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Fezzi S, Ding D, Mahfoud F, Huang J, Lansky AJ, Tu S, Wijns W. Illusion of revascularization: does anyone achieve optimal revascularization during percutaneous coronary intervention? Nat Rev Cardiol 2024:10.1038/s41569-024-01014-0. [PMID: 38710772 DOI: 10.1038/s41569-024-01014-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 05/08/2024]
Abstract
This Perspective article is a form of 'pastiche', inspired by the 1993 review by Lincoff and Topol entitled 'Illusion of reperfusion', and explores how their concept continues to apply to percutaneous revascularization in patients with coronary artery disease and ischaemia. Just as Lincoff and Topol argued that reperfusion of acute myocardial infarction was facing unresolved obstacles that hampered clinical success in 1993, we propose that challenging issues are similarly jeopardizing the potential benefits of stent-based angioplasty today. By analysing the appropriateness and efficacy of percutaneous coronary intervention (PCI), we emphasize the limitations of relying solely on visual angiographic guidance, which frequently leads to inappropriate stenting and overtreatment in up to one-third of patients and the associated increased risk of periprocedural myocardial infarction. The lack of optimal revascularization observed in half of patients undergoing PCI confers risks such as suboptimal physiology after PCI, residual angina and long-term stent-related events, leaving an estimated 76% of patients with an 'illusion of revascularization'. These outcomes highlight the need to refine our diagnostic tools by integrating physiological assessments with targeted intracoronary imaging and emerging strategies, such as co-registration systems and angiography-based computational methods enhanced by artificial intelligence, to achieve optimal revascularization outcomes.
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Affiliation(s)
- Simone Fezzi
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Daixin Ding
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland
- Department of Cardiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Felix Mahfoud
- Saarland University Hospital, Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Homburg/Saar, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- University Heart Center Basel, Department of Cardiology, University Basel, Basel, Switzerland
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Alexandra J Lansky
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Shengxian Tu
- Department of Cardiology, Ren Ji Hospital, School of Medicine, and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.
| | - William Wijns
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland.
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2
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Matsumura M, Maehara A, Davis JE, Kumar G, Sharp A, Samady H, Seto AH, Cohen D, Patel MR, Ali ZA, Stone GW, Jeremias A. Changes in post-PCI physiology based on anatomical vessel location: a DEFINE PCI substudy. EUROINTERVENTION 2023; 19:e903-e912. [PMID: 38031488 PMCID: PMC10719742 DOI: 10.4244/eij-d-23-00517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/24/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Anatomical vessel location affects post-percutaneous coronary intervention (PCI) physiology. AIMS We aimed to compare the post-PCI instantaneous wave-free ratio (iFR) in left anterior descending (LAD) versus non-LAD vessels and to identify the factors associated with a suboptimal post-PCI iFR. METHODS DEFINE PCI was a multicentre, prospective, observational study in which a blinded post-PCI iFR pullback was used to assess residual ischaemia following angiographically successful PCI. RESULTS Pre- and post-PCI iFR recordings of 311 LAD and 195 non-LAD vessels were compared. Though pre-PCI iFR in the LAD vessels (median 0.82 [0.63, 0.86]) were higher compared with those in non-LAD vessels (median 0.72 [0.49, 0.84]; p<0.0001), post-PCI iFR were lower in the LAD vessels (median 0.92 [0.88, 0.94] vs 0.98 [0.95, 1.00]; p<0.0001). The prevalence of a suboptimal post-PCI iFR of <0.95 was higher in the LAD vessels (77.8% vs 22.6%; p<0.0001). While the overall frequency of residual physiological diffuse disease (31.4% vs 38.6%; p=0.26) and residual focal disease in the non-stented segment (49.6% vs 50.0%; p=0.99) were similar in both groups, residual focal disease within the stented segment was more common in LAD versus non-LAD vessels (53.7% vs 27.3%; p=0.0009). Improvement in iFR from pre- to post-PCI was associated with angina relief regardless of vessel location. CONCLUSIONS After angiographically successful PCI, post-PCI iFR is lower in the LAD compared with non-LAD vessels, resulting in a higher prevalence of suboptimal post-PCI iFR in LAD vessels. This difference is, in part, due to a greater frequency of a residual focal pressure gradient within the stented segment which may be amenable to more aggressive PCI.
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Affiliation(s)
| | - Akiko Maehara
- Cardiovascular Research Foundation, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Justin E Davis
- Hammersmith Hospital, Imperial College NHS Trust, London, United Kingdom
| | | | - Andrew Sharp
- Royal Devon & Exeter NHS Foundation Trust, Exeter, United Kingdom
| | | | | | - David Cohen
- Cardiovascular Research Foundation, New York, NY, USA
- St. Francis Hospital, Roslyn, NY, USA
| | | | - Ziad A Ali
- Cardiovascular Research Foundation, New York, NY, USA
- St. Francis Hospital, Roslyn, NY, USA
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Allen Jeremias
- Cardiovascular Research Foundation, New York, NY, USA
- St. Francis Hospital, Roslyn, NY, USA
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Elbadawi A, Sedhom R, Ghoweba M, Etewa AM, Kayani W, Rahman F. Contemporary Use of Coronary Physiology in Cardiology. Cardiol Ther 2023; 12:589-614. [PMID: 37668939 DOI: 10.1007/s40119-023-00329-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023] Open
Abstract
Coronary angiography has a limited ability to predict the functional significance of intermediate coronary lesions. Hence, physiological assessment of coronary lesions, via fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR), has been introduced to determine their functional significance. An accumulating body of evidence has consolidated the role of physiology-guided revascularization, particularly among patients with stable ischemic heart disease. The use of FFR or iFR to guide decision-making in patients with stable ischemic heart disease and intermediate coronary lesions received a class I recommendation from major societal guidelines. Nevertheless, the role of coronary physiology testing is less clear among certain patients' groups, including patients with serial coronary lesions, acute coronary syndromes, aortic stenosis, heart failure, as well as post-percutaneous coronary interventions. In this review, we aimed to discuss the utility and clinical evidence of coronary physiology (mainly FFR and iFR), with emphasis on those specific patient groups.
