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Ma Z, Tu C, Zhang B, Zhang D, Song X, Zhang H. A meta-analysis comparing the diagnostic performance of computed tomography-derived fractional flow reserve and coronary computed tomography angiography at different levels of coronary artery calcium score. Eur Radiol 2024; 34:5621-5632. [PMID: 38334761 DOI: 10.1007/s00330-024-10591-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/30/2023] [Accepted: 11/30/2023] [Indexed: 02/10/2024]
Abstract
OBJECTIVES The impact of coronary calcification on the diagnostic accuracy of computed tomography-derived fractional flow reserve (CT-FFR) and coronary computed tomography angiography (CCTA) remains a crucial consideration. This meta-analysis aims to compare the diagnostic performance of CT-FFR and CCTA at different levels of coronary artery calcium score (CACS). METHODS AND RESULTS We searched PubMed, Embase, and the Cochrane Library for relevant articles on CCTA, CT-FFR, and invasive fractional flow reserve (FFR). Ten studies were included to evaluate the diagnostic performance of CT-FFR and CCTA at the per-patient and per-vessel levels in four CACS groups. Invasive FFR was used as the reference standard. Except for the CACS ≥ 400 group, the AUC of CT-FFR was higher than those of CCTA in other subgroups of CACS (in CACS < 100 (per-patient, 0.9 (95% CI 0.87-0.92) vs. 0.32 (95% CI 0.28-0.36); per-vessel, 0.92 (95% CI 0.89-0.94) vs. 0.66 (95% CI 0.62-0.7); both p < 0.001), CACS ≥ 100 (per-patient, 0.86 (95% CI 0.82-0.88) vs. 0.44 (95% CI 0.4-0.48); per-vessel, 0.88 (95% CI 0.85-0.9) vs. 0.51 (95% CI 0.46-0.55); both p < 0.001), and CACS < 400 (per-patient, 0.9 (95% CI 0.87-0.93) vs. 0.74 (95% CI 0.7-0.78), p < 0.001; per-vessel, 0.8 (95% CI 0.76-0.83) vs. 0.74 (95% CI 0.7-0.78); p = 0.02)). CONCLUSIONS CT-FFR demonstrates superior diagnostic performance in low CACS groups (CACS < 400) than CCTA in detecting hemodynamic stenoses in patients with coronary artery disease (CAD). CLINICAL RELEVANCE STATEMENT Computed tomography-derived fractional flow reserve might be utilized to determine the necessity of invasive coronary angiography in coronary artery disease patients with coronary artery calcium score < 400. KEY POINTS • There is a lack of meta-analysis comparing the diagnostic performance of computed tomography-derived fractional flow reserve and coronary computed tomography angiography at different levels of calcification. • Computed tomography-derived fractional flow reserve only has a better diagnostic performance than coronary computed tomography angiography with low amounts of coronary calcium. • For the low coronary artery calcium score group, computed tomography-derived fractional flow reserve might be a good non-invasive method to detect hemodynamic stenoses in coronary artery disease patients.
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Affiliation(s)
- Zhao Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People's Republic of China
| | - Chenchen Tu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People's Republic of China
| | - Baoen Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People's Republic of China
| | - Dongfeng Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People's Republic of China.
| | - Xiantao Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People's Republic of China.
| | - Hongjia Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People's Republic of China
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Stanley GA, Scherer MD, Hajostek MM, Yammine H, Briggs CS, CrespoSoto HO, Nussbaum T, Arko FR. Utilization of coronary computed tomography angiography and computed tomography-derived fractional flow reserve in a critical limb-threatening ischemia cohort. J Vasc Surg Cases Innov Tech 2024; 10:101272. [PMID: 38435790 PMCID: PMC10907840 DOI: 10.1016/j.jvscit.2023.101272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/23/2023] [Indexed: 03/05/2024] Open
Abstract
Objective Patients with peripheral arterial disease (PAD) have a significant risk of myocardial infarction and death secondary to concomitant coronary artery disease (CAD). This is particularly true in patients with critical limb-threatening ischemia (CLTI) who exceed a 20% mortality rate at 6 months despite standard treatment with risk factor modification. Although systematic preoperative coronary testing is not recommended for patients with PAD without cardiac symptoms, the clinical manifestations of CAD are often muted in patients with CLTI due to poor mobility and activity intolerance. Thus, the true incidence and impact of "silent" CAD in a CLTI cohort is unknown. This study aims to determine the prevalence of ischemia-producing coronary artery stenosis in a CLTI cohort using coronary computed tomography angiography (cCTA) and computed tomography (CT)-derived fractional flow reserve (FFRCT), a noninvasive imaging modality that has shown significant correlation to cardiac catheterization in the detection of clinically relevant coronary ischemia. Methods Patients presenting with newly diagnosed CLTI at our institution from May 2020 to April 2021 were screened for underlying CAD. Included subjects had no known history of CAD, no cardiac symptoms, and no anginal equivalent complaints at presentation. Patients underwent cCTA and FFRCT evaluation and were classified by the anatomic location and severity of CAD. Significant coronary ischemia was defined as FFRCT ≤0.80 distal to a >30% coronary stenosis, and severe coronary ischemia was documented at FFRCT ≤0.75, consistent with established guidelines. Results A total of 170 patients with CLTI were screened; 65 patients (38.2%) had no coronary symptoms and met all inclusion/exclusion criteria. Twenty-four patients (31.2%) completed cCTA and FFRCT evaluation. Forty-one patients have yet to complete testing secondary to socioeconomic factors (insurance denial, transportation inaccessibility, testing availability, etc). The mean age of included subjects was 65.4 ± 7.0 years, and 15 (62.5%) were male. Patients presented with ischemic rest pain (n = 7; 29.1%), minor tissue loss (n = 14; 58.3%) or major tissue loss (n = 3; 12.5%). Significant (≥50%) coronary artery stenosis was noted on cCTA in 19 of 24 patients (79%). Significant left main coronary artery stenosis was identified in two patients (10%). When analyzed with FFRCT, 17 patients (71%) had hemodynamically significant coronary ischemia (FFRCT ≤0.8), and 54% (n = 13) had lesion-specific severe coronary ischemia (FFRCT ≤0.75). The mean FFRCT in patients with coronary ischemia was 0.70 ± 0.07. Multi-vessel disease pattern was present in 53% (n = 9) of patients with significant coronary stenosis. Conclusions The use of cCTA-derived fractional flow reserve demonstrates a significant percentage of patients with CLTI have silent (asymptomatic) coronary ischemia. More than one-half of these patients have lesion-specific severe ischemia, which may be associated with increased mortality when treated solely with risk factor modification. cCTA and FFRCT diagnosis of significant coronary ischemia has the potential to improve cardiac care, perioperative morbidity, and long-term survival curves of patients with CLTI. Systemic improvements in access to care will be needed to allow for broad application of these imaging assessments should they prove universally valuable. Additional study is required to determine the benefit of selective coronary revascularization in patients with CLTI.
