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Lodi Rizzini M, Candreva A, Mazzi V, Pagnoni M, Chiastra C, Aben JP, Fournier S, Cook S, Muller O, De Bruyne B, Mizukami T, Collet C, Gallo D, Morbiducci U. Blood Flow Energy Identifies Coronary Lesions Culprit of Future Myocardial Infarction. Ann Biomed Eng 2024; 52:226-238. [PMID: 37733110 PMCID: PMC11252236 DOI: 10.1007/s10439-023-03362-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/02/2023] [Indexed: 09/22/2023]
Abstract
The present study establishes a link between blood flow energy transformations in coronary atherosclerotic lesions and clinical outcomes. The predictive capacity for future myocardial infarction (MI) was compared with that of established quantitative coronary angiography (QCA)-derived predictors. Angiography-based computational fluid dynamics (CFD) simulations were performed on 80 human coronary lesions culprit of MI within 5 years and 108 non-culprit lesions for future MI. Blood flow energy transformations were assessed in the converging flow segment of the lesion as ratios of kinetic and rotational energy values (KER and RER, respectively) at the QCA-identified minimum lumen area and proximal lesion sections. The anatomical and functional lesion severity were evaluated with QCA to derive percentage area stenosis (%AS), vessel fractional flow reserve (vFFR), and translesional vFFR (ΔvFFR). Wall shear stress profiles were investigated in terms of topological shear variation index (TSVI). KER and RER predicted MI at 5 years (AUC = 0.73, 95% CI 0.65-0.80, and AUC = 0.76, 95% CI 0.70-0.83, respectively; p < 0.0001 for both). The predictive capacity for future MI of KER and RER was significantly stronger than vFFR (p = 0.0391 and p = 0.0045, respectively). RER predictive capacity was significantly stronger than %AS and ΔvFFR (p = 0.0041 and p = 0.0059, respectively). The predictive capacity for future MI of KER and RER did not differ significantly from TSVI. Blood flow kinetic and rotational energy transformations were significant predictors for MI at 5 years (p < 0.0001). The findings of this study support the hypothesis of a biomechanical contribution to the process of plaque destabilization/rupture leading to MI.
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Affiliation(s)
- Maurizio Lodi Rizzini
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Corso Duca degli Abruzzi 24, 10129, Turin, Italy
| | - Alessandro Candreva
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Corso Duca degli Abruzzi 24, 10129, Turin, Italy
- Department of Cardiology, Zurich University Hospital, Zurich, Switzerland
| | - Valentina Mazzi
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Corso Duca degli Abruzzi 24, 10129, Turin, Italy
| | - Mattia Pagnoni
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Claudio Chiastra
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Corso Duca degli Abruzzi 24, 10129, Turin, Italy
| | | | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Stephane Cook
- Department of Cardiology, HFR Fribourg, Fribourg, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | | | | | - Carlos Collet
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Diego Gallo
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Corso Duca degli Abruzzi 24, 10129, Turin, Italy
| | - Umberto Morbiducci
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Corso Duca degli Abruzzi 24, 10129, Turin, Italy.
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Sharifkazemi M, Hooshanginezhad Z, Zoroufian A, Shamsa K. Is it the Time to Move Towards Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve Guided Percutaneous Coronary Intervention? The Pros and Cons. Curr Cardiol Rev 2023; 19:e190123212887. [PMID: 36658709 PMCID: PMC10494271 DOI: 10.2174/1573403x19666230119115228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/08/2022] [Accepted: 11/21/2022] [Indexed: 01/21/2023] Open
Abstract
Coronary artery disease is the leading cause of mortality worldwide. Diagnosis is conventionally performed by direct visualization of the arteries by invasive coronary angiography (ICA), which has inherent limitations and risks. Measurement of fractional flow reserve (FFR) has been suggested for a more accurate assessment of ischemia in the coronary artery with high accuracy for determining the severity and decision on the necessity of intervention. Nevertheless, invasive coronary angiography-derived fractional flow reserve (ICA-FFR) is currently used in less than one-third of clinical practices because of the invasive nature of ICA and the need for additional equipment and experience, as well as the cost and extra time needed for the procedure. Recent technical advances have moved towards non-invasive high-quality imaging modalities, such as magnetic resonance, single-photon emission computed tomography, and coronary computed tomography (CT) scan; however, none had a definitive modality to confirm hemodynamically significant coronary artery stenosis. Coronary computed tomography angiography (CCTA) can provide accurate anatomic and hemodynamic data about the coronary lesion, especially calculating fractional flow reserve derived from CCTA (CCTA-FFR). Although growing evidence has been published regarding CCTA-FFR results being comparable to ICA-FFR, CCTA-FFR has not yet replaced the invasive conventional angiography, pending additional studies to validate the advantages and disadvantages of each diagnostic method. Furthermore, it has to be identified whether revascularization of a stenotic lesion is plausible based on CCTA-FFR and if the therapeutic plan can be determined safely and accurately without confirmation from invasive methods. Therefore, in the present review, we will outline the pros and cons of using CCTA-FFR vs. ICA-FFR regarding diagnostic accuracy and treatment decision-making.
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Affiliation(s)
| | - Zahra Hooshanginezhad
- Division of Cardiology, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arezou Zoroufian
- Division of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Shamsa
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
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Zhang J, Zhao N, Xu B, Xie L, Yin W, An Y, Yan H, Yu Y, Lu B. Angiographic Lesion Morphology Provides Incremental Value to Generalize Quantitative Flow Ratio for Predicting Myocardial Ischemia. Front Cardiovasc Med 2022; 9:872498. [PMID: 35734275 PMCID: PMC9207314 DOI: 10.3389/fcvm.2022.872498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
AimThe quantitative flow ratio (QFR) is favorable for functional assessment of coronary artery stenosis without pressure wires and induction of hyperemia. The aim of this study was to explore whether angiographic lesion morphology provides incremental value to generalize QFR for predicting myocardial ischemia in unselected patients.MethodsThis study was a substudy to the CT-FFR CHINA trial, referring 345 participants from five centers with suspected coronary artery disease on coronary CT angiography for diagnostic invasive coronary angiography (ICA). Fractional flow reserve (FFR) was measured in all vessels with 30–90% diameter stenosis. QFR was calculated in 186 lesions from 159 participants in a blinded manner. In addition, parameters to characterize lesion features were recorded or measured, including left anterior descending arteries (LADs)-involved lesions, side branch located at stenotic lesion (BL), multiple lesions (ML), minimal lumen diameter (MLD), reference lumen diameter (RLD), percent diameter stenosis (%DS), lesion length (LL), and LL/MLD4. Logistic regression was used to construct two kinds of models by combining single or two lesion parameters with the QFR. The performances of these models were compared with that of QFR on a per-vessel level.ResultsA total of 148 participants (mean age: 59.5 years; 101 men) with 175 coronary arteries were included for final analysis. In total, 81 (46%) vessels were considered hemodynamically significant. QFR correctly classified 82.29% of the vessels using FFR with a cutoff of 0.80 as reference standard. The area under the receiver operating characteristic curve (AUC) of QFR was 0.86 with a sensitivity, specificity, positive predictive value, and negative predictive value of 80.25, 84.04, 81.25, and 83.16%, respectively. The combined models (QFR + LAD + MLD, QFR + LAD + %DS, QFR + BL + MLD, and QFR + BL + %DS) outperformed QFR with higher AUCs (0.91 vs. 0.86, P = 0.02; 0.91 vs. 0.86, P = 0.02; 0.91 vs. 0.86, P = 0.02; 0.90 vs. 0.86, P = 0.03, respectively). Compared with QFR, the sensitivity of the combined models (QFR + BL and QFR + MLD) was improved (91.36 vs. 80.25%, 91.36 vs. 80.25%, respectively, both P < 0.05) without compromised specificity or accuracy.ConclusionCombined with angiographic lesion parameters, QFR can be optimized for predicting myocardial ischemia in unselected patients.
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Affiliation(s)
- Jie Zhang
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Na Zhao
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihua Xie
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weihua Yin
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunqiang An
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hankun Yan
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yitong Yu
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Lu
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Bin Lu,
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Ding D, Huang J, Westra J, Cohen DJ, Chen Y, Andersen BK, Holm NR, Xu B, Tu S, Wijns W. Immediate post-procedural functional assessment of percutaneous coronary intervention: current evidence and future directions. Eur Heart J 2021; 42:2695-2707. [PMID: 33822922 DOI: 10.1093/eurheartj/ehab186] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/17/2021] [Accepted: 03/11/2021] [Indexed: 01/10/2023] Open
Abstract
Percutaneous coronary intervention (PCI) guided by coronary physiology provides symptomatic benefit and improves patient outcomes. Nevertheless, over one-fourth of patients still experience recurrent angina or major adverse cardiac events following the index procedure. Coronary angiography, the current workhorse for evaluating PCI efficacy, has limited ability to identify suboptimal PCI results. Accumulating evidence supports the usefulness of immediate post-procedural functional assessment. This review discusses the incidence and possible mechanisms behind a suboptimal physiology immediately after PCI. Furthermore, we summarize the current evidence base supporting the usefulness of immediate post-PCI functional assessment for evaluating PCI effectiveness, guiding PCI optimization, and predicting clinical outcomes. Multiple observational studies and post hoc analyses of datasets from randomized trials demonstrated that higher post-PCI functional results are associated with better clinical outcomes as well as a reduced rate of residual angina and repeat revascularization. As such, post-PCI functional assessment is anticipated to impact patient management, secondary prevention, and resource utilization. Pre-PCI physiological guidance has been shown to improve clinical outcomes and reduce health care costs. Whether similar benefits can be achieved using post-PCI physiological assessment requires evaluation in randomized clinical outcome trials.