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Affiliation(s)
- Ayman Elbadawi
- Division of Cardiology, Christus Good Shepherd, 707 East Marshall Avenue, Longview, TX, 75604, USA.
| | - Ramy Sedhom
- Department of Internal Medicine, Einstein Medical Centre, Philadelphia, PA, USA
| | - Mohamed Ghoweba
- Department of Internal Medicine, Christus Good Shepherd, Longview, TX, 75601, USA
| | | | - Waleed Kayani
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Faisal Rahman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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4
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Budrys P, Peace A, Baranauskas A, Davidavicius G. Intravascular Ultrasound vs. Fractional Flow Reserve for Percutaneous Coronary Intervention Optimization in Long Coronary Artery Lesions. Diagnostics (Basel) 2023; 13:2921. [PMID: 37761287 PMCID: PMC10528528 DOI: 10.3390/diagnostics13182921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 08/29/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND intravascular ultrasound (IVUS) and fractional flow reserve (FFR) have both been shown to be superior to angiography in optimizing percutaneous coronary intervention (PCI). However, there is still a lack of comparative studies between PCI optimization using physiology and intravascular imaging head-to-head. The aim of this study was to compare the effectiveness of FFR and IVUS PCI optimization strategies on the functional PCI result (assessed with FFR) immediately post-PCI and at 9-12 months after the treatment of long coronary lesions. METHODS This was a single-center study comparing post-PCI FFR between two different PCI optimization strategies (FFR and IVUS). The study included 154 patients who had hemodynamically significant long lesions, necessitating a stent length of 30 mm or more. The procedural outcomes were functional PCI result immediately post-PCI and at 9-12 months after treatment. Clinical outcomes included target vessel failure (TVF) and functional target vessel restenosis rate during follow-up. RESULTS Baseline clinical characteristics and FFR (0.65 [0.55-0.71]) did not differ significantly between the two groups and the left anterior descending artery was treated in 82% of cases. The FFR optimization strategy resulted in a significantly shorter stented segment (49 mm vs. 63 mm, p = 0.001) compared to the IVUS optimization strategy. Although the rates of optimal functional PCI result (FFR > 0.9) did not significantly differ between the FFR and IVUS optimization strategies, a proportion of patients in the FFR group (12%) experienced poor post-PCI functional outcome with FFR values ≤ 0.8, which was not observed in the IVUS group. At the 9-12 month follow-up, 20% of patients in the FFR group had target-vessel-related myocardial ischemia, compared to 6% in the IVUS group. The rates of TVF and functional target vessel restenosis during follow-up were also numerically higher in the FFR optimization group. CONCLUSIONS The use of FFR PCI optimization strategy in the treatment of long coronary artery lesions is associated with a higher incidence of poor functional PCI result and larger myocardial ischemia burden at follow-up compared to the IVUS optimization strategy. However, this discrepancy did not translate into a statistically significant difference in clinical outcomes. This study highlights the importance of using IVUS to optimize long lesions functional PCI outcomes.
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Affiliation(s)
- Povilas Budrys
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Aaron Peace
- Department of Cardiology, Western Health and Social Care Trust, Derry BT47 6SB, UK
| | - Arvydas Baranauskas
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Giedrius Davidavicius
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
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Trans-Stent FFR Gradient as a Modifiable Integrant in Predicting Long-Term Target Vessel Failure. JACC Cardiovasc Interv 2022; 15:2192-2202. [DOI: 10.1016/j.jcin.2022.08.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/09/2022]
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6
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Functional Patterns of Coronary Disease. JACC Cardiovasc Interv 2022; 15:2174-2191. [DOI: 10.1016/j.jcin.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 11/09/2022]
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Fezzi S, Huang J, Lunardi M, Ding D, Ribichini FL, Tu S, Wijns W. Coronary physiology in the catheterisation laboratory: an A to Z practical guide. ASIAINTERVENTION 2022; 8:86-109. [PMID: 36798834 PMCID: PMC9890586 DOI: 10.4244/aij-d-22-00022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/21/2022] [Indexed: 11/16/2022]
Abstract
Coronary revascularisation, either percutaneous or surgical, aims to improve coronary flow and relieve myocardial ischaemia. The decision-making process in patients with coronary artery disease (CAD) remains largely based on invasive coronary angiography (ICA), even though until recently ICA could not assess the functional significance of coronary artery stenoses. Invasive wire-based approaches for physiological evaluations were developed to properly assess the ischaemic relevance of epicardial CAD. Fractional flow reserve (FFR) and later, instantaneous wave-free ratio (iFR), were shown to improve clinical outcomes in several patient subsets when used for coronary revascularisation guidance or deferral and for procedural optimisation of percutaneous coronary intervention (PCI) results. Despite accumulating evidence and positive guideline recommendations, the adoption of invasive physiology has remained quite low, mainly due to technical and economic issues as well as to operator-resistance to change. Coronary image-based computational physiology has been recently developed, with promising results in terms of accuracy and a reduction in computational time, costs, radiation exposure and risks for the patient. Lastly, the integration of intracoronary imaging and physiology allows for individualised PCI treatment, aiming at complete relief of ischaemia through optimised morpho-functional immediate procedural results. Instead of a conventional state-of-the-art review, this A to Z dictionary attempts to provide a practical guide for the application of coronary physiology in the catheterisation laboratory, exploring several methods, their pitfalls, and useful tips and tricks.