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Affiliation(s)
| | | | | | - Halim Yammine
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC
| | | | | | - Tzvi Nussbaum
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC
| | - Frank R. Arko
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC
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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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Wamil M, Goncalves M, Rutherford A, Borlotti A, Pellikka PA. Multi-modality cardiac imaging in the management of diabetic heart disease. Front Cardiovasc Med 2022; 9:1043711. [DOI: 10.3389/fcvm.2022.1043711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Diabetic heart disease is a major healthcare problem. Patients with diabetes show an excess of death from cardiovascular causes, twice as high as the general population and those with diabetes type 1 and longer duration of the disease present with more severe cardiovascular complications. Premature coronary artery disease and heart failure are leading causes of morbidity and reduced life expectancy. Multimodality cardiac imaging, including echocardiography, cardiac computed tomography, nuclear medicine, and cardiac magnetic resonance play crucial role in the diagnosis and management of different pathologies included in the definition of diabetic heart disease. In this review we summarise the utility of multi-modality cardiac imaging in characterising ischaemic and non-ischaemic causes of diabetic heart disease and give an overview of the current clinical practice. We also describe emerging imaging techniques enabling early detection of coronary artery inflammation and the non-invasive characterisation of the atherosclerotic plaque disease. Furthermore, we discuss the role of MRI-derived techniques in studying altered myocardial metabolism linking diabetes with the development of diabetic cardiomyopathy. Finally, we discuss recent data regarding the use of artificial intelligence applied to large imaging databases and how those efforts can be utilised in the future in screening of patients with diabetes for early signs of disease.
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Rajiah P, Cummings KW, Williamson E, Young PM. CT Fractional Flow Reserve: A Practical Guide to Application, Interpretation, and Problem Solving. Radiographics 2022; 42:340-358. [PMID: 35119968 DOI: 10.1148/rg.210097] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CT fractional flow reserve (FFRCT) is a physiologic simulation technique that models coronary flow from routine coronary CT angiography (CTA). To evaluate lesion-specific ischemia, FFRCT is measured 2 cm distal to a stenotic lesion. FFRCT greater than 0.8 is normal, 0.76-0.8 is borderline, and 0.75 or less is abnormal. FFRCT should always be interpreted in correlation with clinical and anatomic coronary CTA findings. FFRCT increases the specificity of coronary CTA in the evaluation of coronary artery disease, decreases the prevalence of nonobstructive disease in invasive coronary angiography (ICA), and helps with revascularization decisions and planning. Patients with intermediate-risk coronary anatomy at CTA and abnormal FFRCT can undergo ICA and revascularization, whereas those with normal FFRCT can be safely deferred from ICA. In borderline FFRCT values, management is decided in the context of the clinical scenario, but many cases could be safely managed with medical treatment. There are some limitations and pitfalls of FFRCT. Abnormal FFRCT values can be seen in mild stenosis, and normal FFRCTvalues can be seen in severe stenosis. Gradually decreasing or abnormal low FFRCT values at the distal vessel without a proximal focal lesion could be due to diffuse atherosclerosis. Coronary stents, bypass grafts, coronary anomalies, coronary dissection, transcatheter aortic valve replacement, unstable angina, and acute or recent myocardial infarction are situations in which FFRCT has not been validated and should not be used at this time. The authors provide a practical guide to the applications and interpretation of FFRCT, focusing on common pitfalls and challenges. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Prabhakar Rajiah
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
| | - Kristopher W Cummings
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
| | - Eric Williamson
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
| | - Phillip M Young
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
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Lossnitzer D, Klenantz S, Andre F, Goerich J, Schoepf UJ, Pazzo KL, Sommer A, Brado M, Gückel F, Sokiranski R, Becher T, Akin I, Buss SJ, Baumann S. Stable patients with suspected myocardial ischemia: comparison of machine-learning computed tomography-based fractional flow reserve and stress perfusion cardiovascular magnetic resonance imaging to detect myocardial ischemia. BMC Cardiovasc Disord 2022; 22:34. [PMID: 35120459 PMCID: PMC8817462 DOI: 10.1186/s12872-022-02467-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Machine-Learning Computed Tomography-Based Fractional Flow Reserve (CT-FFRML) is a novel tool for the assessment of hemodynamic relevance of coronary artery stenoses. We examined the diagnostic performance of CT-FFRML compared to stress perfusion cardiovascular magnetic resonance (CMR) and tested if there is an additional value of CT-FFRML over coronary computed tomography angiography (cCTA). METHODS Our retrospective analysis included 269 vessels in 141 patients (mean age 67 ± 9 years, 78% males) who underwent clinically indicated cCTA and subsequent stress perfusion CMR within a period of 2 months. CT-FFRML values were calculated from standard cCTA. RESULTS CT-FFRML revealed no hemodynamic significance in 79% of the patients having ≥ 50% stenosis in cCTA. Chi2 values for the statistical relationship between CT-FFRML and stress perfusion CMR was significant (p < 0.0001). CT-FFRML and cCTA (≥ 70% stenosis) provided a per patient sensitivity of 88% (95%CI 64-99%) and 59% (95%CI 33-82%); specificity of 90% (95%CI 84-95%) and 85% (95%CI 78-91%); positive predictive value of 56% (95%CI 42-69%) and 36% (95%CI 24-50%); negative predictive value of 98% (95%CI 94-100%) and 94% (95%CI 90-96%); accuracy of 90% (95%CI 84-94%) and 82% (95%CI 75-88%) when compared to stress perfusion CMR. The accuracy of cCTA (≥ 50% stenosis) was 19% (95%CI 13-27%). The AUCs were 0.89 for CT-FFRML and 0.74 for cCTA (≥ 70% stenosis) and therefore significantly different (p < 0.05). CONCLUSION CT-FFRML compared to stress perfusion CMR as the reference standard shows high diagnostic power in the identification of patients with hemodynamically significant coronary artery stenosis. This could support the role of cCTA as gatekeeper for further downstream testing and may reduce the number of patients undergoing unnecessary invasive workup.
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Affiliation(s)
- Dirk Lossnitzer
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Selina Klenantz
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Florian Andre
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Johannes Goerich
- The Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Heidelberg, Germany
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Kyle L Pazzo
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Andre Sommer
- The Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Heidelberg, Germany
| | - Matthias Brado
- The Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Heidelberg, Germany
| | - Friedemann Gückel
- The Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Heidelberg, Germany
| | - Roman Sokiranski
- The Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Heidelberg, Germany
| | - Tobias Becher
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Sebastian J Buss
- The Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Heidelberg, Germany
| | - Stefan Baumann
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
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Kamo Y, Fujimoto S, Nozaki YO, Aoshima C, Kawaguchi YO, Dohi T, Kudo A, Takahashi D, Takamura K, Hiki M, Okai I, Okazaki S, Tomizawa N, Kumamaru KK, Aoki S, Minamino T. Incremental Diagnostic Value of CT Fractional Flow Reserve Using Subtraction Method in Patients with Severe Calcification: A Pilot Study. J Clin Med 2021; 10:jcm10194398. [PMID: 34640414 PMCID: PMC8509262 DOI: 10.3390/jcm10194398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 12/30/2022] Open
Abstract
Although on-site workstation-based CT fractional flow reserve (CT-FFR) is an emerging method for assessing vessel-specific ischemia in coronary artery disease, severe calcification is a significant factor affecting CT-FFR’s diagnostic performance. The subtraction method significantly improves the diagnostic value with respect to anatomic stenosis for patients with severe calcification in coronary CT angiography (CCTA). We evaluated the diagnostic capability of CT-FFR using the subtraction method (subtraction CT-FFR) in patients with severe calcification. This study included 32 patients with 45 lesions with severe calcification (Agatston score >400) who underwent both CCTA and subtraction CCTA using 320-row area detector CT and also received invasive FFR within 90 days. The diagnostic capabilities of CT-FFR and subtraction CT-FFR were compared. The sensitivities, specificities, positive predictive values (PPVs), and negative predictive values (NPVs) of CT-FFR vs. subtraction CT-FFR for detecting hemodynamically significant stenosis, defined as FFR ≤ 0.8, were 84.6% vs. 92.3%, 59.4% vs. 75.0%, 45.8% vs. 60.0%, and 90.5% vs. 96.0%, respectively. The area under the curve for subtraction CT-FFR was significantly higher than for CT-FFR (0.84 vs. 0.70) (p = 0.04). The inter-observer and intra-observer variabilities of subtraction CT-FFR were 0.76 and 0.75, respectively. In patients with severe calcification, subtraction CT-FFR had an incremental diagnostic value over CT-FFR, increasing the specificity and PPV while maintaining the sensitivity and NPV with high reproducibility.