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Affiliation(s)
- Daixin Ding
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, University Road, Galway H91 TK3, Ireland.,Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, No. 1954 Hua Shan Road, Xuhui District, Shanghai 200030, China
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, University Road, Galway H91 TK3, Ireland.,Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, No. 1954 Hua Shan Road, Xuhui District, Shanghai 200030, China
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - David Joel Cohen
- St. Francis Hospital, Roslyn NY and Cardiovascular Research Foundation, 100 Port Washington Blvd (Middle Neck Road), New York, NY 11576, USA
| | - Yundai Chen
- Department of Cardiology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing 100853, China
| | | | - Niels Ramsing Holm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Bo Xu
- Catheterization Laboratories, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, A 167, Beilishi Road, Xicheng District, Beijing 100037, China
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, No. 1954 Hua Shan Road, Xuhui District, Shanghai 200030, China.,Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou, Fujian 350001, China
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, University Road, Galway H91 TK3, Ireland
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Shahinian JH, Chong AY, Glineur D. Cutting-Edge Coronary Imaging Guiding CABG. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:218-222. [PMID: 33877923 PMCID: PMC8609503 DOI: 10.1177/15569845211008162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Jasmin H. Shahinian
- Department of Cardiac Surgery, University of Ottawa Heart Institute, Canada
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Aun Yeong Chong
- Department of Cardiology, University of Ottawa Heart Institute, Canada
| | - David Glineur
- Department of Cardiac Surgery, University of Ottawa Heart Institute, Canada
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A Computational Analysis of the Influence of a Pressure Wire in Evaluating Coronary Stenosis. FLUIDS 2021. [DOI: 10.3390/fluids6040165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiovascular disease is one of the world’s leading causes of morbidity and mortality. Fractional flow reserve (FFR) was proposed in the 1990s to more accurately evaluate the functional severity of intermediate coronary stenosis, and it is currently the gold standard in cardiac catheterization laboratories where coronary pressure and flow are routinely obtained. The clinical measurement of FFR relies on a pressure wire for the recording of pressures; however, in computational fluid dynamics studies, an FFR is frequently predicted using a wire-absent model. We aim to investigate the influence of the physical presence of a 0.014-inch (≈0.36 mm) pressure wire in the calculation of virtual FFR. Ideal and patient-specific models were simulated with the absence and presence of a pressure wire. The computed FFR reduced from 0.96 to 0.93 after inserting a wire in a 3-mm non-stenosed (pipe) ideal model. In mild stenotic cases, the difference in FFR between the wire-absent and wire-included models was slight. The overestimation in severe case was large but is of less clinical significance because, in practice, this tight lesion does not require sophisticated measurement to be considered critical. However, an absence of the pressure wire in simulations could contribute to an over-evaluation for an intermediate coronary stenosis.
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Impact of aging on the effects of intracoronary adenosine, peak hyperemia and its duration during fractional flow reserve assessment. Coron Artery Dis 2021; 32:625-631. [PMID: 33471468 DOI: 10.1097/mca.0000000000001019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Functional assessment of coronary stenoses is crucial for determining the correct therapeutic strategy. Age-related modifications in cardiovascular function could alter the functional significance of an intermediate coronary lesion. Therefore, the aim of the present study was to investigate the impact of age on fractional flow reserve (FFR) measurements in patients with intermediate coronary artery disease. METHODS We included patients undergoing coronary angiography at our Division of Cardiology from June 2008 to February 2019 for elective indication or recent acute coronary syndrome and receiving FFR assessment for an intermediate coronary stenosis (angiographic 40-70% stenoses). FFR measurement was performed by pressure-recording guidewire (Prime Wire; Volcano Imaging System Philips Healthcare, San Diego, California, USA), after induction of hyperemia with intracoronary boluses of adenosine (from 60 to 720 μg, with dose doubling at each step). RESULTS We included in our study 276 patients, undergoing FFR evaluation on 314 lesions, that were divided according to age (< or ≥70 years). Elderly patients displayed a higher cardiovascular risk profile and received more often specific therapy. We found significantly higher FFR values and lower Delta FFR and time to recovery in patients with age ≥70 years old even with high-dose adenosine. Elderly patients showed a trend in lower percentage of positive FFRs, especially with high-dose (P = 0.09). Overall, any FFR ≤ 0.80 was observed in 33.5% of younger patients and 21.1% of patients ≥70 years (P = 0.02). Results were confirmed after correction for baseline differences [adjusted odds ratio (95% confidence interval) = 0.60 (0.33-1.09), P = 0.08]. CONCLUSION This is one of the first studies investigating the impact of age on the measurement of FFR with high-dose adenosine. Patients with age >70 years old with intermediate CAD are more likely to have higher FFR values and lower duration of hyperemia after adenosine boluses, as compared with younger patients.
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Johnson DT, Fournier S, Kirkeeide RL, De Bruyne B, Gould KL, Johnson NP. Phasic pressure measurements for coronary and valvular interventions using fluid-filled catheters: Errors, automated correction, and clinical implications. Catheter Cardiovasc Interv 2020; 96:E268-E277. [PMID: 32077561 PMCID: PMC7539962 DOI: 10.1002/ccd.28780] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/13/2019] [Accepted: 02/07/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We sought to develop an automatic method for correcting common errors in phasic pressure tracings for physiology-guided interventions on coronary and valvular stenosis. BACKGROUND Effective coronary and valvular interventions rely on accurate hemodynamic assessment. Phasic (subcycle) indexes remain intrinsic to valvular stenosis and are emerging for coronary stenosis. Errors, corrections, and clinical implications of fluid-filled catheter phasic pressure assessments have not been assessed in the current era of ubiquitous, high-fidelity pressure wire sensors. METHODS We recruited patients undergoing invasive coronary physiology assessment. Phasic aortic pressure signals were recorded simultaneously using a fluid-filled guide catheter and 0.014″ pressure wire before and after standard calibration as well as after pullback. We included additional subjects undergoing hemodynamic assessment before and after transcatheter aortic valve implantation. Using the pressure wire as reference standard, we developed an automatic algorithm to match phasic pressures. RESULTS Removing pressure offset and temporal shift produced the largest improvements in root mean square (RMS) error between catheter and pressure wire signals. However, further optimization <1 mmHg RMS error was possible by accounting for differential gain and the oscillatory behavior of the fluid-filled guide. The impact of correction was larger for subcycle (like systole or diastole) versus whole-cycle metrics, indicating a key role for valvular stenosis and emerging coronary pressure ratios. CONCLUSIONS When calibrating phasic aortic pressure signals using a pressure wire, correction requires these parameters: offset, timing, gain, and oscillations (frequency and damping factor). Automatically eliminating common errors may improve some clinical decisions regarding physiology-based intervention.
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Affiliation(s)
- Daniel T. Johnson
- Weatherhead PET Center, Division of Cardiology, Department of MedicineMcGovern Medical School at UTHealth and Memorial Hermann HospitalHoustonTexas
| | - Stephane Fournier
- Department of CardiologyCardiovascular Center Aalst OLV HospitalAalstBelgium
- Department of CardiologyLausanne University Center HospitalSwitzerland
| | - Richard L. Kirkeeide
- Weatherhead PET Center, Division of Cardiology, Department of MedicineMcGovern Medical School at UTHealth and Memorial Hermann HospitalHoustonTexas
| | - Bernard De Bruyne
- Department of CardiologyCardiovascular Center Aalst OLV HospitalAalstBelgium
| | - K. Lance Gould
- Weatherhead PET Center, Division of Cardiology, Department of MedicineMcGovern Medical School at UTHealth and Memorial Hermann HospitalHoustonTexas
| | - Nils P. Johnson
- Weatherhead PET Center, Division of Cardiology, Department of MedicineMcGovern Medical School at UTHealth and Memorial Hermann HospitalHoustonTexas
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Witberg G, De Bruyne B, Fearon WF, Achenbach S, Engstrom T, Matsuo H, Kornowski R. Diagnostic Performance of Angiogram-Derived Fractional Flow Reserve. JACC Cardiovasc Interv 2020; 13:488-497. [DOI: 10.1016/j.jcin.2019.10.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/15/2019] [Accepted: 10/22/2019] [Indexed: 11/16/2022]
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10
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[Coronary physiology in the catheter laboratory]. Herz 2020; 46:15-23. [PMID: 31938804 DOI: 10.1007/s00059-019-04878-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 11/21/2019] [Accepted: 12/06/2019] [Indexed: 01/10/2023]
Abstract
The regulation of coronary flow is mainly located in the resistance vessels of the microcirculation, so that the functional relevance of a coronary stenosis arises from the interaction between the epicardial stenosis and the downstream microcirculation. These complex interactions are precisely detectable by physiological measurements, such as the instantaneous wave-free ratio (iwFR) or the fractional flow reserve (FFR). In contrast, the purely visual assessment of the coronary anatomy could lead to misinterpretation and possibly to incorrect revascularization decisions. Consequently, in the current guidelines on myocardial revascularization of the European Society of Cardiology (ESC) the measurement of iwFR and FFR has a class IA indication in intermediate stenoses with unclear hemodynamic relevance. Despite this clear recommendation, physiological measurements are not yet regularly used in the clinical routine. Besides the purely hemodynamic assessment, novel methods such as co-registration and coronary mapping can be used for virtual planning of percutaneous coronary interventions, especially in vessels with diffuse lesions and serial stenoses. Furthermore, invasive flow measurements are also helpful for risk stratification between conservative and interventional treatment of patients with acute coronary syndrome, where additional factors of flow limitation, such as coronary spasm, thrombus and acute disturbance of the microcirculation play an important role.
