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Rawal H, Nguyen TD, Igbinomwanhia E, Klein LW. Clinical effects of physiologic lesion testing in influencing treatment strategy for multi-vessel coronary artery disease. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 40:100378. [PMID: 38510505 PMCID: PMC10945951 DOI: 10.1016/j.ahjo.2024.100378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 03/22/2024]
Abstract
Background The application of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in multivessel coronary artery disease (CAD) patients has not been definitively explored. We herein assessed how treatment strategies were decided based on FFR/iFR values in vessels selected clinically. Specifically, we sought to determine whether treatment selection was based on whether the vessel tested was the clinical target stenosis. Methods 270 consecutive patients with angiographically determined multivessel disease who underwent FFR/iFR testing were included. Patients were classified initially based on their angiographic findings, then re-evaluated from FFR/iFR results (normal or abnormal). Tested lesions were classified into target or non-target lesions based on clinical and non-invasive evaluations. Results Abnormal FFR/iFR values were demonstrated in 51.9 % of patients, in whom 51.4 % received coronary stenting (PCI) and 44.3 % had bypass surgery (CABG). With two-vessel CAD patients, medical therapy was preferred when the target lesion was normal (72.6 %), while PCI was preferred when it was abnormal (78.4 %). In non-target lesions, PCI was preferred regardless of FFR/iFR results (78.0 %). With three-vessel CAD patients, CABG was preferred when the target lesion was abnormal (68.5 %), and there was no difference in the selected modality when it was normal. Furthermore, the incidence of tested lesions was higher in the left anterior descending (LAD) compared to other coronary arteries, and two-vessel CAD patients with LAD stenoses were more frequently treated by PCI. Conclusion The use of invasive physiologic testing in multivessel CAD patients may alter the preferred treatment strategy, leading to an overall increase in PCI selection.
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Affiliation(s)
- Harsh Rawal
- University of Connecticut, St Francis Hospital, Hartford, CT, United States of America
| | - Tung D. Nguyen
- Department of Physiology & Biophysics, University of Illinois at Chicago – College of Medicine, Chicago, IL, United States of America
| | - Efehi Igbinomwanhia
- Department of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States of America
| | - Lloyd W. Klein
- Department of Cardiology, University of California – San Francisco, San Francisco, CA, United States of America
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Lohmann P, Bundschuh RA, Miederer I, Mottaghy FM, Langen KJ, Galldiks N. Clinical Applications of Radiomics in Nuclear Medicine. Nuklearmedizin 2023; 62:354-360. [PMID: 37935406 DOI: 10.1055/a-2191-3271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Radiomics is an emerging field of artificial intelligence that focuses on the extraction and analysis of quantitative features such as intensity, shape, texture and spatial relationships from medical images. These features, often imperceptible to the human eye, can reveal complex patterns and biological insights. They can also be combined with clinical data to create predictive models using machine learning to improve disease characterization in nuclear medicine. This review article examines the current state of radiomics in nuclear medicine and shows its potential to improve patient care. Selected clinical applications for diseases such as cancer, neurodegenerative diseases, cardiovascular problems and thyroid diseases are examined. The article concludes with a brief classification in terms of future perspectives and strategies for linking research findings to clinical practice.