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Affiliation(s)
- Yuki Kamo
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
| | - Shinichiro Fujimoto
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
- Correspondence: ; Tel.: +81-3-5802-1056
| | - Yui O. Nozaki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
| | - Chihiro Aoshima
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
| | - Yuko O. Kawaguchi
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
| | - Tomotaka Dohi
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
| | - Ayako Kudo
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
| | - Daigo Takahashi
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
| | - Kazuhisa Takamura
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
| | - Makoto Hiki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
| | - Iwao Okai
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
| | - Shinya Okazaki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
| | - Nobuo Tomizawa
- Department of Radiology, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (N.T.); (K.K.K.); (S.A.)
| | - Kanako K. Kumamaru
- Department of Radiology, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (N.T.); (K.K.K.); (S.A.)
| | - Shigeki Aoki
- Department of Radiology, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (N.T.); (K.K.K.); (S.A.)
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan; (Y.K.); (Y.O.N.); (C.A.); (Y.O.K.); (T.D.); (A.K.); (D.T.); (K.T.); (M.H.); (I.O.); (S.O.); (T.M.)
- Japan Agency for Medical Research and Development-Core Research for Evolutionary Medical Science and Technology (AMED-CREST), Japan Agency for Medical Research and Development, Tokyo 100-0004, Japan
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Recent Trends in Artificial Intelligence-Assisted Coronary Atherosclerotic Plaque Characterization. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910003. [PMID: 34639303 PMCID: PMC8508413 DOI: 10.3390/ijerph181910003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/12/2021] [Accepted: 09/17/2021] [Indexed: 01/21/2023]
Abstract
Coronary artery disease is a major cause of morbidity and mortality worldwide. Its underlying histopathology is the atherosclerotic plaque, which comprises lipid, fibrous and—when chronic—calcium components. Intravascular ultrasound (IVUS) and intravascular optical coherence tomography (IVOCT) performed during invasive coronary angiography are reference standards for characterizing the atherosclerotic plaque. Fine image spatial resolution attainable with contemporary coronary computed tomographic angiography (CCTA) has enabled noninvasive plaque assessment, including identifying features associated with vulnerable plaques known to presage acute coronary events. Manual interpretation of IVUS, IVOCT and CCTA images demands scarce physician expertise and high time cost. This has motivated recent research into and development of artificial intelligence (AI)-assisted methods for image processing, feature extraction, plaque identification and characterization. We performed parallel searches of the medical and technical literature from 1995 to 2021 focusing respectively on human plaque characterization using various imaging modalities and the use of AI-assisted computer aided diagnosis (CAD) to detect and classify atherosclerotic plaques, including their composition and the presence of high-risk features denoting vulnerable plaques. A total of 122 publications were selected for evaluation and the analysis was summarized in terms of data sources, methods—machine versus deep learning—and performance metrics. Trends in AI-assisted plaque characterization are detailed and prospective research challenges discussed. Future directions for the development of accurate and efficient CAD systems to characterize plaque noninvasively using CCTA are proposed.
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Li Y, Jia K, Jia Y, Yang Y, Yao Y, Chen M, Peng Y. Understanding the predictive value and methods of risk assessment based on coronary computed tomographic angiography in populations with coronary artery disease: a review. PRECISION CLINICAL MEDICINE 2021; 4:192-203. [PMID: 35693218 PMCID: PMC8982592 DOI: 10.1093/pcmedi/pbab018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/23/2021] [Accepted: 07/23/2021] [Indexed: 02/05/2023] Open
Abstract
Risk assessment in coronary artery disease plays an essential role in the early identification of high-risk patients. However, conventional invasive imaging procedures all require long intraprocedural times and high costs. The rapid development of coronary computed tomographic angiography (CCTA) and related image processing technology has facilitated the formulation of noninvasive approaches to perform comprehensive evaluations. Evidence has shown that CCTA has outstanding performance in identifying the degree of stenosis, plaque features, and functional reserve. Moreover, advancements in radiomics and machine learning allow more comprehensive interpretations of CCTA images. This paper reviews conventional as well as novel diagnostic and risk assessment tools based on CCTA.
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Affiliation(s)
- Yiming Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Kaiyu Jia
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yuheng Jia
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yong Yang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yijun Yao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
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10
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Tian XW, Ma AL, Zhou RB, Jiang LJ, Hao Y, Zou XG. Advances in Cardiac Computed Tomography Functional Imaging Technology. Cardiology 2020; 145:615-622. [PMID: 32829331 DOI: 10.1159/000505317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 12/09/2019] [Indexed: 11/19/2022]
Abstract
Cardiovascular disease (CVD) is the leading cause of death among patients in China, and cardiac computed tomography (CT) is one of the most commonly used examination methods for CVD. Coronary artery CT angiography can be used for the morphologic evaluation of the coronary artery. At present, cardiac CT functional imaging has become an important direction of development of CT. At present, common CT functional imaging technologies include transluminal attenuation gradient, stress dynamic CT myocardial perfusion imaging, and CT-fractional flow reserve. These three imaging modes are introduced and analyzed in this review.
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Affiliation(s)
- Xu-Wei Tian
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China
| | - Ai-Lin Ma
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China
| | - Ren-Bing Zhou
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China
| | - Liu-Jiang Jiang
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China
| | - Yue Hao
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China
| | - Xiao-Guang Zou
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China,
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11
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Tanabe Y, Kurata A, Matsuda T, Yoshida K, Baruah D, Kido T, Mochizuki T, Rajiah P. Computed tomographic evaluation of myocardial ischemia. Jpn J Radiol 2020; 38:411-433. [PMID: 32026226 PMCID: PMC7186254 DOI: 10.1007/s11604-020-00922-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/20/2020] [Indexed: 01/02/2023]
Abstract
Myocardial ischemia is caused by a mismatch between myocardial oxygen consumption and oxygen delivery in coronary artery disease (CAD). Stratification and decision-making based on ischemia improves the prognosis in patients with CAD. Non-invasive tests used to evaluate myocardial ischemia include stress electrocardiography, echocardiography, single-photon emission computed tomography, and magnetic resonance imaging. Invasive fractional flow reserve is considered the reference standard for assessment of the hemodynamic significance of CAD. Computed tomography (CT) angiography has emerged as a first-line imaging modality for evaluation of CAD, particularly in the population at low to intermediate risk, because of its high negative predictive value; however, CT angiography does not provide information on the hemodynamic significance of stenosis, which lowers its specificity. Emerging techniques, e.g., CT perfusion and CT-fractional flow reserve, help to address this limitation of CT, by determining the hemodynamic significance of coronary artery stenosis. CT perfusion involves acquisition during the first pass of contrast medium through the myocardium following pharmacological stress. CT-fractional flow reserve uses computational fluid dynamics to model coronary flow, pressure, and resistance. In this article, we review these two functional CT techniques in the evaluation of myocardial ischemia, including their principles, technology, advantages, limitations, pitfalls, and the current evidence.