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Affiliation(s)
- Simone Fezzi
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland,Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland,Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Mattia Lunardi
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland,Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Daixin Ding
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland,Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Flavio L. Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China,Department of Cardiology, Fujian Medical University Union Hospital, Fujian, China
| | - William Wijns
- The Lambe Institute for Translational Research, Galway National University of Ireland Galway (NUIG), Costello Road, Shantalla, Galway, H91 V4AY, Ireland
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8
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Prognostic value of post-percutaneous coronary intervention diastolic pressure ratio. Neth Heart J 2022; 30:352-359. [PMID: 35391616 PMCID: PMC9270544 DOI: 10.1007/s12471-022-01680-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/20/2022] Open
Abstract
Aim To evaluate the distribution of a generic diastolic pressure ratio (dPR) after angiographically successful percutaneous coronary intervention (PCI) and to assess its association with the 2‑year incidence of target vessel failure (TVF), defined as a composite of cardiac mortality, target vessel revascularisation, target vessel myocardial infarction and stent thrombosis. Methods The dPR SEARCH study is a post hoc analysis of the prospective single-centre FFR-SEARCH registry, in which physiological assessment was performed after angiographically successful PCI in a total of 1000 patients, using a dedicated microcatheter. dPR was calculated offline with recently validated software in a subset of 735 patients. Results Mean post-PCI dPR was 0.95 ± 0.06. Post-PCI dPR was ≤ 0.89 in 15.2% of the patients. The cumulative incidence of TVF at 2‑year follow-up was 9.4% in patients with a final post-PCI dPR ≤ 0.89 as compared to 6.1% in patients with a post-PCI dPR > 0.89 (adjusted hazard ratio [HR] for dPR ≤ 0.89: 1.53; 95% CI 0.74–3.13; p = 0.249). dPR ≤ 0.89 was associated with significantly higher cardiac mortality at 2 years; adjusted HR 2.40; 95% CI 1.01–5.68; p = 0.047. Conclusions In a real-world setting, despite optimal angiographic PCI results, 15.2% of the patients had a final post-PCI dPR of ≤ 0.89, which was associated with a higher incidence of TVF and a significantly higher cardiac mortality rate. Supplementary Information The online version of this article (10.1007/s12471-022-01680-0) contains supplementary material, which is available to authorized users.
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Erbay A, Penzel L, Abdelwahed YS, Klotsche J, Heuberger A, Schatz AS, Steiner J, Haghikia A, Sinning D, Fröhlich GM, Landmesser U, Stähli BE, Leistner DM. Prognostic Impact of Pancoronary Quantitative Flow Ratio Assessment in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes. Circ Cardiovasc Interv 2021; 14:e010698. [PMID: 34674555 DOI: 10.1161/circinterventions.121.010698] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Quantitative flow ratio (QFR) has been introduced as a novel angiography-based modality for fast hemodynamic assessment of coronary artery lesions and validated against fractional flow reserve. This study sought to define the prognostic role of pancoronary QFR assessment in patients with acute coronary syndrome (ACS) including postinterventional culprit and nonculprit vessels. METHODS In a total of 792 patients with ACS (48.6% ST-segment-elevation ACS and 51.4% non-ST-segment-elevation ACS), QFR analyses of postinterventional culprit (n=792 vessels) and nonculprit vessels (n=1231 vessels) were post hoc performed by investigators blinded to clinical outcomes. The follow-up comprised of major adverse cardiovascular events, including all-cause mortality, nonfatal myocardial infarction, and ischemia-driven coronary revascularization within 2 years after the index ACS event. RESULTS Major adverse cardiovascular events as composite end point occurred in 99 patients (12.5%). QFR with an optimal cutoff value of 0.89 for postinterventional culprit vessels and 0.85 for nonculprit vessels emerged as independent predictor of major adverse cardiovascular events after ACS (nonculprit arteries: adjusted odds ratio, 3.78 [95% CI, 2.21-6.45], P<0.001 and postpercutaneous coronary intervention culprit arteries: adjusted odds ratio, 3.60 [95% CI, 2.09-6.20], P<0.001). CONCLUSIONS The present study for the first time demonstrates the prognostic implications of a pancoronary angiography-based functional lesion assessment in patients with ACS. Hence, QFR offers a novel tool to advance risk stratification and guide therapeutic management after ACS.
