Cardiology Department, The Mater Private Hospital Cork, Cork, Ireland
| | - Colin Berry
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Damien Collison
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - David Corcoran
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Hany Eteiba
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Richard Good
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Margaret McEntegart
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Stuart Watkins
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - John D McClure
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Kenneth Mangion
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Thomas Joseph Ford
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Stuart Hood
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Paul Rocchiccioli
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Aadil Shaukat
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Mitchell Lindsay
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Keith G Oldroyd
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
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Kang DY, Ahn JM, Lee CH, Lee PH, Park DW, Kang SJ, Lee SW, Kim YH, Lee CW, Park SW, Park SJ. Deferred vs. performed revascularization for coronary stenosis with grey-zone fractional flow reserve values: data from the IRIS-FFR registry. Eur Heart J 2019. [PMID: 29529177 DOI: 10.1093/eurheartj/ehy079] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Aims The optimal fractional flow reserve (FFR) cut-off value for revascularization is debated. We evaluated the prognosis for deferred and performed revascularization in coronary stenosis with FFR values in the grey zone (0.75-0.80). Methods and results This study included 1334 native coronary stenosis with grey-zone FFR values in 1334 patients from the prospective multicentre Interventional Cardiology Research In-cooperation Society Fractional Flow Reserve registry. Revascularization was deferred for 683 patients (deferred group) and performed for 651 (performed group). The primary outcome, a composite of death, target-vessel myocardial infarction (MI), and target vessel revascularization (TVR) occurred in 55 (8.1%) patients in the deferred group and 55 (8.4%) in the performed group [adjusted hazard ratio (aHR) 1.05, 95% confidence interval (CI) 0.67-1.66; P = 0.79] during a median follow-up of 2.9 years (interquartile range 1.5-4.1 years). Overall mortality and spontaneous MI did not differ between the groups (mortality 2.5% vs. 2.0%; aHR 0.82, 95% CI 0.34-2.00; P = 0.66; spontaneous MI 0.7% vs. 0.5%; aHR 1.85, 95% CI 0.35-9.75; P = 0.47). Myocardial infarction was significantly higher in the performed group (0.7% vs. 3.2%; aHR 0.27, 95% CI 0.09-0.80; P = 0.02) mainly because of a higher risk of periprocedural MI. Target vessel revascularization was significantly higher in the deferred group (5.7% vs. 3.7%; aHR 2.17, 95% CI 1.17-4.02; P = 0.01). Conclusion For coronary stenosis with grey-zone FFR, revascularization was not associated with better clinical outcomes. The higher likelihood of periprocedural MI with revascularization was offset by the higher likelihood of TVR with deferral. Trial registration Clinicaltrials.gov identifier: NCT01366404.
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Affiliation(s)
- Do-Yoon Kang
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, South Korea
| | - Jung-Min Ahn
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, South Korea
| | - Cheol Hyun Lee
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, South Korea
| | - Pil Hyung Lee
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, South Korea
| | - Duk-Woo Park
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, South Korea
| | - Soo-Jin Kang
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, South Korea
| | - Seung-Whan Lee
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, South Korea
| | - Young-Hak Kim
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, South Korea
| | - Cheol Whan Lee
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, South Korea
| | - Seong-Wook Park
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, South Korea
| | - Seung-Jung Park
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, South Korea
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Andreou C, Zimmermann FM, Tonino PAL, Maniotis C, Koutouzis M, Poulimenos LE, Triantafyllis AS. Optimal Treatment Strategy for Coronary Artery Stenoses with Grey Zone Fractional Flow Reserve Values. A Systematic Review and Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:392-397. [PMID: 31227391 DOI: 10.1016/j.carrev.2019.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/14/2019] [Accepted: 05/17/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES We conducted a review and meta-analysis of published data to compare revascularization to deferral strategy for coronary lesions with grey zone fractional flow reserve (FFR). BACKGROUND Optimal treatment for coronary stenoses with FFR values between 0.75 and 0.80, the so-called grey zone, remains a matter of debate. METHODS We included all studies evaluating revascularization versus deferral for lesions with grey zone FFR. The primary outcome was study-defined major adverse cardiac events (MACE). Secondary outcomes were the composite of death or MI and target vessel revascularization (TVR). A total of 2362 patients were included, of whom 1181 underwent revascularization (revascularization group) and 1181 received medical treatment only (deferral group). RESULTS After a mean follow-up period of 2.4 years, no difference was found for the primary outcome of the study-defined MACE between the two groups [RR = 1.33 (0.73-2.44), p = 0.35]. In addition, there was no difference for the secondary outcomes of death or MI and TVR between the two groups [RR = 1.39 (0.56-3.47), p = 0.48 and RR = 1.49 (0.89-2.51), p = 0.13, respectively]. CONCLUSIONS In this meta-analysis revascularization of coronary stenoses with grey zone FFR showed no advantage over a deferral strategy in terms of study-defined MACE. Case by case judgment should be implemented to guide treatment in this special subset of patients.