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Affiliation(s)
- Philipp Lohmann
- Institute of Neuroscience and Medicine (INM-3/-4), Forschungszentrum Jülich GmbH, Jülich, Germany
| | | | - Isabelle Miederer
- Department of Nuclear Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Felix M Mottaghy
- Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany
- Center for Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Duesseldorf, Germany
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Karl Josef Langen
- Institute of Neuroscience and Medicine (INM-3/-4), Forschungszentrum Jülich GmbH, Jülich, Germany
- Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Norbert Galldiks
- Faculty of Medicine and University Hospital Cologne, Department of Neurology, University of Cologne, Cologne, Germany
- Institute of Neuroscience and Medicine (INM-3/-4), Forschungszentrum Jülich GmbH, Jülich, Germany
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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3
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Degtiarova G, Garefa C, Boehm R, Ciancone D, Sepulcri D, Gebhard C, Giannopoulos AA, Pazhenkottil AP, Kaufmann PA, Buechel RR. Radiomics for the detection of diffusely impaired myocardial perfusion: A proof-of-concept study using 13N-ammonia positron emission tomography. J Nucl Cardiol 2023; 30:1474-1483. [PMID: 36600174 PMCID: PMC10371953 DOI: 10.1007/s12350-022-03179-y] [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: 04/18/2022] [Accepted: 11/28/2022] [Indexed: 01/06/2023]
Abstract
AIM The current proof-of-concept study investigates the value of radiomic features from normal 13N-ammonia positron emission tomography (PET) myocardial retention images to identify patients with reduced global myocardial flow reserve (MFR). METHODS Data from 100 patients with normal retention 13N-ammonia PET scans were divided into two groups, according to global MFR (i.e., < 2 and ≥ 2), as derived from quantitative PET analysis. We extracted radiomic features from retention images at each of five different gray-level (GL) discretization (8, 16, 32, 64, and 128 bins). Outcome independent and dependent feature selection and subsequent univariate and multivariate analyses was performed to identify image features predicting reduced global MFR. RESULTS A total of 475 radiomic features were extracted per patient. Outcome independent and dependent feature selection resulted in a remainder of 35 features. Discretization at 16 bins (GL16) yielded the highest number of significant predictors of reduced MFR and was chosen for the final analysis. GLRLM_GLNU was the most robust parameter and at a cut-off of 948 yielded an accuracy, sensitivity, specificity, negative and positive predictive value of 67%, 74%, 58%, 64%, and 69%, respectively, to detect diffusely impaired myocardial perfusion. CONCLUSION A single radiomic feature (GLRLM_GLNU) extracted from visually normal 13N-ammonia PET retention images independently predicts reduced global MFR with moderate accuracy. This concept could potentially be applied to other myocardial perfusion imaging modalities based purely on relative distribution patterns to allow for better detection of diffuse disease.
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Affiliation(s)
- Ganna Degtiarova
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Chrysoula Garefa
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Reto Boehm
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Domenico Ciancone
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Daniel Sepulcri
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Andreas A. Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Aju P. Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Philipp A. Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Ronny R. Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
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4
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Ai H, Zheng N, Li L, Yang G, Li H, Tang G, Zhou Q, Zhang H, Yu X, Xu F, Zhao Y, Sun F. Agreement of Angiography-Derived and Wire-Based Fractional Flow Reserves in Percutaneous Coronary Intervention. Front Cardiovasc Med 2021; 8:654392. [PMID: 33969017 PMCID: PMC8102686 DOI: 10.3389/fcvm.2021.654392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Coronary angiography-derived fractional flow reserve (caFFR) measurements have shown good correlations and agreement with invasive wire-based fractional flow reserve (FFR) measurements. However, few studies have examined the diagnostic performance of caFFR measurements before and after percutaneous coronary intervention (PCI). This study sought to compare the diagnostic performance of caFFR measurements against wire-based FFR measurements in patients before and after PCI. Methods: Patients who underwent FFR-guided PCI were eligible for the acquisition of caFFR measurements. Offline caFFR measurements were performed by blinded hospital operators in a core laboratory. The primary endpoint was the vessel-oriented composite endpoint (VOCE), defined as a composite of vessel-related cardiovascular death, vessel-related myocardial infarction, and target vessel revascularization. Results: A total of 105 pre-PCI caFFR measurements and 65 post-PCI caFFR measurements were compared against available wire-based FFR measurements. A strong linear correlation was found between wire-based FFR and caFFR measurements (r = 0.77; p < 0.001) before PCI, and caFFR measurements also showed a high correlation (r = 0.82; p < 0.001) with wire-based FFR measurements after PCI. A total of 6 VOCEs were observed in 61 patients during follow-up. Post-PCI FFR values (≤0.82) in the target vessel was the strongest predictor of VOCE [hazard ratio (HR): 5.59; 95% confidence interval (CI): 1.12–27.96; p = 0.036). Similarly, patients with low post-PCI caFFR values (≤0.83) showed an 8-fold higher risk of VOCE than those with high post-PCI caFFR values (>0.83; HR: 8.83; 95% CI: 1.46–53.44; p = 0.017). Conclusion: The study showed that the caFFR measurements were well-correlated and in agreement with invasive wire-based FFR measurements before and after PCI. Similar to wire-based FFR measurements, post-PCI caFFR measurements can be used to identify patients with a higher risk for adverse events associated with PCI.