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Andell P, Berntorp K, Christiansen EH, Gudmundsdottir IJ, Sandhall L, Venetsanos D, Erlinge D, Fröbert O, Koul S, Reitan C, Götberg M. Reclassification of Treatment Strategy With Instantaneous Wave-Free Ratio and Fractional Flow Reserve: A Substudy From the iFR-SWEDEHEART Trial. JACC Cardiovasc Interv 2019; 11:2084-2094. [PMID: 30336812 DOI: 10.1016/j.jcin.2018.07.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/16/2018] [Accepted: 07/24/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The authors sought to compare reclassification of treatment strategy following instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR). BACKGROUND iFR was noninferior to FFR in 2 large randomized controlled trials in guiding coronary revascularization. Reclassification of treatment strategy by FFR is well-studied, but similar reports on iFR are lacking. METHODS The iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome Trial) study randomized 2,037 participants with stable angina or acute coronary syndrome to treatment guided by iFR or FFR. Interventionalists entered the preferred treatment (optimal medical therapy [OMT], percutaneous coronary intervention [PCI], or coronary artery bypass grafting [CABG]) on the basis of coronary angiograms, and the final treatment decision was mandated by the iFR/FFR measurements. RESULTS In the iFR/FFR (n = 1,009/n = 1,004) populations, angiogram-based treatment approaches were similar (p = 0.50) with respect to OMT (38%/35%), PCI of 1 (37%/39%), 2 (15%/16%), and 3 vessels (2%/2%) and CABG (8%/8%). iFR and FFR reclassified 40% and 41% of patients, respectively (p = 0.78). The majority of reclassifications were conversion of PCI to OMT in both the iFR/FFR groups (31.4%/29.0%). Reclassification increased with increasing number of lesions evaluated (odds ratio per evaluated lesion for FFR: 1.46 [95% confidence interval: 1.22 to 1.76] vs. iFR 1.37 [95% confidence interval: 1.18 to 1.59]). Reclassification rates for patients with 1, 2, and 3 assessed vessels were 36%, 52%, and 53% (p < 0.01). CONCLUSIONS Reclassification of treatment strategy of intermediate lesions was common and occurred in 40% of patients with iFR or FFR. The most frequent reclassification was conversion from PCI to OMT regardless of physiology modality. Irrespective of the physiological index reclassification of angiogram-based treatment strategy increased with the number of lesions evaluated.
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Affiliation(s)
- Pontus Andell
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden.
| | - Karolina Berntorp
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | | | | | - Lennart Sandhall
- Departments of Cardiology and Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Dimitrios Venetsanos
- Departments of Cardiology and of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Christian Reitan
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
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Beygui F, Lemaître A, Bignon M, Wain‐Hobson J, Briet C, Ardouin P, Sabatier R, Parienti J, Blanchart K, Roule V. A head‐to‐head comparison of three coronary fractional flow reserve measurement technologies: The fractional flow reserve‐device study. Catheter Cardiovasc Interv 2019; 95:1094-1101. [DOI: 10.1002/ccd.28433] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/21/2019] [Accepted: 07/27/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Farzin Beygui
- Caen University Hospital Caen France
- EA4650, Normandie Université Caen France
- ACTION Academic Research GroupPitié‐Salpêtrière University Hospital Paris France
| | | | | | | | | | | | | | | | | | - Vincent Roule
- Caen University Hospital Caen France
- EA4650, Normandie Université Caen France
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13
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Gaede L, Möllmann H, Rudolph T, Rieber J, Boenner F, Tröbs M. Coronary Angiography With Pressure Wire and Fractional Flow Reserve. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:205-211. [PMID: 31056086 DOI: 10.3238/arztebl.2019.0205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 09/20/2018] [Accepted: 02/04/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Approximately 800 000 coronary angiography procedures are per- formed in Germany each year, mainly in order to identify coronary artery stenoses. As a rule, revascularization is indicated only when coronary artery stenoses cause relevant ischemia, but this cannot be determined unequivocally by angiography alone. Pressure wire measurement and the measurement of fractional flow reserve (FFR) enable direct evaluation of the hemodynamic relevance of coronary artery stenoses during diagnostic coronary angiography. METHODS This review is based on publications retrieved by a selective search in PubMed focusing especially on large randomized trials, registry studies, and meta- analyses on either pressure wire measurement or FFR. RESULTS According to a registry study from France, the hemodynamic evaluation of a stenosis during coronary angiography affected decisions about revascularization in 43% of cases. Randomized multicenter trials have shown that a combined end- point consisting of death, myocardial infarction, or revascularization arose signifi- cantly less commonly in the FFR group than in the group receiving angiography without FFR (13.2% versus 18.3%; p = 0.02), and that patients with one or more hemodynamically significant coronary artery stenoses (FFR ≤ 0.80) benefited more from revascularization than from medical management alone (event rate, 8.1% versus 19.5%; p <0.001). It was also shown that revascularization yields no benefit if relevant ischemia has been ruled out, even if the angiogram shows high-grade coronary artery stenoses. CONCLUSION All cardiac catheter laboratories should be capable of performing pres- sure wire measurements and measurements of FFR and should do so regularly if ischemia due to coronary artery stenosis cannot be demonstrated non-invasively. A pathological FFR measurement is an indication for revascularization.
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Affiliation(s)
- Luise Gaede
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany; Department of Medicine I, St.-Johannes Hospital, Dortmund, Germany; Heart and Diabetes Center North Rhine-Westphalia, Department of Cardiology, Bad Oeynhausen, Germany; Department of Medicine I, Ludwig Maximilians University Munich, and Cardiology Practice, Munich, Germany; Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, Germany
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14
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Omori H, Witberg G, Kawase Y, Tanigaki T, Okamoto S, Hirata T, Sobue Y, Ota H, Kamiya H, Okubo M, Valzer O, Kornowski R, Matsuo H. Angiogram based fractional flow reserve in patients with dual/triple vessel coronary artery disease. Int J Cardiol 2019; 283:17-22. [PMID: 30819589 DOI: 10.1016/j.ijcard.2019.01.072] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 12/06/2018] [Accepted: 01/21/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To assess the performance of angiography derived Fractional Flow Reserve (FFRangio) in multivessel disease (MVD) patients undergoing angiography. BACKGROUND FFR is the reference standard for physiologic assessment of coronary stenosis and guidance of revascularization, especially in patients with MVD, yet it remains grossly underutilized. The non-wire based FFRangio performs well in non-MVD patients, but its accuracy in MVD is unknown. METHODS A prospective clinical study was conducted at Gifu Heart Centre, Japan. Patients underwent physiologic assessment of all relevant coronary lesions using wire-based FFR (wbFFR) and FFRangio. Primary outcome was diagnostic performance (sensitivity, specificity, accuracy) for FFRangio with wbFFR as reference. Other outcomes were the correlation between wbFFR/FFRangio, time required for wbFFR/FFRangio measurements, and the effect of wbFFR/FFRangio on the reclassification of coronary disease severity. RESULTS Fifty patients (118 lesions in total) were included. Mean age was 72 ± 9 years, 72% were male, 36% had triple vessel disease and the average SYNTAX score was 13. The mean measurement of wbFFR and FFRangio were 0.83 ± 0.12 and 0.81 ± 0.11, respectively. Accuracy, sensitivity and specificity for FFRangio were 92.3% (95% CI 79.1-98.4%), 92.4% (95% CI 84.3-97.2%) and 92.4% (95% CI 87.4-97.3%), respectively. Pearson's r between wbFFR and FFRangio was 0.83. FFRangio measurement was faster than wbFFR (9.6 ± 3.4 vs. 15.0 ± 8.9 min, p < 0.001). CONCLUSIONS In patients with MVD, FFRangio shows good correlation and excellent diagnostic performance compared to wbFFR, and measuring FFRangio is faster than wbFFR. These results highlight the potential clinical benefits of utilizing FFRangio among patients with MVD.
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Affiliation(s)
- H Omori
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - G Witberg
- Department of Cardiology, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Y Kawase
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - T Tanigaki
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - S Okamoto
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - T Hirata
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Y Sobue
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - H Ota
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - H Kamiya
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - M Okubo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - O Valzer
- Department of Cardiology, Rabin Medical Center, Petah-Tikva, Israel; CathWorks, Kfar-Saba, Israel
| | - R Kornowski
- Department of Cardiology, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - H Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
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Minamisawa M, Koyama J, Kozuka A, Miura T, Saigusa T, Ebisawa S, Motoki H, Okada A, Ikeda U, Kuwahara K. Duration of myocardial early systolic lengthening for diagnosis of coronary artery disease. Open Heart 2018; 5:e000896. [PMID: 30613412 PMCID: PMC6307609 DOI: 10.1136/openhrt-2018-000896] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 10/12/2018] [Accepted: 11/10/2018] [Indexed: 11/03/2022] Open
Abstract
Objective Myocardial early systolic lengthening (ESL) duration is prolonged in patients with coronary artery disease (CAD). However, the relationship between the fractional flow reserve (FFR), the current gold standard for evaluating physiological myocardial ischaemia, and ESL has not been studied. The aims of this study were to investigate whether left ventricular (LV) ESL duration could identify patients with CAD, and to examine the relationship between FFR and LV ESL duration. Methods In this single-centre, cross-sectional, prospective study of 75 patients with suspected or known CAD, we performed two-dimensional speckle tracking echocardiography at rest on the day before coronary angiography or percutaneous coronary intervention. Apical 3 views were used to examine ESL duration, defined as time from onset of the Q wave to maximum myocardial systolic lengthening. Results Thirty-five patients had non-significant stenosis. Forty patients with CAD underwent FFR testing: 17 had an FFR≥0.8 and 23 had an FFR<0.8. Global ESL duration was 20.9±22.2 ms in patients with non-significant stenosis, 36.4±23.2 ms in patients with FFR≥0.8 and 39.6±29.5 ms in patients with FFR<0.8 (p=0.020). However, global and regional ESL durations were not significantly correlated with FFR and demonstrated poor reproducibility. Conclusion Although myocardial ESL duration was significantly prolonged in patients with CAD compared with patients without CAD, ESL at rest showed poor reproducibility, and this new parameter did not predict FFR in patients with suspected CAD.