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Affiliation(s)
| | | | - Pim A L Tonino
- Heart Center, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | | | - Michalis Koutouzis
- 2nd Department of Cardiology, Hellenic Red Cross Hospital, Athens, Greece
| | | | - Andreas S Triantafyllis
- Heart Center, Catharina Hospital Eindhoven, Eindhoven, the Netherlands; Department of Cardiology, Asklepeion General Hospital, Athens, Greece
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Nishiyama H, Tanabe Y, Kido T, Kurata A, Uetani T, Kido T, Ikeda S, Miyagawa M, Mochizuki T. Incremental diagnostic value of whole-heart dynamic computed tomography perfusion imaging for detecting obstructive coronary artery disease. J Cardiol 2019; 73:425-431. [DOI: 10.1016/j.jjcc.2018.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/19/2018] [Accepted: 10/27/2018] [Indexed: 10/27/2022]
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8
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Kitabata H, Kubo T, Shiono Y, Shimamura K, Ino Y, Tanimoto T, Hayashi Y, Komukai K, Sougawa H, Kimura K, Gohda M, Hashizume T, Obana M, Maeda K, Yamaguchi J, Akasaka T. Comparison of clinical outcomes following percutaneous coronary intervention versus optimal medical therapy based on gray-zone fractional flow reserve in stable angina patients with intermediate coronary artery stenosis (COMFORTABLE prospective study): Study protocol for a multicenter randomized controlled trial. Trials 2019; 20:84. [PMID: 30691507 PMCID: PMC6350281 DOI: 10.1186/s13063-019-3182-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/07/2019] [Indexed: 01/26/2023] Open
Abstract
Background Even in the current drug-eluting stent era, revascularization for coronary stenosis with fractional flow reserve (FFR) between 0.75 and 0.80, the so-called “gray zone,” is a matter of debate. Previous studies have reported conflicting results regarding outcomes of revascularization versus deferral for coronary stenosis when FFR values are in the gray zone, but these studies have had differing designs and populations. We therefore will investigate whether medical therapy plus percutaneous coronary intervention (PCI) is superior to medical therapy alone in reducing major cardiovascular events in patients presenting with coronary stenosis with gray zone FFR values. Methods/design This is a prospective, multicenter, open-label, parallel group, randomized, controlled, superiority study. A total of 410 eligible participants will be recruited and randomized to either the medical therapy plus PCI group or the medical therapy alone group. The primary endpoint is 1-year major adverse cardiac events (MACEs), defined as a combined endpoint of all-cause death, nonfatal myocardial infarction (MI), or unplanned target vessel revascularization (TVR). Secondary endpoints include MACE at 2 and 5 years. Moreover, each individual component of the primary endpoint, cardiovascular death, target vessel-related and non-target vessel-related MI, all MI, clinically driven TVR or non-TVR, all revascularization, stent thrombosis, and angina symptom status will be evaluated at 1, 2, and 5 years. Discussion This is the first prospective, multicenter, randomized, controlled study to investigate the superiority of medical therapy plus PCI over medical therapy by itself in reducing major cardiovascular events in patients presenting with coronary stenosis with “gray zone” FFR values. The results will help interventional cardiologists in making revascularization decisions regarding coronary stenosis with gray zone FFR values. Trial registration University Hospital Medical Information Network Clinical Trials Registry, UMIN000031526. Registered on 1 March 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3182-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hironori Kitabata
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan
| | - Kunihiro Shimamura
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan