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Affiliation(s)
- Hu Ai
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Naixin Zheng
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Le Li
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Guojian Yang
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Li
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Guodong Tang
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qi Zhou
- The MOH Key Laboratory of Geriatrics, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Huiping Zhang
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xue Yu
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Feng Xu
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Zhao
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Fucheng Sun
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
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5
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van Rosendael AR, Bax AM, van den Hoogen IJ, Smit JM, Al'Aref SJ, Achenbach S, Al-Mallah MH, Andreini D, Berman DS, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Chinnaiyan K, Chow BJW, Cury RC, DeLago A, Feuchtner G, Hadamitzky M, Hausleiter J, Kaufmann PA, Kim YJ, Leipsic JA, Maffei E, Marques H, de Araújo Gonçalves P, Pontone G, Raff GL, Rubinshtein R, Villines TC, Gransar H, Lu Y, Peña JM, Lin FY, Shaw LJ, Narula J, Min JK, Bax JJ. Associations between dyspnoea, coronary atherosclerosis, and cardiovascular outcomes: results from the long-term follow-up CONFIRM registry. Eur Heart J Cardiovasc Imaging 2020; 23:266-274. [PMID: 33538308 DOI: 10.1093/ehjci/jeaa323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 11/17/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS The relationship between dyspnoea, coronary artery disease (CAD), and major cardiovascular events (MACE) is poorly understood. This study evaluated (i) the association of dyspnoea with the severity of anatomical CAD by coronary computed tomography angiography (CCTA) and (ii) to which extent CAD explains MACE in patients with dyspnoea. METHODS AND RESULTS From the international COronary CT Angiography EvaluatioN for Clinical Outcomes: An InteRnational Multicenter (CONFIRM) registry, 4425 patients (750 with dyspnoea) with suspected but without known CAD were included and prospectively followed for ≥5 years. First, the association of dyspnoea with CAD severity was assessed using logistic regression analysis. Second, the prognostic value of dyspnoea for MACE (myocardial infarction and death), and specifically, the interaction between dyspnoea and CAD severity was investigated using Cox proportional-hazard analysis. Mean patient age was 60.3 ± 11.9 years, 63% of patients were male and 592 MACE events occurred during a median follow-up duration of 5.4 (IQR 5.1-6.0) years. On uni- and multivariable analysis (adjusting for age, sex, body mass index, chest pain typicality, and risk factors), dyspnoea was associated with two- and three-vessel/left main (LM) obstructive CAD. The presence of dyspnoea increased the risk for MACE [hazard ratio (HR) 1.57, 95% confidence interval (CI): 1.29-1.90], which was modified after adjusting for clinical predictors and CAD severity (HR 1.26, 95% CI: 1.02-1.55). Conversely, when stratified by CAD severity, dyspnoea did not provide incremental prognostic value in one-, two-, or three-vessel/LM obstructive CAD, but dyspnoea did provide incremental prognostic value in non-obstructive CAD. CONCLUSION In patients with suspected CAD, dyspnoea was independently associated with severe obstructive CAD on CCTA. The severity of obstructive CAD explained the elevated MACE rates in patients presenting with dyspnoea, but in patients with non-obstructive CAD, dyspnoea portended additional risk.