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Affiliation(s)
- Yuki Tanabe
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Akira Kurata
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Takuya Matsuda
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kazuki Yoshida
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Dhiraj Baruah
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Teruhito Mochizuki
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
- Department of Radiology, I.M. Sechenov First Moscow State Medical University, Bol'shaya Pirogovskaya Ulitsa, Moscow, Russia
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12
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Lossnitzer D, Chandra L, Rutsch M, Becher T, Overhoff D, Janssen S, Weiss C, Borggrefe M, Akin I, Pfleger S, Baumann S. Additional Value of Machine-Learning Computed Tomographic Angiography-Based Fractional Flow Reserve Compared to Standard Computed Tomographic Angiography. J Clin Med 2020; 9:jcm9030676. [PMID: 32138259 PMCID: PMC7141259 DOI: 10.3390/jcm9030676] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/13/2020] [Accepted: 02/24/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Machine-learning-based computed-tomography-derived fractional flow reserve (CT-FFRML) obtains a hemodynamic index in coronary arteries. We examined whether it could reduce the number of invasive coronary angiographies (ICA) showing no obstructive lesions. We further compared CT-FFRML-derived measurements to clinical and CT-derived scores. Methods: We retrospectively selected 88 patients (63 ± 11years, 74% male) with chronic coronary syndrome (CCS) who underwent clinically indicated coronary computed tomography angiography (cCTA) and ICA. cCTA image data were processed with an on-site prototype CT-FFRML software. Results: CT-FFRML revealed an index of >0.80 in coronary vessels of 48 (55%) patients. This finding was corroborated in 45 (94%) patients by ICA, yet three (6%) received revascularization. In patients with an index ≤ 0.80, three (8%) of 40 were identified as false positive. A total of 48 (55%) patients could have been retained from ICA. CT-FFRML (AUC = 0.96, p ≤ 0.0001) demonstrated a higher diagnostic accuracy compared to the pretest probability or CT-derived scores and showed an excellent sensitivity (93%), specificity (94%), positive predictive value (PPV; 93%) and negative predictive value (NPV; 94%). Conclusion: CT-FFRML could be beneficial for clinical practice, as it may identify patients with CAD without hemodynamical significant stenosis, and may thus reduce the rate of ICA without necessity for coronary intervention.
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Affiliation(s)
- Dirk Lossnitzer
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany, DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany and ECAS (European Center for Angioscience), Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany; (L.C.); (M.R.); (T.B.); (M.B.); (I.A.); (S.P.); (S.B.)
- Correspondence: ; Tel.: +49-621-383-6695; Fax: +49-621-383-2025
| | - Leonard Chandra
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany, DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany and ECAS (European Center for Angioscience), Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany; (L.C.); (M.R.); (T.B.); (M.B.); (I.A.); (S.P.); (S.B.)
| | - Marlon Rutsch
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany, DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany and ECAS (European Center for Angioscience), Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany; (L.C.); (M.R.); (T.B.); (M.B.); (I.A.); (S.P.); (S.B.)
| | - Tobias Becher
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany, DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany and ECAS (European Center for Angioscience), Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany; (L.C.); (M.R.); (T.B.); (M.B.); (I.A.); (S.P.); (S.B.)
| | - Daniel Overhoff
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany; (D.O.); (S.J.)
| | - Sonja Janssen
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany; (D.O.); (S.J.)
| | - Christel Weiss
- Medical Faculty Mannheim, Department of Medical Statistics and Biomathematics, University Medical Center Mannheim, Heidelberg University, 68167 Mannheim, Germany;
| | - Martin Borggrefe
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany, DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany and ECAS (European Center for Angioscience), Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany; (L.C.); (M.R.); (T.B.); (M.B.); (I.A.); (S.P.); (S.B.)
| | - Ibrahim Akin
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany, DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany and ECAS (European Center for Angioscience), Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany; (L.C.); (M.R.); (T.B.); (M.B.); (I.A.); (S.P.); (S.B.)
| | - Stefan Pfleger
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany, DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany and ECAS (European Center for Angioscience), Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany; (L.C.); (M.R.); (T.B.); (M.B.); (I.A.); (S.P.); (S.B.)
| | - Stefan Baumann
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany, DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany and ECAS (European Center for Angioscience), Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany; (L.C.); (M.R.); (T.B.); (M.B.); (I.A.); (S.P.); (S.B.)
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13
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The influence of image quality on diagnostic performance of a machine learning-based fractional flow reserve derived from coronary CT angiography. Eur Radiol 2020; 30:2525-2534. [PMID: 32006167 DOI: 10.1007/s00330-019-06571-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 10/14/2019] [Accepted: 10/31/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate the effect of image quality of coronary CT angiography (CCTA) on the diagnostic performance of a machine learning-based CT-derived fractional flow reserve (FFRCT). METHODS This nationwide retrospective study enrolled participants from 10 individual centers across China. FFRCT analysis was performed in 570 vessels in 437 patients. Invasive FFR and FFRCT values ≤ 0.80 were considered ischemia-specific. Four-score subjective assessment based on image quality and objective measurement of vessel enhancement was performed on a per-vessel basis. The effects of body mass index (BMI), sex, heart rate, and coronary calcium score on the diagnostic performance of FFRCT were studied. RESULTS Among 570 vessels, 216 were considered ischemia-specific by invasive FFR and 198 by FFRCT. Sensitivity and specificity of FFRCT for detecting lesion-specific ischemia were 0.82 and 0.93, respectively. Area under the curve (AUC) of high-quality images (0.93, n = 159) was found to be superior to low-quality images (0.80, n = 92, p = 0.02). Objective image quality and heart rate were also associated with diagnostic performance of FFRCT, whereas there was no statistical difference in diagnostic performance among different BMI, sex, and calcium score groups (all p > 0.05, Bonferroni correction). CONCLUSIONS This retrospective multicenter study supported the FFRCT as a noninvasive test in evaluating lesion-specific ischemia. Subjective image quality, vessel enhancement, and heart rate affect the diagnostic performance of FFRCT. KEY POINTS • FFRCTcan be used to evaluate lesion-specific ischemia. • Poor image quality negatively affects the diagnostic performance of FFRCT. • CCTA with ≥ score 3, intracoronary enhancement degree of 300-400 HU, and heart rate below 70 bpm at scanning could be of great benefit to more accurate FFRCTanalysis.