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Affiliation(s)
- Aslihan Erbay
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Lisa Penzel
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Youssef S Abdelwahed
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Jens Klotsche
- Institute for Epidemiology and Health Care Economics, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (J.K.)
| | - Andrea Heuberger
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Anne-Sophie Schatz
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Julia Steiner
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.).,German Rheumatism Research Centre Berlin, Germany (J.K.)
| | - Arash Haghikia
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - David Sinning
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.)
| | - Georg M Fröhlich
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Ulf Landmesser
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.).,Berlin Institute of Health (BIH), Germany (U.L., D.M.L.)
| | - Barbara E Stähli
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.).,Department of Cardiology, University Heart Centre, University Hospital Zurich, Switzerland (B.E.S.)
| | - David M Leistner
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.).,Berlin Institute of Health (BIH), Germany (U.L., D.M.L.)
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Residual Quantitative Flow Ratio to Estimate Post-Percutaneous Coronary Intervention Fractional Flow Reserve. J Interv Cardiol 2021; 2021:4339451. [PMID: 34548847 PMCID: PMC8426071 DOI: 10.1155/2021/4339451] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Quantitative flow ratio (QFR) computes fractional flow reserve (FFR) based on invasive coronary angiography (ICA). Residual QFR estimates post‐percutaneous coronary intervention (PCI) FFR. This study sought to assess the relationship of residual QFR with post-PCI FFR. Methods Residual QFR analysis, using pre-PCI ICA, was attempted in 159 vessels with post-PCI FFR. QFR lesion location was matched with the PCI location to simulate the performed intervention and allow computation of residual QFR. A post-PCI FFR < 0.90 was used to define a suboptimal PCI result. Results Residual QFR computation was successful in 128 (81%) vessels. Median residual QFR was higher than post-PCI FFR (0.96 Q1–Q3: 0.91–0.99 vs. 0.91 Q1–Q3: 0.86–0.96, p < 0.001). A significant correlation and agreement were observed between residual QFR and post-PCI FFR (R = 0.56 and intraclass correlation coefficient = 0.47, p < 0.001 for both). Following PCI, an FFR < 0.90 was observed in 54 (42%) vessels. Specificity, positive predictive value, sensitivity, and negative predictive value of residual QFR for assessment of the PCI result were 96% (95% confidence interval (CI): 87–99%), 89% (95% CI: 72–96%), 44% (95% CI: 31–59%), and 70% (95% CI: 65–75%), respectively. Residual QFR had an accuracy of 74% (95% CI: 66–82%) and an area under the receiver operating characteristic curve of 0.79 (95% CI: 0.71–0.86). Conclusions A significant correlation and agreement between residual QFR and post-PCI FFR were observed. Residual QFR ≥ 0.90 did not necessarily commensurate with a satisfactory PCI (post-PCI FFR ≥ 0.90). In contrast, residual QFR exhibited a high specificity for prediction of a suboptimal PCI result.
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11
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Zimbardo G, Cialdella P, DI Giusto F, Migliaro S, Anastasia G, Petrolati E, Galante D, D'Amario D, Leone AM. Physiological assessment after percutaneous coronary intervention: the hard truth. Panminerva Med 2021; 63:519-528. [PMID: 34486363 DOI: 10.23736/s0031-0808.21.04363-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Physiologically guided revascularization, using Fractional Flow Reserve (FFR) or instantaneous wave free ratio (iFR) has been demonstrated to be associated with better long-term outcomes compared to an angiographically-guided strategy, mainly avoiding inappropriate coronary stenting and its associated adverse events. On the contrary, the role of invasive physiological assessment after percutaneous coronary intervention (PCI) is much less well established. However, a large body of evidence suggests that a relevant proportion of patients undergoing PCI with a satisfying angiographic result show instead a suboptimal functional product with a potentially negative prognostic impact. For this reason, many efforts have been focused to identify interventional strategies to physiologically optimize PCI. Measuring the functional result after as PCI, especially when performed after a physiological assessment, implies that the operator is ready to accept the hard truth of an unsatisfactory physiological result despite angiographically optimal and, consequently, to optimize the product with some additional effort. The aim of this review is to bridge this gap in knowledge by better defining the paradigm shift of invasive physiological assessment from a simple tool for deciding whether an epicardial stenosis has to be treated to a thoroughly physiological approach to PCI with the suggestion of a practical flow chart.
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Affiliation(s)
| | | | - Federico DI Giusto
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Migliaro
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gianluca Anastasia
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Edoardo Petrolati
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico Galante
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D'Amario
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio M Leone
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy -
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12
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Collison D, Didagelos M, Aetesam-Ur-Rahman M, Copt S, McDade R, McCartney P, Ford TJ, McClure J, Lindsay M, Shaukat A, Rocchiccioli P, Brogan R, Watkins S, McEntegart M, Good R, Robertson K, O'Boyle P, Davie A, Khan A, Hood S, Eteiba H, Berry C, Oldroyd KG. Post-stenting fractional flow reserve vs coronary angiography for optimisation of percutaneous coronary intervention: TARGET-FFR trial. Eur Heart J 2021; 42:4656-4668. [PMID: 34279606 PMCID: PMC8634564 DOI: 10.1093/eurheartj/ehab449] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/29/2021] [Accepted: 06/28/2021] [Indexed: 11/14/2022] Open
Abstract
Aims A fractional flow reserve (FFR) value ≥0.90 after percutaneous coronary intervention (PCI) is associated with a reduced risk of adverse cardiovascular events. TARGET-FFR is an investigator-initiated, single-centre, randomized controlled trial to determine the feasibility and efficacy of a post-PCI FFR-guided optimization strategy vs. standard coronary angiography in achieving final post-PCI FFR values ≥0.90. Methods and results After angiographically guided PCI, patients were randomized 1:1 to receive a physiology-guided incremental optimization strategy (PIOS) or a blinded coronary physiology assessment (control group). The primary outcome was the proportion of patients with a final post-PCI FFR ≥0.90. Final FFR ≤0.80 was a prioritized secondary outcome. A total of 260 patients were randomized (131 to PIOS, 129 to control) and 68.1% of patients had an initial post-PCI FFR <0.90. In the PIOS group, 30.5% underwent further intervention (stent post-dilation and/or additional stenting). There was no significant difference in the primary endpoint of the proportion of patients with final post-PCI FFR ≥0.90 between groups (PIOS minus control 10%, 95% confidence interval −1.84 to 21.91, P = 0.099). The proportion of patients with a final FFR ≤0.80 was significantly reduced when compared with the angiography-guided control group (−11.2%, 95% confidence interval −21.87 to −0.35], P = 0.045). Conclusion Over two-thirds of patients had a physiologically suboptimal result after angiography-guided PCI. An FFR-guided optimization strategy did not significantly increase the proportion of patients with a final FFR ≥0.90, but did reduce the proportion of patients with a final FFR ≤0.80.