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Affiliation(s)
- Alexander R van Rosendael
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA.,Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - A Maxim Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Inge J van den Hoogen
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Jeff M Smit
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Subhi J Al'Aref
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Mouaz H Al-Mallah
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Daniele Andreini
- Department of Cardiology, Centro Cardiologico Monzino, IRCCS Milan, Milan, Italy
| | - Daniel S Berman
- Department of Imaging and Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Matthew J Budoff
- Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, CA, USA
| | - Filippo Cademartiri
- Department of Radiology, Cardiovascular Imaging Center, SDN IRCCS, Naples, Italy
| | - Tracy Q Callister
- Department of Cardiology, Tennessee Heart and Vascular Institute, Hendersonville, TN, USA
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | | | - Benjamin J W Chow
- Department of Medicine and Radiology, University of Ottawa, Ottawa, ON, Canada
| | - Ricardo C Cury
- Department of Radiology, Miami Cardiac and Vascular Institute, Miami, FL, USA
| | | | - Gudrun Feuchtner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Hadamitzky
- Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany
| | - Joerg Hausleiter
- Department of Radiology, Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital, Zurich, Switzerland.,Department of Medicine, University of Zurich, Zurich, Switzerland
| | - Yong-Jin Kim
- Department of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jonathon A Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Erica Maffei
- Department of Radiology, Area Vasta 1/ASUR Marche, Urbino, Italy
| | - Hugo Marques
- Department of Cardiology, UNICA, Unit of Cardiovascular Imaging, Hospital da Luz, Lisboa, Portugal
| | | | - Gianluca Pontone
- Department of Cardiology, Centro Cardiologico Monzino, IRCCS Milan, Milan, Italy
| | - Gilbert L Raff
- Department of Cardiology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Ronen Rubinshtein
- Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Todd C Villines
- Department of Cardiology, Cardiology Service, Walter Reed National Military Center, Bethesda, MD, USA
| | - Heidi Gransar
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Yao Lu
- Department of Healthcare Policy and Research, New York-Presbyterian Hospital, The Weill Cornell Medical College, New York, NY, USA
| | - Jessica M Peña
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Fay Y Lin
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Leslee J Shaw
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Jagat Narula
- Department of Cardiology, Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA
| | - James K Min
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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6
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Asher A, Wragg A, Davies C. Review: FFRCT Changing the Face of Cardiac CT. CURRENT CARDIOVASCULAR IMAGING REPORTS 2020. [DOI: 10.1007/s12410-020-09548-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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7
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Phalgune D, Jadhav A, Hardas S. Utility of fractional flow reserve in moderate in-stent re-stenosis and jailed side branches and comparison of fractional flow reserve with single-photon emission computed tomography-myocardial perfusion imaging in native coronary artery stenosis. HEART INDIA 2020. [DOI: 10.4103/heartindia.heartindia_33_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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8
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Yamauchi Y, Kanzaki Y, Hayashi M, Arai M, Morita H, Komori T, Hoshiga M, Ishizaka N. Improved diagnosis of the number of stenosed coronary artery vessels by segmentation with scatter and photo-peak window data for attenuation correction in myocardial perfusion SPECT. J Nucl Cardiol 2019; 26:574-581. [PMID: 28905206 DOI: 10.1007/s12350-017-1058-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 08/22/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Attenuation correction using segmentation of scatter and photo-peak window data (SSPAC) enables an evaluation of the attenuation map in a patient-specific manner without additional radiation exposure. We compared the accuracy of SSPAC and non-corrected myocardial perfusion scintigraphy methods for diagnosing the number of stenosed coronary artery vessels. METHODS AND RESULTS We retrospectively reviewed the data from 183 consecutive patients who underwent 99mTc-tetrofosmin stress/rest SPECT examination and a coronary angiography within 3 months. The MPS images were reconstructed with and without SSPAC attenuation correction. We examined the accuracy of the quantitative interpretation using summed differential score in the detection of coronary artery disease (CAD). The attenuation maps were successfully determined in 179 of 183 patients (98%). In terms of the vessel-based diagnostic ability, sensitivity, specificity, positive predictive and negative predictive values of the SSPAC and non-correction methods for diagnosing CAD in individual coronary territories were 77%*, 89%, 74%*, and 90%* vs 51%, 87%, 62%, and 82%, respectively (*P < .05). In 35 patients with multi-vessel CAD, those values were 78%*, 81%, 93%, and 55%* vs 49%, 81%, 89%, and 34%, respectively (*P < .05; AUC: 0.82 vs 0.62, P < .05). CONCLUSION SSPAC-corrected SPECT myocardial perfusion images exhibit improved accuracy in the detection of the number of stenosed coronary artery vessels, even in patients with multi-vessel CAD.