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14
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Computed tomography angiography-derived fractional flow reserve (CT-FFR) for the detection of myocardial ischemia with invasive fractional flow reserve as reference: systematic review and meta-analysis. Eur Radiol 2019; 30:712-725. [DOI: 10.1007/s00330-019-06470-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/21/2019] [Accepted: 09/19/2019] [Indexed: 12/22/2022]
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15
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Adjustment of CT-fractional flow reserve based on fluid–structure interaction underestimation to minimize 1-year cardiac events. Heart Vessels 2019; 35:162-169. [DOI: 10.1007/s00380-019-01480-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/01/2019] [Indexed: 02/07/2023]
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16
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Reference parameters for left ventricular wall thickness, thickening, and motion in stress myocardial perfusion CT: Global and regional assessment. Clin Imaging 2019; 56:81-87. [DOI: 10.1016/j.clinimag.2019.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 02/11/2019] [Accepted: 04/09/2019] [Indexed: 11/23/2022]
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17
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Patel AR, Maffessanti F, Patel MB, Kebed K, Narang A, Singh A, Medvedofsky D, Zaidi SJ, Mediratta A, Goyal N, Kachenoura N, Lang RM, Mor-Avi V. Hemodynamic impact of coronary stenosis using computed tomography: comparison between noninvasive fractional flow reserve and 3D fusion of coronary angiography with stress myocardial perfusion. Int J Cardiovasc Imaging 2019; 35:1733-1743. [PMID: 31073698 DOI: 10.1007/s10554-019-01618-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/30/2019] [Indexed: 01/06/2023]
Abstract
Vasodilator-stress CT perfusion imaging in addition to CT coronary angiography (CTCA) may provide a single-test alternative to nuclear stress testing, commonly used to assess hemodynamic significance of stenosis. Another alternative is fractional flow reserve (FFR) calculated from cardiac CT images. We studied the concordance between these two approaches and their relationship to outcomes. We prospectively studied 150 patients with chest pain, who underwent CTCA and regadenoson CT. CTCA images were interpreted for presence and severity of stenosis. Fused 3D displays of subendocardial X-ray attenuation with coronary arteries were created to detect stress perfusion defects (SPD) in each coronary territory. In patients with stenosis > 25%, CT-FFR was quantified. Significant stenosis was determined by: (1) combination of stenosis > 50% with an SPD, (2) CT-FFR ≤ 0.80. Patients were followed-up for 36 ± 25 months for death, myocardial infarction or revascularization. After excluding patients with normal arteries and technical/quality issues, in final analysis of 76 patients, CTCA depicted stenosis > 70% in 13/224 arteries, 50-70% in 24, and < 50% in 187. CT-FFR ≤ 0.80 was found in 41/224 arteries, and combination of SPD with > 50% stenosis in 31/224 arteries. Inter-technique agreement was 89%. Despite high incidence of abnormal CT-FFR (30/76 patients), only 7 patients experienced adverse outcomes; 6/7 also had SPDs. Only 1/9 patients with CT-FFR ≤ 0.80 but normal perfusion had an event. Fusion of CTCA and stress perfusion can help determine the hemodynamic impact of stenosis in one test, in good agreement with CT-FFR. Adding stress CT perfusion analysis may help risk-stratify patients with abnormal CT-FFR.
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Affiliation(s)
- Amit R Patel
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA
| | - Francesco Maffessanti
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA.,Institute of Computational Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Mita B Patel
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA
| | - Kalie Kebed
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA
| | - Akhil Narang
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA
| | - Amita Singh
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA
| | - Diego Medvedofsky
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA
| | - S Javed Zaidi
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA.,Cardiology Department, Advocate Children's Hospital, Chicago, IL, USA
| | - Anuj Mediratta
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA
| | - Neha Goyal
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA
| | - Nadjia Kachenoura
- Laboratoire d'Imagerie Biomédicale, INSERM, CNRS, Sorbonne Université, Paris, France
| | - Roberto M Lang
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA
| | - Victor Mor-Avi
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5758 South Maryland Avenue, M.C. 9067, Chicago, IL, 60637, USA.
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Additional diagnostic value of new CT imaging techniques for the functional assessment of coronary artery disease: a meta-analysis. Eur Radiol 2019; 29:3044-3061. [DOI: 10.1007/s00330-018-5919-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/30/2018] [Accepted: 11/27/2018] [Indexed: 12/14/2022]
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Stähli BE, Erbay A, Steiner J, Klotsche J, Mochmann HC, Skurk C, Lauten A, Landmesser U, Leistner DM. Comparison of resting distal to aortic coronary pressure with angiography-based quantitative flow ratio. Int J Cardiol 2018; 279:12-17. [PMID: 30545620 DOI: 10.1016/j.ijcard.2018.11.093] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/11/2018] [Accepted: 11/15/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Quantitative flow ratio (QFR) is a novel, adenosine-free method for functional coronary lesion interrogation, which is based on 3-dimensional quantitative coronary angiography and computational algorithms. Data on QFR in all-comer patients with intermediate coronary lesions are scarce, and the diagnostic performance in comparison to resting distal to aortic coronary pressure (Pd/Pa) ratio unknown. METHODS A total of 436 patients with 516 vessels undergoing FFR measurements were included in the analysis. Diagnostic performance of QFR, distal to aortic coronary pressure (Pd/Pa) ratio, and anatomic indices versus FFR was assessed. RESULTS FFR ≤0.80 was measured in 19.4% of interrogated vessels. QFR significantly correlated with FFR (r = 0.82, p < 0.001) with good agreement between QFR and FFR (mean difference 0.011, 95% CI 0.008-0.015). The AUC for an FFR ≤0.80 was 0.86 (95% CI 0.83-0.89, p < 0.001) for QFR, 0.76 (0.72-0.80, p < 0.001) for resting Pd/Pa ratio, and 0.63 (0.59-0.67, p < 0.001) for diameter stenosis. The diagnostic accuracy for identifying an FFR ≤0.80 was 93.4% for QFR, 84.3% for resting Pd/Pa ratio, and 80.4% for diameter stenosis. CONCLUSIONS QFR provides a novel diagnostic tool for functional coronary lesion assessment with superior diagnostic accuracy as compared with resting Pd/Pa ratio and anatomic indices. Future studies are needed to determine the non-inferiority of QFR analysis to FFR assessment with respect to clinical outcomes.
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Affiliation(s)
- Barbara E Stähli
- Department of Cardiology, Charité Berlin - University Medicine, Campus Benjamin Franklin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Aslihan Erbay
- Department of Cardiology, Charité Berlin - University Medicine, Campus Benjamin Franklin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Julia Steiner
- Department of Cardiology, Charité Berlin - University Medicine, Campus Benjamin Franklin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Jens Klotsche
- German Rheumatism Research Center Berlin, Berlin, Germany; Institute for Epidemiology and Health Care Economics, Charité Berlin - University Medicine, Campus Mitte, Berlin, Germany
| | - Hans-Christian Mochmann
- Department of Cardiology, Charité Berlin - University Medicine, Campus Benjamin Franklin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Charité Berlin - University Medicine, Campus Benjamin Franklin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Alexander Lauten
- Department of Cardiology, Charité Berlin - University Medicine, Campus Benjamin Franklin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité Berlin - University Medicine, Campus Benjamin Franklin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany; Berlin Institute of Health (BIH), Berlin, Germany
| | - David M Leistner
- Department of Cardiology, Charité Berlin - University Medicine, Campus Benjamin Franklin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany; Berlin Institute of Health (BIH), Berlin, Germany.