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Affiliation(s)
- Damien Collison
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Matthaios Didagelos
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Muhammad Aetesam-Ur-Rahman
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Samuel Copt
- University of Geneva, 24 rue de Général-Dufour, 1211 Genève 4, Switzerland
| | - Robert McDade
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Peter McCartney
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Thomas J Ford
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - John McClure
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Mitchell Lindsay
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Aadil Shaukat
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Paul Rocchiccioli
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Richard Brogan
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Stuart Watkins
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Margaret McEntegart
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Richard Good
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Keith Robertson
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Patrick O'Boyle
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Andrew Davie
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Adnan Khan
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Stuart Hood
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Hany Eteiba
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Colin Berry
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Keith G Oldroyd
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
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13
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Lee JM, Lee SH, Shin D, Choi KH, van de Hoef TP, Kim HK, Samady H, Kakuta T, Matsuo H, Koo BK, Fearon WF, Escaned J. Physiology-Based Revascularization: A New Approach to Plan and Optimize Percutaneous Coronary Intervention. JACC. ASIA 2021; 1:14-36. [PMID: 36338358 PMCID: PMC9627934 DOI: 10.1016/j.jacasi.2021.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/17/2021] [Accepted: 03/20/2021] [Indexed: 06/12/2023]
Abstract
Coronary physiological assessment using fractional flow reserve or nonhyperemic pressure ratios has become a standard of care for patients with coronary atherosclerotic disease. However, most evidence has focused on the pre-interventional use of physiological assessment to aid revascularization decision-making, whereas post-interventional physiological assessment has not been well established. Although evidence for supporting the role of post-interventional physiological assessment to optimize immediate revascularization results and long-term prognosis has been reported, a more thorough understanding of these data is crucial in incorporating post-interventional physiological assessment into daily practice. Recent scientific efforts have also focused on the potential role of pre-interventional fractional flow reserve or nonhyperemic pressure ratio pullback tracings to characterize patterns of coronary atherosclerotic disease to better predict post-interventional physiological outcomes, and thereby identify the appropriate revascularization target. Pre-interventional pullback tracings with dedicated post-processing methods can provide characterization of focal versus diffuse disease or major gradient versus minor gradient stenosis, which would result in different post-interventional physiological results. This review provides a comprehensive look at the current evidence regarding the evolving role of physiological assessment as a functional optimization tool for the entire process of revascularization, and not merely as a pre-interventional tool for revascularization decision-making.
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Key Words
- CI, confidence interval
- DES, drug-eluting stent(s)
- FFR, fractional flow reserve
- HR, hazard ratio
- MACE, major adverse cardiac event(s)
- NHPR, nonhyperemic pressure ratio
- PCI, percutaneous coronary intervention
- TVF, target vessel failure
- VOCE, vessel-related composite event
- fractional flow reserve
- iFR, instantaneous wave-free ratio
- instantaneous wave-free ratio
- nonhyperemic pressure ratios
- percutaneous coronary intervention
- prognosis
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doosup Shin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tim P. van de Hoef
- Department of Clinical and Experimental Cardiology, Amsterdam UMC–University of Amsterdam, Amsterdam, the Netherlands
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Republic of Korea
| | - Habib Samady
- Andreas Gruentzig Cardiovascular Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Javier Escaned
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
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14
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Nagumo S, Collet C, Norgaard BL, Otake H, Ko B, Koo BK, Leipsic J, Andreini D, Heggermont W, Jensen JM, Takahashi Y, Ihdayhid A, Zhang Z, Barbato E, Maeng M, Mizukami T, Bartunek J, Updegrove A, Penicka M, Rogers C, Taylor C, De Bruyne B, Sonck J. Rationale and design of the precise percutaneous coronary intervention plan (P3) study: Prospective evaluation of a virtual computed tomography-based percutaneous intervention planner. Clin Cardiol 2021; 44:446-454. [PMID: 33656754 PMCID: PMC8027584 DOI: 10.1002/clc.23551] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/13/2021] [Accepted: 01/16/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction Fractional flow reserve (FFR) measured after percutaneous coronary intervention (PCI) has been identified as a surrogate marker for vessel related adverse events. FFR can be derived from standard coronary computed tomography angiography (CTA). Moreover, the FFR derived from coronary CTA (FFRCT) Planner is a tool that simulates PCI providing modeled FFRCT values after stenosis opening. Aim To validate the accuracy of the FFRCT Planner in predicting FFR after PCI with invasive FFR as a reference standard. Methods Prospective, international and multicenter study of patients with chronic coronary syndromes undergoing PCI. Patients will undergo coronary CTA with FFRCT prior to PCI. Combined morphological and functional evaluations with motorized FFR hyperemic pullbacks, and optical coherence tomography (OCT) will be performed before and after PCI. The FFRCT Planner will be applied by an independent core laboratory blinded to invasive data, replicating the invasive procedure. The primary objective is to assess the agreement between the predicted FFRCT post‐PCI derived from the Planner and invasive FFR. A total of 127 patients will be included in the study. Results Patient enrollment started in February 2019. Until December 2020, 100 patients have been included. Mean age was 64.1 ± 9.03, 76% were males and 24% diabetics. The target vessels for PCI were LAD 83%, LCX 6%, and RCA 11%. The final results are expected in 2021. Conclusion This study will determine the accuracy and precision of the FFRCT Planner to predict post‐PCI FFR in patients with chronic coronary syndromes undergoing percutaneous revascularization.