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Affiliation(s)
- Yohei Yamauchi
- Department of Cardiology, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki, 569-8686, Japan
| | - Yumiko Kanzaki
- Department of Cardiology, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki, 569-8686, Japan.
| | - Masuo Hayashi
- Department of Radiology, Osaka Medical College, Takatsuki, Japan
| | - Mami Arai
- Department of Radiology, Osaka Medical College, Takatsuki, Japan
| | - Hideaki Morita
- Department of Cardiology, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki, 569-8686, Japan
| | - Tsuyoshi Komori
- Department of Radiology, Osaka Medical College, Takatsuki, Japan
| | - Masaaki Hoshiga
- Department of Cardiology, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki, 569-8686, Japan
| | - Nobukazu Ishizaka
- Department of Cardiology, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki, 569-8686, Japan
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10
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Pellicano M, De Bruyne B, Toth GG, Casselman F, Wijns W, Barbato E. Fractional flow reserve to guide and to assess coronary artery bypass grafting. Eur Heart J 2018; 38:1959-1968. [PMID: 28025191 DOI: 10.1093/eurheartj/ehw505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 09/30/2016] [Indexed: 11/14/2022] Open
Abstract
The aim of this review is to highlight the role of invasive functional evaluation in patients in whom coronary artery bypass graft (CABG) is indicated, and to examine the clinical evidence available in favour of fractional flow reserve (FFR) adoption in these patients, outline appropriate use, as well as point out potential pitfalls. FFR after CABG will also be reviewed, highlighting its correct interpretation and adoption when applied to both native coronary arteries and bypass grafts. Practice European guidelines support the use of FFR to complement coronary angiography with the highest degree of recommendation (Class IA) for the assessment of coronary stenosis before undertaking myocardial revascularization when previous non-invasive functional evaluation is unavailable or not conclusive. As a result, FFR has been adopted in routine clinical practice to guide clinicians decision as to whether or not perform a revascularization. Of note, due to the increasing confidence of the interventional cardiologists, FFR guidance is also being implemented to indicate or guide CABG. This is in anticipation of supportive clear-cut evidence, since recommendations for FFR adoption were based on randomized clinical trials investigating percutaneous coronary intervention (PCI) strategies in which patients with typical indications for CABG were excluded (e.g. left main disease, valvular disease, and coronary anatomy unsuitable for PCI). Based on the critical appraisal of the literature, FFR can play an important role in risk stratification and determining management strategy of patients either before or after CABG.