| | - Yasushi Ino
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan
| | - Takashi Tanimoto
- Department of Cardiovascular Medicine, Shingu Municipal Medical Center, 18-7 Hachibuse, Shingu, Wakayama, 647-0072, Japan
| | - Yasushi Hayashi
- Department of Cardiovascular Medicine, Wakayama Rosai Hospital, 93-1 Kinomoto, Wakayama, Wakayama, 640-8505, Japan
| | - Kenichi Komukai
- Department of Cardiovascular Medicine, Hidaka General Hospital, 116-2 Sono, Gobo, Wakayama, 644-0002, Japan
| | - Hiromichi Sougawa
- Department of Cardiovascular Medicine, Hashimoto Municipal Hospital, 2-8-1Ominedai, Hashimoto, Wakayama, 648-0005, Japan
| | - Keizo Kimura
- Department of Cardiovascular Medicine, Kinan Hospital, 46-7 Shinjocho, Tanabe, Wakayama, 646-8588, Japan
| | - Masahiro Gohda
- Department of Cardiovascular Medicine, Seiyu Memorial Hospital, 391 Nishitai, Wakayama, 649-6335, Japan
| | - Toshikazu Hashizume
- Department of Cardiovascular Medicine, Minami Wakayama Medical Center, 27-1 Takinaicho, Tanabe, Wakayama, 646-8558, Japan
| | - Masahiro Obana
- Department of Cardiovascular Medicine, Saiseikai Wakayama Hospital, 45 Junibancho, Wakayama, 640-8158, Japan
| | - Kazuisa Maeda
- Department of Cardiovascular Medicine, Naga Municipal Hospital, 1282 Uchita, Kinokawa, 649-6414, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan
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9
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Kawase Y, Matsuo H, Akasaka T, Shiono Y, Tanaka N, Amano T, Kozuma K, Nakamura M, Yokoi H, Kobayashi Y, Ikari Y. Clinical use of physiological lesion assessment using pressure guidewires: an expert consensus document of the Japanese Association of Cardiovascular Intervention and Therapeutics. Cardiovasc Interv Ther 2018; 34:85-96. [PMID: 30588572 DOI: 10.1007/s12928-018-0559-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 01/10/2023]
Abstract
In this document, the background, concept, and current evidence are briefly summarized. The focus is on the clinical application of physiological lesion assessment from a practical standpoint for facilities that do not have ample experience. Finally, the characteristics of new resting indexes are summarized.
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10
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Du Y, Yang B, Zhang J, Liu W, Wang Z, Ji Q, Ma X, Han H, Guo Y, Liu X, Zhao Y, Zhou Y. Optimal Revascularization Threshold of Fractional Flow Reserve and its Effect on Outcomes: Perspectives From a High-Volume Center in China. Angiology 2018; 70:423-430. [PMID: 30343583 DOI: 10.1177/0003319718806394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This study aimed to investigate the favorable revascularization threshold for fractional flow reserve (FFR) in daily practice. Between March 2013 and March 2017 in a high-volume center in China, 903 patients with 1210 lesions underwent coronary intervention with adjunctive FFR and were consecutively enrolled. The mean FFR was 0.80 ± 0.11, revascularization was deferred for 68% of lesions, and the median follow-up period was 21 months. For lesions with an FFR > 0.80, deferral of revascularization appeared safe. In contrast, for lesions with an FFR ≤ 0.80, deferral of revascularization was associated with a greater risk of target lesion failure (TLF) than revascularization (hazard ratio [HR] 4.63, 95% confidence interval [CI] 2.02-10.06, P < .001). For lesions with an FFR value in the gray-zone (0.76-0.80), medical treatment alone was less effective than revascularization ( P = .020). For deferred lesions, FFR was an independent predictor for the future risk of TLF, when data were categorized (HR [FFR ≤ 0.75 vs FFR ≥ 0.86] 3.35, 95% CI 1.13-9.97, P = .030; HR [FFR 0.76-0.80 vs FFR ≥ 0.86] 4.01, 95% CI 1.73-9.31, P = .001) or continuous (HR 0.004, 95% CI 0.00-0.13, P = .002). Thus, an FFR value of 0.80 appears to be the optimal threshold for decision-making regarding revascularization and risk stratification.