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Affiliation(s)
- Masatoshi Minamisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Jun Koyama
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ayako Kozuka
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takashi Miura
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tatsuya Saigusa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Soichiro Ebisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ayako Okada
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Uichi Ikeda
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
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16
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Verdoia M, Erbetta R, Sagazio E, Barbieri L, Negro F, Suryapranata H, Kedhi E, De Luca G. Impact of increasing dose of intracoronary adenosine on peak hyperemia duration during fractional flow reserve assessment. Int J Cardiol 2018; 284:16-21. [PMID: 30293665 DOI: 10.1016/j.ijcard.2018.09.088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 07/30/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Fractional Flow Reserve (FFR) is currently indicated as a first line strategy for the functional assessment of intermediate coronary stenoses. However, the protocol for inducing hyperemia still lacks standardization. Intracoronary adenosine boli, with a progressive increase to high-dosage, have been proposed as a sensitive and accurate strategy for the classification of coronary stenoses, although being potentially affected by the achievement of plateau of the effect and by a less prolonged and stable hyperemia as compared to intravenous administration. Therefore, the aim of the present study was to define the conditioning parameters and assess the impact of increasing-dose intracoronary adenosine on peak hyperemia duration in patients undergoing FFR for intermediate coronary stenoses. METHODS FFR was assessed in patients with intermediate (40 to 70%) lesions by pressure-recording guidewire (Prime Wire, Volcano), after induction of hyperemia with intracoronary boli of adenosine (from 60 to 1440 μg, with dose doubling at each step). Hyperemic duration was defined as the time for the variation form minimum FFR ± 0.02 and time to recovery till baseline values. RESULTS We included 87 patients, undergoing FFR evaluation of 101 lesions. Mean peak hyperemia duration and time to recovery significantly increased with adenosine doses escalation (p = 0.02 and p < 0.001). Peak hyperemia duration and time to recovery with 1440 μg adenosine were 14.5 ± 12.6 s and 45.2 ± 30.7 s, respectively. Hyperemia duration was not related to Quantitative Coronary Angiography (QCA) parameters or FFR values. In fact, a similar increase in the time of hyperemic peak was noted when comparing patients with positive or negative FFR (pbetween = 0.87) or patients with lesions < or ≥20 mm (pbetween = 0.92) and lesions involving left main coronary or proximal left anterior descending artery (LAD) (pbetween = 0.07). A linear relationship was observed between time to recovery and FFR variations, with a greater time to baseline required in patients with FFR ≤ 0.80 (p = 0.003) and in lesions ≥ 20 mm (p = 0.006), but not in LAD/LM lesions (p = 0.55). CONCLUSIONS The present study shows a progressive raise in the duration of peak hyperemia and time to recovery, after the administration of increasing doses of intracoronary adenosine for the assessment of FFR. Therefore, considering the potential advantages of a high-dose adenosine protocol, allowing a more prolonged hyperemia and a more precise and reliable measurement of FFR, further larger studies with such FFR strategy should certainly be advocated to confirm its safety and benefits, before its routinely use recommendation.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Riccardo Erbetta
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Emanuele Sagazio
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Lucia Barbieri
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; ASST Santi Paolo e Carlo, Milano, Italy
| | - Federica Negro
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | | | - Elvin Kedhi
- Division of Cardiology, ISALA Hospital, Zwolle, the Netherlands
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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17
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Murthy VL, Bateman TM, Beanlands RS, Berman DS, Borges-Neto S, Chareonthaitawee P, Cerqueira MD, deKemp RA, DePuey EG, Dilsizian V, Dorbala S, Ficaro EP, Garcia EV, Gewirtz H, Heller GV, Lewin HC, Malhotra S, Mann A, Ruddy TD, Schindler TH, Schwartz RG, Slomka PJ, Soman P, Di Carli MF, Einstein A, Russell R, Corbett JR. Clinical Quantification of Myocardial Blood Flow Using PET: Joint Position Paper of the SNMMI Cardiovascular Council and the ASNC. J Nucl Cardiol 2018; 25:269-297. [PMID: 29243073 DOI: 10.1007/s12350-017-1110-x] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Venkatesh L Murthy
- Frankel Cardiovascular Center, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | | | - Rob S Beanlands
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Daniel S Berman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Salvador Borges-Neto
- Division of Nuclear Medicine, Department of Radiology, and Division of Cardiology, Department of Medicine, Duke University School of Medicine, Duke University Health System, Durham, NC, USA
| | | | | | - Robert A deKemp
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - E Gordon DePuey
- Division of Nuclear Medicine, Department of Radiology, Mt. Sinai St. Luke's and Mt. Sinai West Hospitals, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward P Ficaro
- Division of Nuclear Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Henry Gewirtz
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Gary V Heller
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
| | | | - Saurabh Malhotra
- Division of Cardiovascular Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | | | - Terrence D Ruddy
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Thomas H Schindler
- Division of Nuclear Medicine, Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ronald G Schwartz
- Cardiology Division, Department of Medicine, and Nuclear Medicine Division, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Piotr J Slomka
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Prem Soman
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew Einstein
- Division of Cardiology, Department of Medicine, and Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Raymond Russell
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - James R Corbett
- Frankel Cardiovascular Center, Division of Cardiovascular Medicine, Department of Internal Medicine, and Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
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18
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Motwani M, Motlagh M, Gupta A, Berman DS, Slomka PJ. Reasons and implications of agreements and disagreements between coronary flow reserve, fractional flow reserve, and myocardial perfusion imaging. J Nucl Cardiol 2018; 25:104-119. [PMID: 26715599 DOI: 10.1007/s12350-015-0375-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 12/02/2015] [Indexed: 01/10/2023]
Abstract
Information on coronary physiology and myocardial blood flow (MBF) in patients with suspected angina is increasingly important to inform treatment decisions. A number of different techniques including myocardial perfusion imaging (MPI), noninvasive estimation of MBF, and coronary flow reserve (CFR), as well as invasive methods for CFR and fractional flow reserve (FFR) are now readily available. However, despite their incorporation into contemporary guidelines, these techniques are still poorly understood and their interpretation to guide revascularization decisions is often inconsistent. In particular, these inconsistencies arise when there are discrepancies between the various techniques. The purpose of this article is therefore to review the basic principles, techniques, and clinical value of MPI, FFR, and CFR-with particular focus on interpreting their agreements and disagreements.
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Affiliation(s)
- Manish Motwani
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mahsaw Motlagh
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anuj Gupta
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr J Slomka
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Hirose K, Chikamori T, Hida S, Tanaka N, Yamashita J, Igarashi Y, Saitoh T, Tanaka H, Yamashina A. Application of pressure-derived myocardial fractional flow reserve in chronic hemodialysis patients. J Cardiol 2018; 71:52-58. [DOI: 10.1016/j.jjcc.2017.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 05/19/2017] [Accepted: 05/26/2017] [Indexed: 01/25/2023]
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20
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Murthy VL, Bateman TM, Beanlands RS, Berman DS, Borges-Neto S, Chareonthaitawee P, Cerqueira MD, deKemp RA, DePuey EG, Dilsizian V, Dorbala S, Ficaro EP, Garcia EV, Gewirtz H, Heller GV, Lewin HC, Malhotra S, Mann A, Ruddy TD, Schindler TH, Schwartz RG, Slomka PJ, Soman P, Di Carli MF. Clinical Quantification of Myocardial Blood Flow Using PET: Joint Position Paper of the SNMMI Cardiovascular Council and the ASNC. J Nucl Med 2017; 59:273-293. [PMID: 29242396 DOI: 10.2967/jnumed.117.201368] [Citation(s) in RCA: 147] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 09/11/2017] [Indexed: 12/30/2022] Open
Affiliation(s)
- Venkatesh L Murthy
- Frankel Cardiovascular Center, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Rob S Beanlands
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Daniel S Berman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Salvador Borges-Neto
- Division of Nuclear Medicine, Department of Radiology, and Division of Cardiology, Department of Medicine, Duke University School of Medicine, Duke University Health System, Durham, North Carolina
| | | | | | - Robert A deKemp
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - E Gordon DePuey
- Division of Nuclear Medicine, Department of Radiology, Mt. Sinai St. Luke's and Mt. Sinai West Hospitals, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Edward P Ficaro
- Division of Nuclear Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Henry Gewirtz
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gary V Heller
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
| | | | - Saurabh Malhotra
- Division of Cardiovascular Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - April Mann
- Hartford Hospital, Hartford, Connecticut
| | - Terrence D Ruddy
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thomas H Schindler
- Division of Nuclear Medicine, Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ronald G Schwartz
- Cardiology Division, Department of Medicine, and Nuclear Medicine Division, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York; and
| | - Piotr J Slomka
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Prem Soman
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Boston, Massachusetts
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Liu X, Peng C, Xia Y, Gao Z, Xu P, Wang X, Xian Z, Yin Y, Jiao L, Wang D, Shi L, Huang W, Liu X, Zhang H. Hemodynamics analysis of the serial stenotic coronary arteries. Biomed Eng Online 2017; 16:127. [PMID: 29121932 PMCID: PMC5679505 DOI: 10.1186/s12938-017-0413-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 10/11/2017] [Indexed: 11/25/2022] Open
Abstract
Coronary arterial stenoses, particularly serial stenoses in a single branch, are responsible for complex hemodynamic properties of the coronary arterial trees, and the uncertain prognosis of invasive intervention. Critical information of the blood flow redistribution in the stenotic arterial segments is required for the adequate treatment planning. Therefore, in this study, an image based non-invasive functional assessment is performed to investigate the hemodynamic significances of serial stenoses. Twenty patient-specific coronary arterial trees with different combinations of stenoses were reconstructed from the computer tomography angiography for the evaluation of the hemodynamics. Our results showed that the computed FFR based on CTA images (FFRCT) pullback curves with wall shear stress (WSS) distribution could provide more effectively examine the physiological significance of the locations of the segmental narrowing and the curvature of the coronary arterial segments. The paper thus provides the diagnostic efficacy of FFRCT pullback curve for noninvasive quantification of the hemodynamics of stenotic coronary arteries with serial lesions, compared to the gold standard invasive FFR, to provide a reliable physiological assessment of significant amount of coronary artery stenosis. Further, we were also able to demonstrate the potential of carrying out virtual revascularization, to enable more precise PCI procedures and improve their outcomes.