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Affiliation(s)
- Sakura Nagumo
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium.,Department of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Bjarne L Norgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Hiromasa Otake
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Brian Ko
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Clayton, Victoria, Australia
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Jonathon Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milano - Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi, Milan, Italy
| | | | - Jesper M Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Yu Takahashi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Abdul Ihdayhid
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Clayton, Victoria, Australia
| | - Zinlong Zhang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Takuya Mizukami
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium.,Clinical Research Institute for Clinical Pharmacology and Therapeutics, Showa University, Tokyo, Japan
| | | | | | | | | | | | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium.,Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
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15
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Masdjedi K, van Zandvoort LJ, Balbi MM, Nuis RJ, Wilschut J, Diletti R, de Jaegere PPT, Zijlstra F, Van Mieghem NM, Daemen J. Validation of novel 3-dimensional quantitative coronary angiography based software to calculate fractional flow reserve post stenting. Catheter Cardiovasc Interv 2020; 98:671-677. [PMID: 33022098 PMCID: PMC8519140 DOI: 10.1002/ccd.29311] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 08/02/2020] [Accepted: 09/21/2020] [Indexed: 12/11/2022]
Abstract
Objectives To validate novel dedicated 3D‐QCA based on the software to calculate post PCI vessel‐FFR (vFFR) in a consecutive series of patients, to assess the diagnostic accuracy, and to assess inter‐observer variability. Background Low post percutaneous coronary intervention (PCI) fractional flow reserve (FFR) predicts future adverse cardiac events. However, FFR assessment requires the insertion of a pressure wire in combination with the use of a hyperemic agent. Methods FAST POST study is an observational, retrospective, single‐center cohort study. One hundred patients presenting with stable angina or non ST‐elevation myocardial infarction, who underwent post PCI FFR assessment using a dedicated microcatheter were included. Two orthogonal angiographic projections were acquired to create a 3D reconstruction of the coronary artery using the CAAS workstation 8.0. vFFR was subsequently calculated using the aortic root pressure. Results Mean age was 65±12 years and 70% were male. Mean microcatheter based FFR and vFFR were 0.91±0.07 and 0.91±0.06, respectively. A good linear correlation was found between FFR and vFFR (r = 0.88; p <.001). vFFR had a higher accuracy in the identification of patients with FFR values <0.90, AUC 0.98 (95% CI: 0.96‐1.00) as compared with 3D‐QCA AUC 0.62 (95% CI: 0.94‐0.74). Assessment of vFFR had a low inter‐observer variability (r = 0.95; p <.001). Conclusion 3D‐QCA derived post PCI vFFR correlates well with invasively measured microcatheter based FFR and has a high diagnostic accuracy to detect FFR <0.90 with low inter‐observer variability.
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Affiliation(s)
- Kaneshka Masdjedi
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Matthew M Balbi
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rutger-Jan Nuis
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jeroen Wilschut
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Peter P T de Jaegere
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Joost Daemen
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
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16
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Collison D, McClure JD, Berry C, Oldroyd KG. A randomized controlled trial of a physiology-guided percutaneous coronary intervention optimization strategy: Rationale and design of the TARGET FFR study. Clin Cardiol 2020; 43:414-422. [PMID: 32037592 PMCID: PMC7244297 DOI: 10.1002/clc.23342] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 01/09/2023] Open
Abstract
Post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) ≥0.90 confers an improved cardiac prognosis. There are currently limited data available to determine how often it is possible to improve an angiographically acceptable but physiologically suboptimal result. A physiology-guided optimization strategy can achieve a clinically meaningful increase in the proportion of patients achieving a final post-PCI FFR ≥0.90 compared to standard care. Following angiographically successful PCI procedures, 260 patients will be randomized (1:1) to receive either a physiology-guided incremental optimization strategy (intervention group) or blinded post-PCI coronary physiology measurements (control group). Patients undergoing successful, standard-of-care PCI for either stable angina or non-ST-segment-elevation myocardial infarction who meet the study's inclusion and exclusion criteria will be eligible for randomization. The primary endpoint is defined as the proportion of patients with a final post-PCI FFR result ≥0.90. Secondary endpoints include change from baseline in Seattle Angina Questionnaire and EQ-5D-5L scores at 3 months and the rate of target vessel failure and its components (cardiac death, myocardial infarction, stent thrombosis, unplanned rehospitalization with target vessel revascularization) at 3 months and 1 year. 260 individual patients were successfully randomized between March 2018 and November 2019. Key baseline demographics of the study population are reported within. TARGET FFR is an investigator-initiated, prospective, single-center, randomized controlled trial of an FFR-guided PCI optimization strategy. The study has completed recruitment and is now in clinical follow-up. It is anticipated that primary results will be presented in Autumn 2020. ClinicalTrials.gov Identifier: NCT03259815. [Correction added on Apr 3 2020, after first online publication: Clinical Trials identifier added.].