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Affiliation(s)
- Yu Du
- 1 Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Bangguo Yang
- 2 Department of Cardiology, Fuwai Yunnan Cardiovascular Hospital, Yunnan, China
| | - Jianwei Zhang
- 1 Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Wei Liu
- 1 Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Zhijian Wang
- 1 Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Qingwei Ji
- 1 Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Xiaoteng Ma
- 1 Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Hongya Han
- 1 Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yonghe Guo
- 1 Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Xiaoli Liu
- 1 Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yingxin Zhao
- 1 Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yujie Zhou
- 1 Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
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11
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Bundhun PK, Gupta C, Huang F. Should fraction flow reserve be considered an important decision-making tool to stratify patients with stable coronary artery disease for percutaneous coronary intervention?: A meta-analysis. Medicine (Baltimore) 2017; 96:e8748. [PMID: 29145326 PMCID: PMC5704871 DOI: 10.1097/md.0000000000008748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Nowadays, fraction flow reserve (FFR) is being discussed in every percutaneous coronary intervention (PCI) capable hospitals. Owing to recent development in the medical field, FFR-guided PCI should be able to find a place in Interventional Cardiology. At present, the importance of FFR to stratify patients who require PCI has seldom systematically been investigated. In this analysis, we aimed to compare the major adverse cardiac events (MACEs) mainly in patients with stable coronary artery disease (CAD) to whom PCI was recommended and deferred respectively based on the FFR value. METHODS Electronic databases were searched for studies comparing FFR-recommended versus FFR-deferred coronary stenting. Long-term MACEs, mortality, and myocardial infarction (MI) were considered as the clinical endpoints in this analysis. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and the analyses were carried out by the latest version of the RevMan software. RESULTS A total number of 1753 patients (670 patients were revascularized, whereas 1083 patients were deferred from revascularization based on the FFR value) were analyzed. Current results showed MACEs and MI were significantly higher in the FFR-recommended PCI group with OR 1.34 (95% CI: 1.05-1.72; P = .02) and OR 1.73 (95% CI: 1.19-2.51; P = .004, I = 0%), respectively. However, mortality was similarly manifested with OR 1.23 (95% CI: 0.92-1.63; P = .16, I = 0%). CONCLUSION Significantly higher MACEs were observed in patients to whom PCI was recommended compared to those patients who were deferred from undergoing PCI based on the FFR values. Therefore, FFR might indeed be an important decision-making procedural tool, which should be used to stratify stable CAD patients with an advanced disease and who are qualified candidates for PCI. Further research should confirm this hypothesis.