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Affiliation(s)
- Xin Liu
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Science, Southern Medical University, 1023-1063 Shatai South Road, Baiyun, Guangzhou, 510515 Guangdong China
| | - Changnong Peng
- Department of Cardiology, Shenzhen Sun Yat-Sen Cardiovascular Hospital, Shenzhen, 518055 China
| | - Yufa Xia
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
| | - Zhifan Gao
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
- Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences, Shenzhen, 518055 China
| | - Pengcheng Xu
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Science, Southern Medical University, 1023-1063 Shatai South Road, Baiyun, Guangzhou, 510515 Guangdong China
| | - Xiaoqing Wang
- Department of Cardiology, Shenzhen Sun Yat-Sen Cardiovascular Hospital, Shenzhen, 518055 China
| | - Zhanchao Xian
- Department of Cardiology, Shenzhen Sun Yat-Sen Cardiovascular Hospital, Shenzhen, 518055 China
| | - Youbing Yin
- Shenzhen Keya Medical Technology, Shenzhen, China
| | - Liqun Jiao
- Xuanwu Hospital, Capital University of Medical Sciences, Beijing, China
| | - Defeng Wang
- Department of Imaging and Interventional Radiology, Prince Of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Lin Shi
- Department of Imaging and Interventional Radiology, Prince Of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Wenhua Huang
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Science, Southern Medical University, 1023-1063 Shatai South Road, Baiyun, Guangzhou, 510515 Guangdong China
| | - Xin Liu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
| | - Heye Zhang
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
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22
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Coronary CT-Derived Fractional Flow Reserve. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0234-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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23
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Pellicano M, Lavi I, De Bruyne B, Vaknin-Assa H, Assali A, Valtzer O, Lotringer Y, Weisz G, Almagor Y, Xaplanteris P, Kirtane AJ, Codner P, Leon MB, Kornowski R. Validation Study of Image-Based Fractional Flow Reserve During Coronary Angiography. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.005259. [DOI: 10.1161/circinterventions.116.005259] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 07/17/2017] [Indexed: 11/16/2022]
Abstract
Background—
Fractional flow reserve (FFR), an index of the hemodynamic severity of coronary stenoses, is derived from invasive measurements and requires a pressure-monitoring guidewire and hyperemic stimulus. Angiography-derived FFR measurements (FFR
angio
) may have several advantages. The aim of this study is to assess the diagnostic performance and interobserver reproducibility of FFR
angio
in patients with stable coronary artery disease.
Methods and Results—
FFR
angio
is a computational method based on rapid flow analysis for the assessment of FFR. FFR
angio
uses the patient’s hemodynamic data and routine angiograms to generate a complete 3-dimensional coronary tree with color-coded FFR values at any epicardial location. Hyperemic flow ratio is derived from an automatic resistance-based lumped model of the entire coronary tree. A total of 203 lesions were analyzed in 184 patients from 4 centers. Values derived using FFR
angio
ranged from 0.5 to 0.97 (median 0.85) and correlated closely (Spearman ρ=0.90;
P
<0.001) with the invasive FFR measurements, which ranged from 0.5 to 1 (median 0.84). In Bland–Altman analyses, the 95% limits of agreement between these methods ranged from −0.096 to 0.112. Using an FFR cutoff value of 0.80, the sensitivity, specificity, and diagnostic accuracy of FFR
angio
were 88%, 95%, and 93%, respectively. The intraclass coefficient between 2 blinded operators was 0.962 with a 95% confidence interval from 0.950 to 0.971,
P
<0.001.
Conclusions—
There is a high concordance between FFR
angio
and invasive FFR. The color-coded display of FFR values during coronary angiography facilitates the integration of physiology and anatomy for decision making on revascularization in patients with stable coronary artery disease.
Clinical Trial Registration—
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT03005028.
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Affiliation(s)
- Mariano Pellicano
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Ifat Lavi
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Bernard De Bruyne
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Hana Vaknin-Assa
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Abid Assali
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Orna Valtzer
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Yonit Lotringer
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Giora Weisz
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Yaron Almagor
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Panagiotis Xaplanteris
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Ajay J. Kirtane
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Pablo Codner
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Martin B. Leon
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
| | - Ran Kornowski
- From the Cardiovascular Center Aalst, OLV Hospital, Belgium (M.P., B.D.B., P.X.); Rabin Medical Center, Petach Tikva, Israel (I.L., H.V.-A., A.A., O.V., P.C., R.K.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P.); CathWorks Ltd, Ra’anana, Israel (I.L., O.V., Y.L.); Columbia University Medical Center, New York-Presbyterian Hospital (A.J.K., P.C., M.B.L.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W., Y.A.)
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24
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Xaplanteris P, Barbato E, De Bruyne B. Catheter-based functional metrics of the coronary circulation. J Nucl Cardiol 2017; 24:1178-1189. [PMID: 27604111 DOI: 10.1007/s12350-016-0652-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 07/23/2016] [Indexed: 01/10/2023]
Abstract
In patients with stable chest pain, decision making about treatment strategy should be based on anatomical and functional information on the coronary circulation. Traditionally, the functional data are obtained by non-invasive testing which aims at detecting and localizing 'myocardial ischemia.' Yet, the diagnostic accuracy of diagnostic testing is over-rated in the literature, so that in clinical practice, a sizable proportion of patients undergo a coronary angiogram without prior useful functional information. Therefore, several methods have been developed to obtain similar information in the catheterization laboratory. Here we review briefly some of these methods. Some of them are used routinely in clinical practice, and others are under development.
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Affiliation(s)
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV-Clinic, Moorselbaan 164, 9300, Aalst, Belgium
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV-Clinic, Moorselbaan 164, 9300, Aalst, Belgium.
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25
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Fractional flow reserve in below the knee arteries with critical limb ischemia and validation against gold-standard morphologic, functional measures and long term clinical outcomes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:175-181. [PMID: 28866449 DOI: 10.1016/j.carrev.2017.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 01/29/2023]
Abstract
INTRODUCTION The aim of this study was to assess the applicability of fractional flow reserve measurement (FFR) in below-the-knee (BTK) arteries and to evaluate its correlation with non-invasive functional parameters before and after angioplasty. METHODS We enrolled 39 patients with severe BTK arterial lesions. Inclusion criteria were critical limb ischemia (Rutherford 4-6) and angiographically proven arterial stenosis of the distal lower limb (percent diameter stenosis ≥70%). Exclusion criteria were chronic total occlusion, diabetic foot syndrome and non-viable distal lower limb. The transstenotic distal/proximal pressure ratio was measured under resting (Pd/Pa) and hyperemic (FFR) conditions induced by 40mg intra-arterial Papaverin and was compared with quantitative angiography-, laser Doppler- and duplex ultrasound-derived measurements before and after percutaneous angioplasty (PTA). RESULTS Comparing measurements before and after PTA, we found significant improvements in the resting Pd/Pa values (0.79 [0.67-0.90] vs 0.90 [0.85-0.97]; p<0.001) and FFR values (0.60±0.19 vs 0.76±0.15; p<0.001), respectively. At baseline, Pd/Pa ratio and FFR were significantly albeit weakly correlated with % area stenosis (r:-0.31, p=0.05 and r:-0.31, p=0.05, respectively). After PTA, neither Pd/Pa nor FFR remained correlated with % area stenosis. Similarly, prior PTA, Pd/Pa ratio and FFR were significantly correlated with TcO2% and perfusion unit change (r:0.48, p<0.01 and r:0.34, p<0.05, respectively), but after intervention, these significant correlations vanished. Pd/Pa and FFR values did not show correlation with duplex ultrasound-derived measurements. At 1year, major adverse events (MAEs) and major adverse cardiovascular and cerebrovascular (MACCEs) were observed in 7 (17.9%) and in 9 (23.1%) patients, respectively. CONCLUSION CLI due to severe BTK arterial disease was associated with several impediments of baseline pressure measurements which were significantly improved after successful PTA and stenting. Significant relationships between pressure data and functional and imaging parameters existed prior intervention but vanished after. Further studies are required to determine the clinical value of pre- and post-PTA pressure measurements in BTK arterial disease.
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26
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Toth GG, Johnson NP, Jeremias A, Pellicano M, Vranckx P, Fearon WF, Barbato E, Kern MJ, Pijls NHJ, De Bruyne B. Standardization of Fractional Flow Reserve Measurements. J Am Coll Cardiol 2017; 68:742-53. [PMID: 27515335 DOI: 10.1016/j.jacc.2016.05.067] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Abstract
Pressure wire-based fractional flow reserve is considered the standard of reference for evaluation of the ischemic potential of coronary stenoses and the expected benefit from revascularization. Accordingly, its application in daily practice or for research purposes has to be as standardized as possible to avoid technical or operator-related artifacts in pressure recordings. This document proposes a standardized way of acquiring, recording, interpreting, and archiving the pressure tracings for daily practice and for the purpose of clinical research involving a core laboratory. Proposed standardized steps enhance the uniformity of clinical practices and data interpretation.
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Affiliation(s)
| | - Nils P Johnson
- Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Division of Cardiology, Department of Medicine, University of Texas Medical School and Memorial Hermann Hospital, Houston, Texas
| | - Allen Jeremias
- Stony Brook University and Cardiovascular Research Foundation, New York, New York
| | | | - Pascal Vranckx
- Hartcentrum Hasselt, Division of Cardiology and Critical Care Medicine, Hasselt, Belgium
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California
| | - Emanuele Barbato
- Cardiovascular Center Aalst, Aalst, Belgium; Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Morton J Kern
- Irvine Medical Center, University of California, Irvine, California
| | - Nico H J Pijls
- Irvine Medical Center, University of California, Irvine, California; Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
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27
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Corcoran D, Hennigan B, Berry C. Fractional flow reserve: a clinical perspective. Int J Cardiovasc Imaging 2017; 33:961-974. [PMID: 28577046 PMCID: PMC5489582 DOI: 10.1007/s10554-017-1159-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 01/02/2017] [Indexed: 01/10/2023]
Abstract
Fractional flow reserve (FFR) is a reference invasive diagnostic test to assess the physiological significance of an epicardial coronary artery stenosis. FFR-guided percutaneous coronary intervention in stable coronary artery disease has been assessed in three seminal clinical trials and the indications for FFR assessment are expanding into other clinical scenarios. In this article we review the theoretical, experimental and clinical basis for FFR measurement. We place FFR measurement in the context of the comprehensive invasive assessment of coronary physiology in patients presenting with known or suspected angina pectoris in daily clinical practice, and review the recent developments in FFR assessment.