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Affiliation(s)
- Damien Collison
- West of Scotland Regional Heart and Lung CentreGolden Jubilee National HospitalClydebankUK
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - John D. McClure
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - Colin Berry
- West of Scotland Regional Heart and Lung CentreGolden Jubilee National HospitalClydebankUK
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - Keith G. Oldroyd
- West of Scotland Regional Heart and Lung CentreGolden Jubilee National HospitalClydebankUK
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
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17
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Uretsky BF, Agarwal SK, Vallurupalli S, Al-Hawwas M, Hasan R, Miller K, Hakeem A. Prospective Evaluation of the Strategy of Functionally Optimized Coronary Intervention. J Am Heart Assoc 2020; 9:e015073. [PMID: 32013707 PMCID: PMC7033880 DOI: 10.1161/jaha.119.015073] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Long‐term outcomes after percutaneous coronary intervention (PCI) relate in part to residual ischemia in the treated vessel, as reflected by post‐PCI fractional flow reserve (FFR). The strategy of FFR after PCI and treatment of residual ischemia—known as functionally optimized coronary intervention (FCI)—may be feasible and capable of improving outcomes. Methods and Results Feasibility and results of FCI using an optical‐sensor pressure wire were prospectively evaluated in an all‐comer population with 50% to 99% lesions and ischemic FFR (≤0.80; ClinicalTrials.gov identifier NCT03227588). FCI was attempted in 250 vessels in 226 consecutive patients. The PCI success rate was 99.6% (249/250 vessels). FCI technical success—that is, FFR before and after PCI and PCI itself using the FFR wire—was 92% (230/250 vessels). Incidence of residual ischemia in the treated vessel was 36.5%. Approximately a third of these vessels (34.5%, n=29) were considered appropriate for further intervention, with FFR increasing from 0.71±0.07 to 0.81±0.06 (P<0.001). Pressure wire pullback showed FFR ≤0.8 at distal stent edge was 7.9% and 0.7% proximal to the stent. FFR increase across the stent was larger in the ischemic than in the nonischemic group (0.06 [interquartile range: 0.04–0.08] versus 0.03 [interquartile range: 0.01–0.05]; P<0.0001) compatible with stent underexpansion as a contributor to residual ischemia. Conclusions FCI is a feasible and safe clinical strategy that identifies residual ischemia in a large proportion of patients undergoing angiographically successful PCI. Further intervention can improve ischemia. The impact of this strategy on long‐term outcomes needs further study.
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Affiliation(s)
- Barry F Uretsky
- Central Arkansas Veterans Health System Little Rock AR.,University of Arkansas for Medical Sciences Little Rock AR
| | - Shiv K Agarwal
- Central Arkansas Veterans Health System Little Rock AR.,University of Arkansas for Medical Sciences Little Rock AR
| | - Srikanth Vallurupalli
- Central Arkansas Veterans Health System Little Rock AR.,University of Arkansas for Medical Sciences Little Rock AR
| | - Malek Al-Hawwas
- Central Arkansas Veterans Health System Little Rock AR.,University of Arkansas for Medical Sciences Little Rock AR
| | - Rimsha Hasan
- University of Arkansas for Medical Sciences Little Rock AR
| | | | - Abdul Hakeem
- Robert Wood Johnson University Hospital Rutgers University New Brunswick NJ
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18
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Gosling RC, Morris PD, Lawford PV, Hose DR, Gunn JP. Personalised fractional flow reserve: a novel concept to optimise myocardial revascularisation. EUROINTERVENTION 2019; 15:707-713. [PMID: 30561366 DOI: 10.4244/eij-d-18-00668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIMS Fractional flow reserve (FFR) represents the percentage reduction in coronary flow relative to a hypothetically normal artery; however, percutaneous coronary intervention (PCI) seldom achieves physiological normality (FFR 1.00), particularly in the context of diffuse disease. In this study we describe a method for calculating the vessel-specific maximal achievable FFR (FFRmax) providing a personalised assessment of what PCI can achieve. METHODS AND RESULTS FFR measurements were obtained from 71 patients (100 arteries) undergoing angiography. Three-dimensional (3D) coronary anatomy was reconstructed from angiographic images. An ideal intervention, in which all stenoses are removed, was modelled, and the FFRmax calculated. The "personalised" FFR (FFRpers) was calculated as measured FFR/FFRmax. PCI was performed in 52 vessels and post-PCI FFR measured in 50. FFRmax was compared to post-PCI measured FFRs. The mean FFRmax was 0.92 (±0.04). This was on average 0.04 (±0.05) higher than the corresponding post-PCI measured FFR (p<0.001). FFRpers was significantly higher (0.06±0.04) than measured FFR (p<0.001), indicating that FFR overestimates flow restoration achievable with PCI. CONCLUSIONS A patient's maximal achievable FFR can now be determined prior to PCI. This approach provides a more realistic assessment of the physiological benefit of PCI than is implied by baseline FFR and may prevent unnecessary intervention.