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Affiliation(s)
- Pravesh Kumar Bundhun
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University
| | | | - Feng Huang
- Institute of Cardiovascular Diseases and Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P. R. China
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12
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Tanaka N, Pijls NH, Yamashita J, Kimura Y, Ogawa M, Murata N, Sakoda K, Hoshino K, Hokama Y, Yamashina A. Analysis of suboptimal stent deployment using intravascular ultrasound and coronary pressure pullback measurement. J Cardiol 2017; 69:613-618. [DOI: 10.1016/j.jjcc.2016.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 09/05/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
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13
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Won KB, Nam CW, Cho YK, Yoon HJ, Park HS, Kim H, Han S, Hur SH, Kim YN, Park SH, Han JK, Koo BK, Kim HS, Doh JH, Lee SY, Yang HM, Lim HS, Yoon MH, Tahk SJ, Kim KB. Clinical Outcomes in Patients with Deferred Coronary Lesions according to Disease Severity Assessed by Fractional Flow Reserve. J Korean Med Sci 2016; 31:1929-1936. [PMID: 27822931 PMCID: PMC5102856 DOI: 10.3346/jkms.2016.31.12.1929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 09/04/2016] [Indexed: 11/20/2022] Open
Abstract
Data on the clinical outcomes in deferred coronary lesions according to functional severity have been limited. This study evaluated the clinical outcomes of deferred lesions according to fractional flow reserve (FFR) grade using Korean FFR registry data. Among 1,294 patients and 1,628 lesions in Korean FFR registry, 665 patients with 781 deferred lesions were included in this study. All participants were consecutively categorized into 4 groups according to FFR; group 1: ≥ 0.96 (n = 56), group 2: 0.86-0.95 (n = 330), group 3: 0.81-0.85 (n = 170), and group 4: ≤ 0.80 (n = 99). Primary endpoint was major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction, and target vessel revascularization. The median follow-up period was 2.1 years. During follow-up, the incidence of MACE in groups 1-4 was 1.8%, 7.6%, 8.8%, and 13.1%, respectively. Compared to group 1, the cumulative rate by Kaplan-Meier analysis of MACE was not different for groups 2 and 3. However, group 4 had higher cumulative rate of MACE compared to group 1 (log-rank P = 0.013). In the multivariate Cox hazard models, only FFR (hazard ratio [HR], 0.95; P = 0.005) was independently associated with MACE among all participants. In contrast, previous history of percutaneous coronary intervention (HR, 2.37; P = 0.023) and diagnosis of acute coronary syndrome (ACS) (HR, 2.35; P = 0.015), but not FFR, were independent predictors for MACE in subjects with non-ischemic (FFR ≥ 0.81) deferred coronary lesions. Compared to subjects with ischemic deferred lesions, clinical outcomes in subjects with non-ischemic deferred lesions according to functional severity are favorable. However, longer-term follow-up may be necessary.
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Affiliation(s)
- Ki Bum Won
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
- Division of Cardiology, Ulsan University Hospital, Ulsan, Korea
| | - Chang Wook Nam
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea.
| | - Yun Kyeong Cho
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyuck Jun Yoon
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyoung Seob Park
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyungseop Kim
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Seongwook Han
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Seung Ho Hur
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Yoon Nyun Kim
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Sang Hyun Park
- Division of Cardiology, Eulji University Hospital, Daejeon, Korea
| | - Jung Kyu Han
- Division of Cardiology, Seoul National University Hospital, Seoul, Korea
| | - Bon Kwon Koo
- Division of Cardiology, Seoul National University Hospital, Seoul, Korea
| | - Hyo Soo Kim
- Division of Cardiology, Seoul National University Hospital, Seoul, Korea
| | - Joon Hyung Doh
- Division of Cardiology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sung Yun Lee
- Division of Cardiology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hyoung Mo Yang
- Division of Cardiology, Ajou University Medical Center, Suwon, Korea
| | - Hong Seok Lim
- Division of Cardiology, Ajou University Medical Center, Suwon, Korea
| | - Myeong Ho Yoon
- Division of Cardiology, Ajou University Medical Center, Suwon, Korea
| | - Seung Jea Tahk
- Division of Cardiology, Ajou University Medical Center, Suwon, Korea
| | - Kwon Bae Kim
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
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14
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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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15
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Sakoda K, Tanaka N, Hokama Y, Hoshino K, Murata N, Yamashita J, Yamashina A. Association of moderate chronic kidney disease with insufficient improvement of fractional flow reserve after stent implantation. Catheter Cardiovasc Interv 2015; 88:E38-44. [DOI: 10.1002/ccd.26258] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 08/20/2015] [Accepted: 09/16/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Kunihiro Sakoda
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Nobuhiro Tanaka
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Yohei Hokama
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Kou Hoshino
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Naotaka Murata
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Jun Yamashita
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Akira Yamashina
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
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