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Affiliation(s)
- Mariano Pellicano
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium.,Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bernard De Bruyne
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium
| | - Gabor G Toth
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium.,University Heart Center Graz, Medical University Graz, Graz, Austria
| | - Filip Casselman
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium
| | - William Wijns
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium.,The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway and Saolta University Healthcare Group, Galway, Ireland
| | - Emanuele Barbato
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium.,Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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11
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Warisawa T, Cook CM, Akashi YJ, Davies JE. Past, Present and Future of Coronary Physiology. ACTA ACUST UNITED AC 2018; 71:656-667. [PMID: 29551700 DOI: 10.1016/j.rec.2018.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 01/29/2018] [Indexed: 01/10/2023]
Abstract
It is well known that the apparent significant coronary stenosis on angiography sometimes does not cause significant ischemia, and vice versa. For this reason, decision-making based on coronary physiology is becoming more and more important. Fractional flow reserve (FFR), which has emerged as a useful tool to determine which lesions need revascularization in the catheterization laboratory, now has a class IA indication in the European Society of Cardiology guidelines. More recently, the instantaneous wave-free ratio, which is considered easier to use than FFR, has been graded as equivalent to FFR. This review discusses the concepts of FFR and instantaneous wave-free ratio, current evidence supporting their use, and future directions in coronary physiology.
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Affiliation(s)
- Takayuki Warisawa
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Christopher M Cook
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Justin E Davies
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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Tanaka H, Takahashi T, Ohashi N, Tanaka K, Okada T, Kihara Y. Diagnostic value of thallium-201 myocardial perfusion IQ-SPECT without and with computed tomography-based attenuation correction to predict clinically significant and insignificant fractional flow reserve: A single-center prospective study. Medicine (Baltimore) 2017; 96:e9275. [PMID: 29390486 PMCID: PMC5758188 DOI: 10.1097/md.0000000000009275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to clarify the predictive value of fractional flow reserve (FFR) determined by myocardial perfusion imaging (MPI) using thallium (Tl)-201 IQ-SPECT without and with computed tomography-based attenuation correction (CT-AC) for patients with stable coronary artery disease (CAD).We assessed 212 angiographically identified diseased vessels using adenosine-stress Tl-201 MPI-IQ-SPECT/CT in 84 consecutive, prospectively identified patients with stable CAD. We compared the FFR in 136 of the 212 diseased vessels using visual semiquantitative interpretations of corresponding territories on MPI-IQ-SPECT images without and with CT-AC.FFR inversely correlated most accurately with regional summed difference scores (rSDS) in images without and with CT-AC (r = -0.584 and r = -0.568, respectively, both P < .001). Receiver-operating characteristics analyses using rSDS revealed an optimal FFR cut-off of <0.80 without and with CT-AC. Although the diagnostic accuracy of FFR <0.80 did not significantly differ, FFR ≥0.82 was significantly more accurate with, than without CT-AC. Regions with rSDS ≥2 without or with CT-AC predicted FFR <0.80, and those with rSDS ≤1 without and with CT-AC predicted FFR ≥0.81, with 73% and 83% sensitivity, 84% and 67% specificity, and 79% and 75% accuracy, respectively.Although limited by the sample size and the single-center design, these findings showed that the IQ-SPECT system can predict FFR at an optimal cut-off of <0.80, and we propose a novel application of CT-AC to MPI-IQ-SPECT for predicting clinically significant and insignificant FFR even in nonobese patients.