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Affiliation(s)
- Rebecca C Gosling
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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19
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Yang H, Lim H, Yoon M, Seo K, Choi B, Choi S, Hwang G, Tahk S. Usefulness of the trans‐stent fractional flow reserve gradient for predicting clinical outcomes. Catheter Cardiovasc Interv 2019; 95:E123-E129. [DOI: 10.1002/ccd.28363] [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: 10/24/2018] [Revised: 04/12/2019] [Accepted: 05/18/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Hyoung‐Mo Yang
- Department of CardiologyAjou University School of Medicine Suwon Republic of Korea
| | - Hong‐Seok Lim
- Department of CardiologyAjou University School of Medicine Suwon Republic of Korea
| | - Myeong‐Ho Yoon
- Department of CardiologyAjou University School of Medicine Suwon Republic of Korea
| | - Kyoung‐Woo Seo
- Department of CardiologyAjou University School of Medicine Suwon Republic of Korea
| | - Byoung‐Joo Choi
- Department of CardiologyAjou University School of Medicine Suwon Republic of Korea
| | - So‐Yeon Choi
- Department of CardiologyAjou University School of Medicine Suwon Republic of Korea
| | - Gyo‐Seung Hwang
- Department of CardiologyAjou University School of Medicine Suwon Republic of Korea
| | - Seung‐Jea Tahk
- Department of CardiologyAjou University School of Medicine Suwon Republic of Korea
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20
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van Bommel RJ, Masdjedi K, Diletti R, Lemmert ME, van Zandvoort L, Wilschut J, Zijlstra F, de Jaegere P, Daemen J, van Mieghem NM. Routine Fractional Flow Reserve Measurement After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2019; 12:e007428. [DOI: 10.1161/circinterventions.118.007428] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
| | | | - Roberto Diletti
- Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | | | - Jeroen Wilschut
- Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Peter de Jaegere
- Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands
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21
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Hakeem A, Uretsky BF. Role of Postintervention Fractional Flow Reserve to Improve Procedural and Clinical Outcomes. Circulation 2019; 139:694-706. [DOI: 10.1161/circulationaha.118.035837] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Abdul Hakeem
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ (A.H.)
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22
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Barbin CM, Vasudevan A, Choi JW, McCullough PA, Schussler JM, Vallabhan RC, Stoler RC. Frequency of abnormal fractional flow reserve measurements among major coronary arteries. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:143-146. [PMID: 29807815 DOI: 10.1016/j.carrev.2018.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/28/2018] [Accepted: 04/12/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Fractional flow reserve(FFR) is a validated tool for evaluating functional severity and guiding the revascularization of angiographically moderate coronary artery lesions. OBJECTIVE To study if there is a higher frequency of positive FFR measurements in the left anterior descending(LAD) versus other major coronary arteries and also evaluate the differences in the total length of the stent placed. METHODS A retrospective cohort study including all subjects (January 2011 to December 2015) who had fractional flow reserve (FFR) measured during coronary catheterization was conducted. Coronary catheterizations with FFR at a single tertiary care center were reviewed and FFR ≤ 0.80 post adenosine was deemed positive. The differences in the baseline characteristics and the degree of stenosis were compared between the different vessel groups. RESULTS Of the 758 vessels included in the analysis, the majority were LAD(51.3%) followed by right coronary artery(RCA)(22.8%), Circumflex(22.2%), Left main(2.2%), and Ramus intermedius(1.5%). 25.1% of 758 vessels were FFR positive. The proportion of positive FFR were higher among LAD versus other vessels(33.2%vs.16.5%,p < 0.001), while no differences were noted between RCA and circumflex(p = 0.87) or other vessels excluding LAD(p = 0.69). Of 175 patients who received stents, no statistical difference was noted in the median[range] total length of the stent between LAD(22[9-64]) and the other coronary arteries (18[8-42])(p = 0.19). In patients with an FFR <0.75, we found that the stent length(median [range]) was significantly longer in LAD(28[9-42]) than the other coronary arteries(18[8-42])(p = 0.03). CONCLUSION In our study, FFR was almost twice as likely to be positive in the LAD when compared to other major coronary arteries. Furthermore, there was a trend towards FFR positive LAD lesions needing longer stents than other coronary arteries. This data should encourage operators to evaluate moderate, long lesions in the LAD with FFR, as they have a higher probability of functional significance.
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Affiliation(s)
- Clay M Barbin
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, United States.
| | - Anupama Vasudevan
- Baylor Scott & White Research Institute, Dallas, TX, United States; Texas A&M Health Science Center College of Medicine, Dallas Campus, Dallas, TX, United States.
| | - James W Choi
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, United States; Texas A&M Health Science Center College of Medicine, Dallas Campus, Dallas, TX, United States.
| | - Peter A McCullough
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, United States; Texas A&M Health Science Center College of Medicine, Dallas Campus, Dallas, TX, United States
| | - Jeffrey M Schussler
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, United States; Texas A&M Health Science Center College of Medicine, Dallas Campus, Dallas, TX, United States.
| | - Ravi C Vallabhan
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, United States; Texas A&M Health Science Center College of Medicine, Dallas Campus, Dallas, TX, United States.
| | - Robert C Stoler
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, United States; Texas A&M Health Science Center College of Medicine, Dallas Campus, Dallas, TX, United States.
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