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20
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Asher A, Singhal A, Thornton G, Wragg A, Davies C. FFR CT derived from computed tomography angiography: the experience in the UK. Expert Rev Cardiovasc Ther 2018; 16:919-929. [PMID: 30347174 DOI: 10.1080/14779072.2018.1538786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Non-invasive fractional flow reserve derived from CT coronary angiography (FFRCT) represents a novel technology to investigate coronary artery disease. The application of computational flow dynamics to anatomical data provides the clinician with a further functional assessment to inform decision-making in patients with coronary artery disease. In the UK FFRCT has received medical technology approval for use since February 2017. Areas covered: This article discusses the mathematical and physiological principles underpinning calculation of non-invasive fractional flow reserve (FFR), as well as discussing the differences between the commercially available technologies. Diagnostic accuracy, cost effectiveness and safety of non-invasive FFR from the early clinical trials is examined. Further to this the potential implications of the use of non-invasive FFR in clinical practice in the UK are discussed. Expert commentary: Non-invasive FFR represents a promising comprehensive imaging technology providing both anatomical and physiological data to accurately diagnose obstructive coronary artery disease. The technology has yet to prove to be cost effective in 'real world' cohorts before becoming integrated into everyday clinical practice and guidelines in the United Kingdom.
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Affiliation(s)
- Alex Asher
- a The Royal London Hospital and St Bartholomew's Hospital, London, Barts Health NHS Trust , London , UK
| | - Arvind Singhal
- a The Royal London Hospital and St Bartholomew's Hospital, London, Barts Health NHS Trust , London , UK
| | - George Thornton
- a The Royal London Hospital and St Bartholomew's Hospital, London, Barts Health NHS Trust , London , UK
| | - Andrew Wragg
- a The Royal London Hospital and St Bartholomew's Hospital, London, Barts Health NHS Trust , London , UK
| | - Ceri Davies
- a The Royal London Hospital and St Bartholomew's Hospital, London, Barts Health NHS Trust , London , UK
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21
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Noninvasive CT-based hemodynamic assessment of coronary lesions derived from fast computational analysis: a comparison against fractional flow reserve. Eur Radiol 2018; 29:2117-2126. [PMID: 30324382 DOI: 10.1007/s00330-018-5781-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 08/30/2018] [Accepted: 09/20/2018] [Indexed: 12/30/2022]
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22
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Kim C, Hong SJ, Ahn CM, Kim JS, Kim BK, Ko YG, Choi BW, Choi D, Jang Y, Hong MK. Clinical Implications of Moderate Coronary Stenosis on Coronary Computed Tomography Angiography in Patients with Stable Angina. Yonsei Med J 2018; 59:937-944. [PMID: 30187700 PMCID: PMC6127420 DOI: 10.3349/ymj.2018.59.8.937] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/12/2018] [Accepted: 08/02/2018] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The present study investigated the diagnostic accuracy and clinical implications of moderate stenosis (50-69%, Coronary Artery Disease Reporting and Data System, grade 3) on coronary computed tomography angiography (CCTA), compared with invasive coronary angiography (ICA). MATERIALS AND METHODS Two hundred and seventy-six patients who underwent ICA due to moderate stenosis alone on CCTA were selected from our prospective registry cohort. RESULTS Diagnostic concordance between CCTA and ICA was found in only 50 (18%) patients. Among the 396 vessels and 508 segments with moderate stenosis, diagnostic concordance was found in 132 vessels (33%) and 127 segments (25%). Segments with calcified plaque had lower diagnostic concordance than those with mixed or non-calcified plaque (22% vs. 28% vs. 27%, respectively, p=0.001). While calcified plaque burden did not have an influence on severe stenosis (≥70%) on ICA, higher burden of non-calcified plaque was correlated with a greater incidence of ICA-based severe stenosis, which was more frequent in patients with ≥3 segments of non-calcified plaque (75%) than those without non-calcified plaque (22%, p<0.001). Typical angina and mixed or non-calcified plaque were correlated with a higher incidence of under-diagnosis, while the use of next-generation computed tomography scanners reduced the incidence of under-diagnosis. Increased body weight, left circumflex artery involvement, and calcified plaque were independent factors that increased the risk of over-diagnosis of CCTA. CONCLUSION The diagnosis of moderate stenosis by CCTA may be limited in estimating the exact degree of ICA-based anatomical stenosis. Unlike calcific burden, non-calcific burden was positively correlated with the presence of severe stenosis on ICA.
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Affiliation(s)
- Choongki Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chul Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Byeong Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Wook Choi
- Division of Cardiovascular Radiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Myeong Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Noninvasive Derivation of Fractional Flow Reserve From Coronary Computed Tomographic Angiography: A Review. J Thorac Imaging 2018; 33:88-96. [PMID: 28817458 DOI: 10.1097/rti.0000000000000289] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Coronary computed tomographic angiography (CCTA) has evolved as a rapid and highly sensitive method for the exclusion of obstructive coronary artery disease. Unfortunately, as it pertains to moderate and severe lesions, the ability to discriminate between those that are hemodynamically significant and those that are nonobstructive is lacking. Consequently, this deficiency can result in a significant number of unnecessary referrals for invasive angiography that yields nonobstructive results. Fractional flow reserve (FFR), which assesses the hemodynamic significance of a specific lesion, when performed during invasive angiography, results in improved patient outcomes compared with visual stenosis assessment alone. Through the application of computational analytic methods to CT-derived anatomic coronary models, noninvasive calculation of FFR has become possible. This allows for the improved ability to differentiate between nonobstructive coronary lesions and those that are truly hemodynamically significant. Currently, HeartFlow FFRCT is the only FDA-approved and commercially available CCTA-derived FFR (CT-FFR) platform. By reducing the number of invasive procedures performed for nonobstructive disease, CT-derived FFR has the ability to lower health care expenditures and become the true gatekeeper to invasive angiography.
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Abstract
Computed tomography (CT) has become an important modality in the evaluation of coronary artery disease (CAD). The tremendous technological advances in CT in the last two decades has made it possible to obtain high quality images of coronary arteries with high spatial and temporal resolutions. Multiple trials have confirmed the accuracy of CT compared to invasive catheter angiography. CT is also able to evaluate beyond the lumen in characterizing and quantifying atherosclerotic plaques, including evaluation of high risk features. Although CTA has low specificity in identification of lesion-specific ischemia, functional techniques are now possible such as CT myocardial perfusion and CT-fractional flow reserve (FFR) which evaluate the hemodynamic significance of stenosis and help with revascularization strategies. Multi-energy CT provides additional information beyond what is possible with a conventional CT and is useful in variety of clinical applications, including myocardial perfusion imaging, lesion characterization and low contrast studies. Large trials have confirmed the ability of CT to predict major adverse cardiovascular events and recent trials have even demonstrated improved clinical outcomes by using CT for the evaluation of CAD. CT is also useful in structural heart disease and 3 D printing is now increasingly used for surgical/interventional planning. Machine learning is evolving rapidly and is likely to impact diagnosis and management.