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Affiliation(s)
- Haruki Tanaka
- Department of Cardiology, Miyoshi Central Hospital, Miyoshi City, Hiroshima, Japan
| | | | - Norihiko Ohashi
- Department of Cardiology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital
| | - Koichi Tanaka
- Department of Cardiology, Miyoshi Central Hospital, Miyoshi City, Hiroshima, Japan
| | - Takenori Okada
- Department of Cardiology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Japan
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Detecting Triple-Vessel Disease with Cadmium Zinc Telluride-Based Single-Photon Emission Computed Tomography Using the Intensity Signal-to-Noise Ratio between Rest and Stress Studies. CONTRAST MEDIA & MOLECULAR IMAGING 2017; 2017:4945680. [PMID: 29114176 PMCID: PMC5661073 DOI: 10.1155/2017/4945680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/10/2017] [Accepted: 08/27/2017] [Indexed: 12/23/2022]
Abstract
The purpose of this study was to investigate if a novel parameter, the stress-to-rest ratio of the signal-to-noise ratio (RSNR) obtained with a cadmium zinc telluride (CZT) SPECT scanner, could be used to distinguish triple-vessel disease (TVD) patients. Methods. One hundred and two patients with suspected coronary artery disease were retrospectively involved. Each subject underwent a Tl-201 SPECT scan and subsequent coronary angiography. Subjects were separated into TVD (n = 41) and control (n = 61) groups based on coronary angiography results using 50% as the stenosis cutoff. The RSNR was calculated by dividing the stress signal-to-noise ratio (SNR) by the rest SNR. Summed scores were calculated using quantitative perfusion SPECT (QPS) for all subjects. Results. The RSNR in the TVD group was found to be significantly lower than that in the control group (0.83 ± 0.15 and 1.06 ± 0.17, resp.; P < 0.01). Receiver-operating characteristic (ROC) analysis showed that RSNR can detect TVD more accurately than the summed difference score with higher sensitivity (85% versus 68%), higher specificity (90% versus 72%), and higher accuracy (88% versus 71%). Conclusion. The RSNR may serve as a useful index to assist the diagnosis of TVD when a fully automatic quantification method is used in CZT-based SPECT studies.
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Foley JRJ, Kidambi A, Biglands JD, Maredia N, Dickinson CJ, Plein S, Greenwood JP. A comparison of cardiovascular magnetic resonance and single photon emission computed tomography (SPECT) perfusion imaging in left main stem or equivalent coronary artery disease: a CE-MARC substudy. J Cardiovasc Magn Reson 2017; 19:84. [PMID: 29110669 PMCID: PMC5674685 DOI: 10.1186/s12968-017-0398-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/16/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Assessment of left main stem (LMS) stenosis has prognostic and therapeutic implications. Data on assessment of LMS disease by cardiovascular magnetic resonance (CMR) and single photon emission computed tomography (SPECT) are limited. CE-MARC is the largest prospective comparison of CMR and SPECT against quantitative invasive coronary angiography (QCA) for detection of coronary artery disease (CAD), and provided the framework for this evaluation. The aims of this study were to compare diagnostic accuracy of visual and quantitative perfusion CMR to SPECT in patients with LMS stable CAD. METHODS Fifty-four patients from the CE-MARC study were included: 27 (4%) with significant LMS or LMS-equivalent disease on QCA, and 27 age/sex-matched patients with no flow-limiting CAD. All patients underwent multi-parametric CMR, SPECT and QCA. Performance of visual and quantitative perfusion CMR by Fermi-constrained deconvolution to detect LMS disease was compared with SPECT. RESULTS Of 27 patients in the LMS group, 22 (81%) had abnormal CMR and 16 (59%) had abnormal SPECT. All patients with abnormal CMR had abnormal perfusion by visual analysis. CMR demonstrated significantly higher area under the curve (AUC) for detection of disease (0.95; 0.85-0.99) over SPECT (0.63; 0.49-0.76) (p = 0.0001). Global mean stress myocardial blood flow (MBF) by CMR in LMS patients was significantly lower than controls (1.77 ± 0.72 ml/g/min vs. 3.28 ± 1.20 ml/g/min, p < 0.001). MBF of <2.08 ml/g/min had sensitivity of 78% and specificity of 85% for diagnosis of LMS disease, with an AUC (0.87; 0.75-0.94) not significantly different to visual CMR analysis (p = 0.18), and more accurate than SPECT (p = 0.003). CONCLUSION Visual stress perfusion CMR had higher diagnostic accuracy than SPECT to detect LMS disease. Quantitative perfusion CMR had similar performance to visual CMR perfusion analysis.