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Affiliation(s)
- David Corcoran
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Barry Hennigan
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK. .,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
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28
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Oh JH, Song S, Kim C, Kim J, Sup Park J, Won Lee H, Hyun Choi J, Cheol Lee H, Soo Cha K, Jong Hong T. The influence of side branch stenosis on fractional flow reserve assessment of the main branch in a swine model. Catheter Cardiovasc Interv 2017; 89:219-225. [PMID: 27535003 DOI: 10.1002/ccd.26457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/21/2015] [Accepted: 01/17/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The aim of this study was to explore the effect of one stenosis in a daughter artery on the fractional flow reserve (FFR) of another stenosis parallels in side branch. BACKGROUND The impact of one stenosis on the FFR of another parallel stenosis has not been evaluated. METHODS The proximal segments of the left anterior descending (LAD) and left circumflex (LCX) arteries were exposed and encircled with a Teflon pledget complex in seven swine (55-70 kg). Five degrees of stenosis (to approximate angiographic diameter stenoses of 0%, 25%, 50%, 75%, and 100%) were made by tightening the pledgets. FFR was evaluated simultaneously in the LAD and the LCX with two pressure wires in each coronary artery. A mixed-effects linear model was used to evaluate the association between the FFR values. RESULTS A total of 115 paired FFR values were obtained. The FFR of the LAD and LCX were not significantly associated with each other (F = 0.237 and P = 0.627 for the LCX FFR to predict the LAD FFR; F = 0.541 and P = 0.463 for the LAD FFR to predict the LCX FFR). CONCLUSIONS The individual FFR values of each parallel stenosis in the LAD and the LCX were not significantly influenced by each other. This relationship was independent of the mean aortic pressure and heart rate. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jun-Hyok Oh
- Department of Cardiology, Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Seunghwan Song
- Department of Thoracic and Cardiovascular Surgery, Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Changhoon Kim
- Department of Preventive Medicine, Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Jeongsu Kim
- Department of Internal Medicine, Pusan National University School of Medicine Cardiovascular Center, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Jin Sup Park
- Department of Cardiology, Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Hye Won Lee
- Department of Cardiology, Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Jung Hyun Choi
- Department of Cardiology, Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Han Cheol Lee
- Department of Cardiology, Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Kwang Soo Cha
- Department of Cardiology, Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Taek Jong Hong
- Department of Cardiology, Medical Research Institute, Pusan National University Hospital, Busan, South Korea
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29
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Echavarria-Pinto M, Petraco R, van de Hoef TP, Gonzalo N, Nijjer S, Tarkin JM, Ibanez B, Sen S, Jimenez-Quevedo P, Nunez-Gil IJ, Nombela-Franco L, Alfonso F, Fernandez-Ortiz A, Macaya C, Piek JJ, Davies J, Escaned J. Fractional flow reserve and minimum Pd/Pa ratio during intravenous adenosine infusion: very similar but not always the same. EUROINTERVENTION 2017; 11:1013-9. [PMID: 25366652 DOI: 10.4244/eijy14m10_09] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Maximum and stable hyperaemia are critical prerequisites for the accurate measurement of fractional flow reserve (FFR). However, in some patients in whom hyperaemia is induced through a central vein (IV) the minimum distal coronary pressure to aortic pressure ratio (Pd/Pa ratio) develops before the stabilisation of hyperaemia. We sought to describe the prevalence, magnitude and clinical implications of this phenomenon. METHODS AND RESULTS The FFR tracing archive of a single institution was reviewed and a total of 104 high-quality IV-FFR recordings from 90 patients were identified. Whenever the minimum Pd/Pa ratio was found before the onset of stable hyperaemia, a search for the lowest Pd/Pa ratio within the steady-state hyperaemic plateau was performed and labelled as FFRstable. Whilst in most cases the minimum Pd/Pa ratio developed during stable hyperaemia, in 19 cases (prevalence of 18.3% [95% CI: 12.0% to 26.8%]) this value was found before the stabilisation of the hyperaemic state. In such cases, the minimum Pd/Pa ratio stabilised later at a higher level (0.77±0.09 vs. 0.81±0.08, p<0.001) (mean difference, 0.03±0.02, range, 0.01 to 0.10). In terms of dichotomous classification of stenosis severity and if FFRstable had been used to decide on revascularisation, reclassification would have occurred in three (2.9%) cases, all presenting a minimum Pd/Pa ratio ≤0.80 with FFRstable >0.80. CONCLUSIONS During IV adenosine infusion, the minimum Pd/Pa ratio occurs before the stabilisation of hyperaemia in a significant proportion of cases. While the overall difference between the minimum Pd/Pa ratio and its FFRstable counterpart is small, reclassification of stenosis severity might occur, if choosing between the minimum and stable values of FFR within the same trace.
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Affiliation(s)
- Mauro Echavarria-Pinto
- Hospital Clinico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
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30
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Intracoronary pressure measurement differences between anterior and posterior coronary territories. Herz 2016; 42:395-402. [DOI: 10.1007/s00059-016-4471-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/08/2016] [Accepted: 07/17/2016] [Indexed: 01/10/2023]
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31
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Han YF, Liu WH, Chen XL, Xiong YY, Yin Q, Xu GL, Zhu WS, Zhang RL, Ma MM, Li M, Dai QL, Sun W, Liu DZ, Duan LH, Liu XF. Severity assessment of intracranial large artery stenosis by pressure gradient measurements: A feasibility study. Catheter Cardiovasc Interv 2016; 88:255-61. [PMID: 26774257 DOI: 10.1002/ccd.26414] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 12/26/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR)-guided revascularization strategy is popular in coronary intervention. However, the feasibility of assessing stenotic severity in intracranial large arteries using pressure gradient measurements still remains unclear. METHODS Between March 2013 and May 2014, 12 consecutive patients with intracranial large artery stenosis (including intracranial internal carotid artery, middle cerebral M1 segment, intracranial vertebral artery, and basilar artery) were enrolled in this study. The trans-stenotic pressure gradient was measured before and/or after percutaneous transluminal angioplasty and stenting (PTAS), and was then compared with percent diameter stenosis. A Pd /Pa cut-off of ≤0.70 was used to guide stenting of hemodynamically significant stenoses. The device-related and procedure-related serious adverse events and recurrent cerebral ischemic events were recorded. RESULTS The target vessel could be reached in all cases. No technical complications occurred due to the specific study protocol. Excellent pressure signals were obtained in all patients. For seven patients who performed PTAS, the mean pre-procedural pressure gradient decreased from 59.0 ± 17.2 to 13.3 ± 13.6 mm Hg after the procedure (P < 0.01). Only one patient who refused stenting experienced a TIA event in the ipsilateral MCA territory. No recurrent ischemic event was observed in other patients. CONCLUSION Mean trans-stenotic pressure gradients can be safely and easily measured with a 0.014-inch fluid-filled guide wire in intracranial large arteries. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Yun-Fei Han
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Wen-Hua Liu
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiang-Liang Chen
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yun-Yun Xiong
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qin- Yin
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ge-Lin Xu
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wu-Sheng Zhu
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ren-Liang Zhang
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Min-Min Ma
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Min- Li
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qi-Liang Dai
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wen- Sun
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - De-Zhi Liu
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Li-Hui Duan
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xin-Feng Liu
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China
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32
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Johnson NP, Kirkeeide RL, Gould KL. History and Development of Coronary Flow Reserve and Fractional Flow Reserve for Clinical Applications. Interv Cardiol Clin 2015; 4:397-410. [PMID: 28581927 DOI: 10.1016/j.iccl.2015.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We discuss the historical development of clinical coronary physiology, emphasizing coronary flow reserve (CFR) and fractional flow reserve (FFR). Our analysis focuses on the clinical motivations and technologic advances that prompted and enabled the application of physiology for patient diagnosis. CFR grew from the general concepts of physiologic and coronary reserve, linking the anatomic severity of a lesion to its impact on hyperemic flow. FFR developed from existing models relating pressure measurements to the potential for flow to increase after removing a stenosis. Because pressure measurements have proved easier and more robust than flow measurements, FFR has become the dominant metric.
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Affiliation(s)
- Nils P Johnson
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA.
| | - Richard L Kirkeeide
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA
| | - K Lance Gould
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA
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Crystal GJ, Klein LW. Fractional flow reserve: physiological basis, advantages and limitations, and potential gender differences. Curr Cardiol Rev 2015; 11:209-19. [PMID: 25329922 PMCID: PMC4558352 DOI: 10.2174/1573403x10666141020113318] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/04/2014] [Accepted: 10/15/2014] [Indexed: 01/31/2023] Open
Abstract
Fractional flow reserve (FFR) is a physiological index of the severity of a stenosis in an epicardial coronary artery, based on the pressure differential across the stenosis. Clinicians are increasingly relying on this method because it is independent of baseline flow, relatively simple, and cost effective. The accurate measurement of FFR is predicated on maximal hyperemia being achieved by pharmacological dilation of the downstream resistance vessels (arterioles). When the stenosis causes FFR to be impaired by > 20%, it is considered to be significant and to justify revascularization. A diminished hyperemic response due to microvascular dysfunction can lead to a false normal FFR value, and a misguided clinical decision. The blunted vasodilation could be the result of defects in the signaling pathways modulated (activated or inhibited) by the drug. This might involve a downregulation or reduced number of vascular receptors, endothelial impairment, or an increased activity of an opposing vasoconstricting mechanism, such as the coronary sympathetic nerves or endothelin. There are data to suggest that microvascular dysfunction is more prevalent in post-menopausal women, perhaps due to reduced estrogen levels. The current review discusses the historical background and physiological basis for FFR, its advantages and limitations, and the phenomenon of microvascular dysfunction and its impact on FFR measurements. The question of whether it is warranted to apply gender-specific guidelines in interpreting FFR measurements is addressed.