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Affiliation(s)
- P Rajiah
- From the Department of Radiology, Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Texas, USA
| | - S Abbara
- From the Department of Radiology, Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Texas, USA
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Agasthi P, Kanmanthareddy A, Khalil C, Egbuche O, Yarlagadda V, Sachdeva R, Arsanjani R. Comparison of Computed Tomography derived Fractional Flow Reserve to invasive Fractional Flow Reserve in Diagnosis of Functional Coronary Stenosis: A Meta-Analysis. Sci Rep 2018; 8:11535. [PMID: 30069020 PMCID: PMC6070545 DOI: 10.1038/s41598-018-29910-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/19/2018] [Indexed: 12/14/2022] Open
Abstract
Computed Tomography derived Fractional Flow Reserve (CTFFR) is an emerging non-invasive imaging modality to assess functional significance of coronary stenosis. We performed a meta-analysis to compare the diagnostic performance of CTFFR to invasive Fractional Flow reserve (FFR). Electronic search was performed to identify relevant articles. Pooled Estimates of sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-) and diagnostic odds ratio (DOR) with corresponding 95% confidence intervals (CI) were calculated at the patient level as well as the individual vessel level using hierarchical logistic regression, summary receiver operating characteristic (SROC) curve and area under the curve were estimated. Our search yielded 559 articles and of these 17 studies was included in the analysis. A total of 2,191 vessels in 1294 patients were analyzed. Pooled estimates of sensitivity, specificity, LR+, LR- and DOR with corresponding 95% CI at per-patient level were 83% (79-87), 72% (68-76), 3.0 (2.6-3.5), 0.23 (0.18-0.29) and 13 (9-18) respectively. Pooled estimates of sensitivity, specificity, LR+, LR- and DOR with corresponding 95% CI at per-vessel level were 85% (83-88), 76% (74-79), 3.6 (3.3-4.0), 0.19 (0.16-0.22) and 19 (15-24). The area under the SROC curve was 0.89 for both per patient level and at the per vessel level. In our meta-analysis, CTFFR demonstrated good diagnostic performance in identifying functionally significant coronary artery stenosis compared to the FFR.
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Affiliation(s)
- Pradyumna Agasthi
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, Arizona, USA.
| | - Arun Kanmanthareddy
- Division of Cardiovascular Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charl Khalil
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Obiora Egbuche
- Division of Cardiology, Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Vivek Yarlagadda
- Department of Internal Medicine, Atlanticare Regional Medical Center, Atlantic City, New Jersey, USA
| | - Rajesh Sachdeva
- Division of Cardiology, Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Reza Arsanjani
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Rutsch M, Renker M, Akin I, Borggrefe M, Baumann S. Coronary computed tomography-derived fractional flow reserve assessment - Finally ready for clinical use? J Cardiovasc Comput Tomogr 2018; 12:e5. [PMID: 29598930 DOI: 10.1016/j.jcct.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 03/14/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Marlon Rutsch
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Matthias Renker
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - Ibrahim Akin
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Stefan Baumann
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
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27
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Fusion of Three-Dimensional Echocardiographic Regional Myocardial Strain with Cardiac Computed Tomography for Noninvasive Evaluation of the Hemodynamic Impact of Coronary Stenosis in Patients with Chest Pain. J Am Soc Echocardiogr 2018; 31:664-673. [PMID: 29576220 DOI: 10.1016/j.echo.2018.01.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Combined evaluation of coronary stenosis and the extent of ischemia is essential in patients with chest pain. Intermediate-grade stenosis on computed tomographic coronary angiography (CTCA) frequently triggers downstream nuclear stress testing. Alternative approaches without stress and/or radiation may have important implications. Myocardial strain measured from echocardiographic images can be used to detect subclinical dysfunction. The authors recently tested the feasibility of fusion of three-dimensional (3D) echocardiography-derived regional resting longitudinal strain with coronary arteries from CTCA to determine the hemodynamic significance of stenosis. The aim of the present study was to validate this approach against accepted reference techniques. METHODS Seventy-eight patients with chest pain referred for CTCA who also underwent 3D echocardiography and regadenoson stress computed tomography were prospectively studied. Left ventricular longitudinal strain data (TomTec) were used to generate fused 3D displays and detect resting strain abnormalities (RSAs) in each coronary territory. Computed tomographic coronary angiographic images were interpreted for the presence and severity of stenosis. Fused 3D displays of subendocardial x-ray attenuation were created to detect stress perfusion defects (SPDs). In patients with stenosis >25% in at least one artery, fractional flow reserve was quantified (HeartFlow). RSA as a marker of significant stenosis was validated against two different combined references: stenosis >50% on CTCA and SPDs seen in the same territory (reference standard A) and fractional flow reserve < 0.80 and SPDs in the same territory (reference standard B). RESULTS Of the 99 arteries with no stenosis >50% and no SPDs, considered as normal, 19 (19%) had RSAs. Conversely, with stenosis >50% and SPDs, RSAs were considerably more frequent (17 of 24 [71%]). The sensitivity, specificity, and accuracy of RSA were 0.71, 0.81, and 0.79, respectively, against reference standard A and 0.83, 0.81, and 0.82 against reference standard B. CONCLUSIONS Fusion of CTCA and 3D echocardiography-derived resting myocardial strain provides combined displays, which may be useful in determination of the hemodynamic or functional impact of coronary abnormalities, without additional ionizing radiation or stress testing.
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Coronary Computed Tomography-Derived Fractional Flow Reserve Assessment-A Gatekeeper in Intermediate Stenoses. Am J Cardiol 2018; 121:778-779. [PMID: 29361287 DOI: 10.1016/j.amjcard.2017.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 12/11/2017] [Indexed: 11/17/2022]
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Tesche C, De Cecco CN, Albrecht MH, Duguay TM, Bayer RR, Litwin SE, Steinberg DH, Schoepf UJ. Coronary CT Angiography–derived Fractional Flow Reserve. Radiology 2017; 285:17-33. [DOI: 10.1148/radiol.2017162641] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Christian Tesche
- From the Division of Cardiovascular Imaging, Department of Radiology and Radiological Science (C.T., C.N.D.C., M.H.A., T.M.D., R.R.B., S.E.L., U.J.S.), and Division of Cardiology, Department of Medicine (R.R.B., S.E.L., D.H.S., U.J.S.), Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260
| | - Carlo N. De Cecco
- From the Division of Cardiovascular Imaging, Department of Radiology and Radiological Science (C.T., C.N.D.C., M.H.A., T.M.D., R.R.B., S.E.L., U.J.S.), and Division of Cardiology, Department of Medicine (R.R.B., S.E.L., D.H.S., U.J.S.), Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260
| | - Moritz H. Albrecht
- From the Division of Cardiovascular Imaging, Department of Radiology and Radiological Science (C.T., C.N.D.C., M.H.A., T.M.D., R.R.B., S.E.L., U.J.S.), and Division of Cardiology, Department of Medicine (R.R.B., S.E.L., D.H.S., U.J.S.), Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260
| | - Taylor M. Duguay
- From the Division of Cardiovascular Imaging, Department of Radiology and Radiological Science (C.T., C.N.D.C., M.H.A., T.M.D., R.R.B., S.E.L., U.J.S.), and Division of Cardiology, Department of Medicine (R.R.B., S.E.L., D.H.S., U.J.S.), Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260
| | - Richard R. Bayer
- From the Division of Cardiovascular Imaging, Department of Radiology and Radiological Science (C.T., C.N.D.C., M.H.A., T.M.D., R.R.B., S.E.L., U.J.S.), and Division of Cardiology, Department of Medicine (R.R.B., S.E.L., D.H.S., U.J.S.), Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260
| | - Sheldon E. Litwin
- From the Division of Cardiovascular Imaging, Department of Radiology and Radiological Science (C.T., C.N.D.C., M.H.A., T.M.D., R.R.B., S.E.L., U.J.S.), and Division of Cardiology, Department of Medicine (R.R.B., S.E.L., D.H.S., U.J.S.), Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260
| | - Daniel H. Steinberg
- From the Division of Cardiovascular Imaging, Department of Radiology and Radiological Science (C.T., C.N.D.C., M.H.A., T.M.D., R.R.B., S.E.L., U.J.S.), and Division of Cardiology, Department of Medicine (R.R.B., S.E.L., D.H.S., U.J.S.), Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260
| | - U. Joseph Schoepf
- From the Division of Cardiovascular Imaging, Department of Radiology and Radiological Science (C.T., C.N.D.C., M.H.A., T.M.D., R.R.B., S.E.L., U.J.S.), and Division of Cardiology, Department of Medicine (R.R.B., S.E.L., D.H.S., U.J.S.), Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260
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Rajiah P, Maroules CD. Myocardial ischemia testing with computed tomography: emerging strategies. Cardiovasc Diagn Ther 2017; 7:475-488. [PMID: 29255691 DOI: 10.21037/cdt.2017.09.06] [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] [Indexed: 11/06/2022]
Abstract
Although cardiac computed tomography (CT) has high negative predictive value to exclude obstructive coronary artery disease (CAD), particularly in the low to intermediate risk population, it has low specificity in the diagnosis of ischemia-inducing lesions. This inability to predict hemodynamically significant stenosis hampers the ability of CT to be an effective gatekeeper for invasive angiography and to guide appropriate revascularization. Recent advances in CT technology have resulted in the development of multiple techniques to provide hemodynamic information and detect lesion-specific ischemia, namely CT perfusion (CTP), CT-derived fractional flow reserve (CT-FFR) and coronary transluminal attenuation gradient (TAG). In this article, we provide a perspective on these emerging CT techniques in the evaluation of myocardial ischemia.
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Affiliation(s)
- Prabhakar Rajiah
- Department of Radiology, Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Texas, USA
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Solecki M, Kruk M, Demkow M, Schoepf UJ, Reynolds MA, Wardziak Ł, Dzielińska Z, Śpiewak M, Miłosz-Wieczorek B, Małek Ł, Marczak M, Kępka C. What is the optimal anatomic location for coronary artery pressure measurement at CT-derived FFR? J Cardiovasc Comput Tomogr 2017; 11:397-403. [PMID: 28844869 DOI: 10.1016/j.jcct.2017.08.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 07/18/2017] [Accepted: 08/12/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND CT-FFR is an area of growing interest in the field of cardiac imaging. However, the specific anatomic location distal to a lesion of interest where CT-FFR should be computed to yield the most valid results has not been examined. This study investigated the most appropriate anatomic location distal to a coronary artery stenosis for obtaining CT-FFR measurements. METHODS 73 patients (60 ± 9 years; 58% male) with at least one coronary lesion with 40-90% stenosis on coronary CTA (either a 2 × 128 slice or a 2 × 192 slice dual-source CT scanner) underwent stress cardiac magnetic resonance (CMR) perfusion imaging for inducible ischemia. 133 coronary arteries and corresponding myocardial territories were analyzed. The most appropriate anatomic location for predicting lesion-specific ischemia via CT-FFR (cFFR version 1.4, Siemens) was determined as either the distance from the lesion of interest or as a multiple of the reference vessel diameter distal to the minimum lumen area (MLA). RESULTS Inducible myocardial ischemia was found on MRI in 24 (18.1%) vessels/corresponding myocardial territories. The area under the ROC curve was A) 0.866 for CT-FFR measurement locations distal to the MLA expressed as a multiple of the reference diameter, B) 0.854 when expressed as a distance (mm) distal to the MLA, C) 0.803 for CT-FFR values measured in the distal vessel, and D) 0.725 according to stenosis severity on coronary CTA (A vs B p = 0.093; A vs D p = 0.003; A vs C p = 0.019; B vs D p = 0.006; B vs C p = 0.061; C vs D p = 0.082). The most optimal thresholds for agreement of CT-FFR with the reference CMR perfusion were at 41 mm or 10.9 times the proximal reference diameter distal to the MLA. CONCLUSIONS Our results suggest that the best agreement of CT-FFR with the reference CMR perfusion study is provided when CT-FFR values are computed at 41 mm or 10.9 times the proximal reference diameter distal to the MLA.
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Affiliation(s)
- Mateusz Solecki
- Coronary Artery Disease and Structural Heart Disease Department, Institute of Cardiology, Alpejska 42 St, 04-628 Warsaw, Poland.
| | - Mariusz Kruk
- Coronary Artery Disease and Structural Heart Disease Department, Institute of Cardiology, Alpejska 42 St, 04-628 Warsaw, Poland.
| | - Marcin Demkow
- Coronary Artery Disease and Structural Heart Disease Department, Institute of Cardiology, Alpejska 42 St, 04-628 Warsaw, Poland.
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 96 Jonathan Lucas St, 29425 Charleston, SC, USA.
| | - Michael A Reynolds
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 96 Jonathan Lucas St, 29425 Charleston, SC, USA.
| | - Łukasz Wardziak
- Coronary Artery Disease and Structural Heart Disease Department, Institute of Cardiology, Alpejska 42 St, 04-628 Warsaw, Poland.
| | - Zofia Dzielińska
- Coronary Artery Disease and Structural Heart Disease Department, Institute of Cardiology, Alpejska 42 St, 04-628 Warsaw, Poland.
| | - Mateusz Śpiewak
- Cardiac Magnetic Resonance Unit, Institute of Cardiology, Alpejska 42 St, 04-628 Warsaw, Poland.
| | - Barbara Miłosz-Wieczorek
- Cardiac Magnetic Resonance Unit, Institute of Cardiology, Alpejska 42 St, 04-628 Warsaw, Poland.
| | - Łukasz Małek
- Cardiac Magnetic Resonance Unit, Institute of Cardiology, Alpejska 42 St, 04-628 Warsaw, Poland; University of Physical Education, Faculty of Rehabilitation, Marymoncka 34 St, 00-968 Warsaw, Poland.
| | - Magdalena Marczak
- Cardiac Magnetic Resonance Unit, Institute of Cardiology, Alpejska 42 St, 04-628 Warsaw, Poland.
| | - Cezary Kępka
- Coronary Artery Disease and Structural Heart Disease Department, Institute of Cardiology, Alpejska 42 St, 04-628 Warsaw, Poland.
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Landreth SP, Spearman JV. Machine Learning in Cardiac CT. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0241-9] [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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