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Affiliation(s)
- George J Crystal
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Chicago, IL 60657, USA.
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Kobayashi N, Hirano K, Nakano M, Ito Y, Sakai T, Ishimori H, Yamawaki M, Araki M, Tsukahara R, Muramatsu T. Measuring Procedure and Maximal Hyperemia in the Assessment of Fractional Flow Reserve for Superficial Femoral Artery Disease. J Atheroscler Thromb 2015; 23:56-66. [PMID: 26310494 DOI: 10.5551/jat.30957] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
AIM The optimal fractional flow reserve (FFR) measurement method for superficial femoral artery (SFA) lesions remains to be established. We clarified the optimal measuring procedure for FFR for SFA lesions and investigated the necessary dose of papaverine for inducing maximal hyperemia in SFA lesions. METHODS Forty-eight patients with SFA lesions who underwent measurement of peripheral FFR (pFFR: distal mean pressure divided by proximal mean pressure) after endovascular treatment by the contralateral femoral crossover approach were prospectively enrolled. In the pFFR measurement, a guide sheath was placed on top of the common iliac bifurcation and pressure equalization was performed. After advancing the pressure wire distal to the SFA lesion, sequential papaverine administration selectively to the affected common iliac artery was performed. RESULTS There were no symptoms, electrocardiogram changes, and significant pressure drops at the guide sheath tip with increasing papaverine dose. pFFR changes following 20, 30, and 40 mg of papaverine were 0.87±0.10, 0.84±0.10, and 0.84±0.10, respectively (P<0.001). Although not significantly different, pFFR decreased more in several patients at 30 mg of papaverine than at 20 mg. The pFFR at 40 mg of papaverine was almost similar to that at 30 mg of papaverine. The necessary papaverine dose was not changed according to sex and number of run-off vessels. CONCLUSIONS The contralateral femoral crossover approach is useful in FFR measurement for SFA lesions, and maximal hyperemia is induced by 30 mg of papaverine.
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Härle T, Bojara W, Meyer S, Elsässer A. Comparison of instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR)--first real world experience. Int J Cardiol 2015; 199:1-7. [PMID: 26179896 DOI: 10.1016/j.ijcard.2015.07.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 03/10/2015] [Accepted: 07/01/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND The instantaneous wave-free ratio (iFR) is a new adenosine-independent index of coronary stenosis severity. Most published data have been based on off-line analyses of pressure recordings in a core laboratory. We prospectively compared real-time iFR and fractional flow reserve (FFR) measurements. METHODS AND RESULTS iFR and FFR were measured in 151 coronary stenoses in 108 patients. Repeated iFR measurements were technically simple, showed excellent agreement [rs=0.99; p<0.0001], and the mean difference between consecutive iFR values was 0.0035 (limits of agreement: -0.019, 0.026). Mean iFR showed a significant correlation with FFR [rs=0.81; p<0.0001]. Receiver-operating characteristic analysis identified an optimal iFR cut-off value of 0.896 for categorization based on an FFR cut-off value 0.8. We compared two different iFR-based diagnostic strategies (iFR-only and hybrid iFR-FFR) with standard FFR: The iFR-only strategy showed good classification agreement (83.4%) with standard FFR. Use of the hybrid iFR-FFR strategy, assessing lesions in an iFR-gray zone of 0.86-0.93 by FFR, improved classification accuracy to 94.7%, and diagnosis would have been established in 61% of patients without adenosine-induced hyperemia. Notably, both iFR and FFR values were significantly higher in the posterior coronary vessels. CONCLUSIONS Real-time iFR measurements are easily performed, have excellent diagnostic performance and confirm available off-line core laboratory data. The excellent agreement between repeated iFR measurements demonstrates the reliability of single measurements. Combining iFR with FFR in a hybrid strategy enhances diagnostic accuracy, exposing fewer patients to adenosine. Overall, iFR is a promising method, but still requires prospective clinical endpoint trial evaluation.
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Affiliation(s)
- Tobias Härle
- Klinikum Oldenburg, Klinik für Kardiologie, Oldenburg, Germany.
| | - Waldemar Bojara
- Gemeinschaftsklinikum Koblenz-Mayen, Medizinische Klinik II, Koblenz, Germany
| | - Sven Meyer
- Klinikum Oldenburg, Klinik für Kardiologie, Oldenburg, Germany; University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
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Abstract
Intracoronary hemodynamic assessment of the physiologic significance of coronary lesions improves clinical outcomes in patients with coronary artery disease. Coronary flow velocity reserve, fractional flow reserve, instantaneous wave-free ratio, and index of microcirculatory resistance utilize sensor-mounted guidewires to approximate coronary flow. Coronary flow velocity reserve and fractional flow reserve rely on pharmacologic administration of adenosine to achieve hyperemia and diagnose epicardial lesion severity. As an adenosine-free index, the instantaneous wave-free ratio utilizes a wave-free period in the mid-late diastole during which resistance is constant and low to assess lesion significance. The index of microcirculatory resistance combines hyperemic pressure measurements with thermodilution to quantify microvascular resistance. We review the physiology, clinical trials, and clinical applications of these invasive hemodynamic assessments.
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de Marchi SF. Determinants of human coronary collaterals. Curr Cardiol Rev 2015; 10:24-8. [PMID: 23638830 PMCID: PMC3968591 DOI: 10.2174/1573403x1001140317114411] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 02/28/2013] [Accepted: 04/19/2013] [Indexed: 01/09/2023] Open
Abstract
The human coronary collateral circulation is prognostically relevant. The understanding of collateral formation and its determinants may guide future therapeutic strategies aiming at promoting collateral growth and functionality, and hence reducing the global burden of coronary artery disease (CAD).
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Mosadegh B, Xiong G, Dunham S, Min JK. Current progress in 3D printing for cardiovascular tissue engineering. Biomed Mater 2015; 10:034002. [DOI: 10.1088/1748-6041/10/3/034002] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Balloon Occlusion Types in the Treatment of Coronary Perforation during Percutaneous Coronary Intervention. Cardiol Res Pract 2014; 2014:784018. [PMID: 25506463 PMCID: PMC4258336 DOI: 10.1155/2014/784018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 11/07/2014] [Accepted: 11/11/2014] [Indexed: 12/31/2022] Open
Abstract
Coronary artery perforation is an uncommon complication in patients with coronary heart disease undergoing percutaneous coronary intervention. However, pericardial tamponade following coronary artery perforation may be lethal, and prompt treatment is crucial in managing such patients. Balloon occlusion and the reversal of anticoagulant activity are the common methods used to prevent cardiac tamponade by reducing the amount of bleeding. Herein, we discuss the pros and cons of currently used occlusion types for coronary perforation. Optimal balloon occlusion methods should reduce the amount of bleeding and ameliorate subsequent myocardial ischemia injury, even during cardiac surgery.
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Tanaka H, Chikamori T, Tanaka N, Hida S, Igarashi Y, Yamashita J, Ogawa M, Shiba C, Usui Y, Yamashina A. Diagnostic performance of a novel cadmium-zinc-telluride gamma camera system assessed using fractional flow reserve. Circ J 2014; 78:2727-34. [PMID: 25241891 DOI: 10.1253/circj.cj-14-0612] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although the novel cadmium-zinc-telluride (CZT) camera system provides excellent image quality, its diagnostic value using thallium-201 as assessed on coronary angiography (CAG) and fractional flow reserve (FFR) has not been validated. METHODS AND RESULTS: To evaluate the diagnostic accuracy of the CZT ultrafast camera system (Discovery NM 530c), 95 patients underwent stress thallium-201 single-photon emission computed tomography (SPECT) and then CAG within 3 months. Image acquisition was performed in the supine and prone positions after stress for 5 and 3 min, respectively, and in the supine position at rest for 10 min. Significant stenosis was defined as ≥90% diameter narrowing on visual estimation, or a lesion with <90% and ≥50% stenosis and FFR ≤0.75. To detect individual coronary stenosis, the respective sensitivity, specificity, and accuracy were 90%, 64%, and 78% for left anterior descending coronary artery stenosis, 78%, 84%, and 81% for left circumflex stenosis, and 83%, 47%, and 60% for right coronary artery (RCA) stenosis. The combination of prone and supine imaging had a higher specificity for RCA disease than supine imaging alone (65% vs. 47%), with an improvement in accuracy from 60% to 72%. CONCLUSIONS Using thallium-201 with short acquisition time, combined with prone imaging, CZT SPECT had a high diagnostic yield in detecting significant coronary stenosis as assessed using FFR.
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Affiliation(s)
- Hirokazu Tanaka
- Department of Cardiology, Tokyo Medical University Ibaraki Medical Center
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Aminian A, Dolatabadi D, Lefebvre P, Khalil G, Zimmerman R, Michalakis G, Lalmand J. Importance of guiding catheter disengagement during measurement of fractional flow reserve in patients with an isolated proximal left anterior descending artery stenosis. Catheter Cardiovasc Interv 2014; 85:595-601. [DOI: 10.1002/ccd.25568] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 05/25/2014] [Indexed: 01/22/2023]
Affiliation(s)
- Adel Aminian
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Dariouch Dolatabadi
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Pascal Lefebvre
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Georges Khalil
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Robert Zimmerman
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Georges Michalakis
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Jacques Lalmand
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
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Toth G, Hamilos M, Pyxaras S, Mangiacapra F, Nelis O, De Vroey F, Di Serafino L, Muller O, Van Mieghem C, Wyffels E, Heyndrickx GR, Bartunek J, Vanderheyden M, Barbato E, Wijns W, De Bruyne B. Evolving concepts of angiogram: fractional flow reserve discordances in 4000 coronary stenoses. Eur Heart J 2014; 35:2831-8. [DOI: 10.1093/eurheartj/ehu094] [Citation(s) in RCA: 211] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Cornerstones in the treatment of coronary artery disease (CAD) are medical therapy and coronary revascularization. In acute settings (ST-elevation myocardial infarction and non-ST-elevation myocardial infarction), percutaneous coronary intervention (PCI) has proven to improve prognosis. The optimal treatment of stable CAD is subject to great controversy. By using fractional flow reserve to guide PCI, it is possible to stent only those lesions that induce myocardial ischemia. This review aims to reflect on the use of FFR-guided PCI in stable CAD.
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Simic I, Zdravkovic V, Vucic R, Iric-Cupic V, Davidovic G, Ignjatovic V, Bankovic D. Fractional Flow Reserve Method in Cardiac Catheterization Laboratory without Cardiosurgical Backup: Initial Experiences. Open Access Maced J Med Sci 2013. [DOI: 10.3889/oamjms.2013.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Coronary artery disease is the most common cause of death in a modern world. This dictates the development a network of Catheterization laboratories without cardiosurgical capabilities.Aim: We postulate that the most valuable tool in the decision process on myocardial revascularization is fractional flow reserve (FFR), especially when we deal with borderline coronary lesions.Material and Methods: A total of 72 patients with 94 intermediate coronary stenosis (30%-70% diameter reduction) were included in this study. We tested FFR and angiography based decision model on myocardial revascularization.Results: Â Mean FFR value on left anterior descending coronary artery (LAD) was lower than in others two arteries (p=0.017). FFR after percutaneous coronary intervention (PCI) was significantly better (p<0.0001). The decision for PCI predominates before FFR diagnostics, but after FFR the decision is quite opposite. There is a weak negative correlation between FFR and diameter of stenosis assessed by angiography (r= - 0.245 p=0.038) and positive correlation between diameter of stenosis assessed by angiography and by quantitative coronary angiography (QCA) (r=0.406 p<0.0005).Conclusion: Â Our results strongly suggest that FFR is necessary tool in centers without possibilities of heart team onsite consultation and that prevents numerous unnecessary PCI.
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Puri R, Nicholls SJ. Treating stable ischemic heart disease with percutaneous coronary intervention - The debate continues. Cardiovasc Diagn Ther 2013; 2:264-7. [PMID: 24282726 DOI: 10.3978/j.issn.2223-3652.2012.10.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 10/25/2012] [Indexed: 01/17/2023]
Affiliation(s)
- Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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Plein S, Motwani M. Fractional flow reserve as the reference standard for myocardial perfusion studies: fool's gold? Eur Heart J Cardiovasc Imaging 2013; 14:1211-3. [PMID: 23793873 DOI: 10.1093/ehjci/jet110] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Sven Plein
- Multidisciplinary Cardiovascular Research Centre and The Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
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Berry C, van 't Veer M, Witt N, Kala P, Bocek O, Pyxaras SA, McClure JD, Fearon WF, Barbato E, Tonino PAL, De Bruyne B, Pijls NHJ, Oldroyd KG. VERIFY (VERification of Instantaneous Wave-Free Ratio and Fractional Flow Reserve for the Assessment of Coronary Artery Stenosis Severity in EverydaY Practice): a multicenter study in consecutive patients. J Am Coll Cardiol 2013; 61:1421-7. [PMID: 23395076 DOI: 10.1016/j.jacc.2012.09.065] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 08/04/2012] [Accepted: 09/11/2012] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study sought to compare fractional flow reserve (FFR) with the instantaneous wave-free ratio (iFR) in patients with coronary artery disease and also to determine whether the iFR is independent of hyperemia. BACKGROUND FFR is a validated index of coronary stenosis severity. FFR-guided percutaneous coronary intervention (PCI) improves clinical outcomes compared to angiographic guidance alone. iFR has been proposed as a new index of stenosis severity that can be measured without adenosine. METHODS We conducted a prospective, multicenter, international study of 206 consecutive patients referred for PCI and a retrospective analysis of 500 archived pressure recordings. Aortic and distal coronary pressures were measured in duplicate in patients under resting conditions and during intravenous adenosine infusion at 140 μg/kg/min. RESULTS Compared to the FFR cut-off value of ≤0.80, the diagnostic accuracy of the iFR value of ≤0.80 was 60% (95% confidence interval [CI]: 53% to 67%) for all vessels studied and 51% (95% CI: 43% to 59%) for those patients with FFR in the range of 0.60 to 0.90. iFR was significantly influenced by the induction of hyperemia: mean ± SD iFR at rest was 0.82 ± 0.16 versus 0.64 ± 0.18 with hyperemia (p < 0.001). Receiver operating characteristics confirmed that the diagnostic accuracy of iFR was similar to resting Pd/Pa and trans-stenotic pressure gradient and significantly inferior to hyperemic iFR. Analysis of our retrospectively acquired dataset showed similar results. CONCLUSIONS iFR correlates weakly with FFR and is not independent of hyperemia. iFR cannot be recommended for clinical decision making in patients with coronary artery disease.
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Affiliation(s)
- Colin Berry
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom.
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De Bruyne B, Pijls NHJ, Kalesan B, Barbato E, Tonino PAL, Piroth Z, Jagic N, Möbius-Winkler S, Rioufol G, Witt N, Kala P, MacCarthy P, Engström T, Oldroyd KG, Mavromatis K, Manoharan G, Verlee P, Frobert O, Curzen N, Johnson JB, Jüni P, Fearon WF. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012; 367:991-1001. [PMID: 22924638 DOI: 10.1056/nejmoa1205361] [Citation(s) in RCA: 1874] [Impact Index Per Article: 156.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The preferred initial treatment for patients with stable coronary artery disease is the best available medical therapy. We hypothesized that in patients with functionally significant stenoses, as determined by measurement of fractional flow reserve (FFR), percutaneous coronary intervention (PCI) plus the best available medical therapy would be superior to the best available medical therapy alone. METHODS In patients with stable coronary artery disease for whom PCI was being considered, we assessed all stenoses by measuring FFR. Patients in whom at least one stenosis was functionally significant (FFR, ≤0.80) were randomly assigned to FFR-guided PCI plus the best available medical therapy (PCI group) or the best available medical therapy alone (medical-therapy group). Patients in whom all stenoses had an FFR of more than 0.80 were entered into a registry and received the best available medical therapy. The primary end point was a composite of death, myocardial infarction, or urgent revascularization. RESULTS Recruitment was halted prematurely after enrollment of 1220 patients (888 who underwent randomization and 332 enrolled in the registry) because of a significant between-group difference in the percentage of patients who had a primary end-point event: 4.3% in the PCI group and 12.7% in the medical-therapy group (hazard ratio with PCI, 0.32; 95% confidence interval [CI], 0.19 to 0.53; P<0.001). The difference was driven by a lower rate of urgent revascularization in the PCI group than in the medical-therapy group (1.6% vs. 11.1%; hazard ratio, 0.13; 95% CI, 0.06 to 0.30; P<0.001); in particular, in the PCI group, fewer urgent revascularizations were triggered by a myocardial infarction or evidence of ischemia on electrocardiography (hazard ratio, 0.13; 95% CI, 0.04 to 0.43; P<0.001). Among patients in the registry, 3.0% had a primary end-point event. CONCLUSIONS In patients with stable coronary artery disease and functionally significant stenoses, FFR-guided PCI plus the best available medical therapy, as compared with the best available medical therapy alone, decreased the need for urgent revascularization. In patients without ischemia, the outcome appeared to be favorable with the best available medical therapy alone. (Funded by St. Jude Medical; ClinicalTrials.gov number, NCT01132495.).
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Affiliation(s)
- Bernard De Bruyne
- Cardiovascular Center Aalst, Onze-Lieve-Vrouw Clinic, Aalst, Belgium.
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Vranckx P, Cutlip DE, McFadden EP, Kern MJ, Mehran R, Muller O. Coronary Pressure–Derived Fractional Flow Reserve Measurements. Circ Cardiovasc Interv 2012; 5:312-7. [DOI: 10.1161/circinterventions.112.968511] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Pascal Vranckx
- From Cardialysis Clinical Research Management and Core Laboratories, Rotterdam, The Netherlands (P.V.); Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (D.E.C.); the Department of Cardiology, Cork University Hospital, Cork, Ireland (E.P.M.); the Division of Cardiology, University of California, Irvine, CA (M.J.K.); Interventional Cardiovascular Research and Clinical Trials, Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (R.M.)
| | - Donald E. Cutlip
- From Cardialysis Clinical Research Management and Core Laboratories, Rotterdam, The Netherlands (P.V.); Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (D.E.C.); the Department of Cardiology, Cork University Hospital, Cork, Ireland (E.P.M.); the Division of Cardiology, University of California, Irvine, CA (M.J.K.); Interventional Cardiovascular Research and Clinical Trials, Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (R.M.)
| | - Eugène P. McFadden
- From Cardialysis Clinical Research Management and Core Laboratories, Rotterdam, The Netherlands (P.V.); Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (D.E.C.); the Department of Cardiology, Cork University Hospital, Cork, Ireland (E.P.M.); the Division of Cardiology, University of California, Irvine, CA (M.J.K.); Interventional Cardiovascular Research and Clinical Trials, Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (R.M.)
| | - Morton J. Kern
- From Cardialysis Clinical Research Management and Core Laboratories, Rotterdam, The Netherlands (P.V.); Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (D.E.C.); the Department of Cardiology, Cork University Hospital, Cork, Ireland (E.P.M.); the Division of Cardiology, University of California, Irvine, CA (M.J.K.); Interventional Cardiovascular Research and Clinical Trials, Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (R.M.)
| | - Roxana Mehran
- From Cardialysis Clinical Research Management and Core Laboratories, Rotterdam, The Netherlands (P.V.); Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (D.E.C.); the Department of Cardiology, Cork University Hospital, Cork, Ireland (E.P.M.); the Division of Cardiology, University of California, Irvine, CA (M.J.K.); Interventional Cardiovascular Research and Clinical Trials, Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (R.M.)
| | - Olivier Muller
- From Cardialysis Clinical Research Management and Core Laboratories, Rotterdam, The Netherlands (P.V.); Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (D.E.C.); the Department of Cardiology, Cork University Hospital, Cork, Ireland (E.P.M.); the Division of Cardiology, University of California, Irvine, CA (M.J.K.); Interventional Cardiovascular Research and Clinical Trials, Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (R.M.)
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