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Affiliation(s)
- James R. J. Foley
- Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT UK
| | - Ananth Kidambi
- Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT UK
| | - John D. Biglands
- Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT UK
| | - Neil Maredia
- Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT UK
| | | | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT UK
| | - John P. Greenwood
- Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT UK
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Götberg M, Cook CM, Sen S, Nijjer S, Escaned J, Davies JE. The Evolving Future of Instantaneous Wave-Free Ratio and Fractional Flow Reserve. J Am Coll Cardiol 2017; 70:1379-1402. [PMID: 28882237 DOI: 10.1016/j.jacc.2017.07.770] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/12/2017] [Accepted: 07/25/2017] [Indexed: 01/10/2023]
Abstract
In this review, the authors reflect upon the role of coronary physiology in the modern management of coronary artery disease. They critically appraise the scientific background of the instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR), from early experimental studies to validation studies against indexes of ischemia, to clinical trials assessing outcome. At this important juncture for the field, the authors make predictions for the future of physiological stenosis assessment, outlining developments for both iFR and FFR in new clinical domains beyond the confines of stable angina. With a focus on the evolving future of iFR and FFR, the authors describe how physiological assessment with iFR may advance its application from simply justifying to guiding revascularization.
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Affiliation(s)
- Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden.
| | | | - Sayan Sen
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Sukhjinder Nijjer
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | | | - Justin E Davies
- Hammersmith Hospital, Imperial College London, London, United Kingdom
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16
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The diagnostic performance of SPECT-MPI to predict functional significant coronary artery disease by fractional flow reserve derived from CCTA (FFRCT): sub-analysis from ACCURACY and VCT001 studies. Int J Cardiovasc Imaging 2017; 33:2067-2072. [DOI: 10.1007/s10554-017-1207-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 06/26/2017] [Indexed: 12/14/2022]
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17
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Relationship Between Coronary Contrast-Flow Quantitative Flow Ratio and Myocardial Ischemia Assessed by SPECT MPI. Eur J Nucl Med Mol Imaging 2017; 44:1888-1896. [DOI: 10.1007/s00259-017-3769-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 06/26/2017] [Indexed: 01/08/2023]
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Gregoire B, Pina-Jomir G, Bontemps L, Janier M, Scheiber C. The value of local normal limits in quantitative Thallium-201 CZT MPI SPECT. J Nucl Cardiol 2017; 24:672-682. [PMID: 26936035 DOI: 10.1007/s12350-016-0430-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/15/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Considering the distinctive characteristics of CZT detectors, automatic quantification of ischemia using normal limits included with software package may deliver suboptimal results for CAD detection. The present study aims to evaluate the benefits of creating normal limits specific to a local population and laboratory protocol. METHODS AND RESULTS Two groups were selected from patients who had undergone a CZT MPI. Normal limits were generated with the QPS application based on the population with low likelihood of CAD. Using the vendor-supplied and the population-specific normal limits i-TPD and vessel-specific SDS results obtained for patients who had subsequently undergone coronary angiography were compared with coronary angiography data. A weak correlation was observed for low i-TPD (stress TPD minus rest TPD) and SDS values. Both databases gave similar values for the area under the ROC curve concerning i-TPD (0.75 to 0.74) and SDS results (0.72 to 0.75 for the LAD, 0.62 to 0.64 for the LCx, and 0.63 to 0.67 for the RCA). Sensitivity (60%), specificity (78%), and predictive positive (84%) and negative (52%) values were also similar with a diagnostic and prognostic threshold value. CONCLUSION The use of a population-specific created database did not influence the diagnostic value of thallium-201 MPI QPS results using a CZT camera.
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Affiliation(s)
- Bastien Gregoire
- Centre de Medicine Nucléaire, Hôpital Louis Pradel, 28, Avenue Doyen Lépine, 69500, Bron, France.
- Université Claude Bernard LYON 1, Faculté de Médecine de Lyon Est., 8 avenue Rockefeller, 69008, Lyon, France.
| | - Géraldine Pina-Jomir
- Centre de Medicine Nucléaire, Hôpital Louis Pradel, 28, Avenue Doyen Lépine, 69500, Bron, France
- Université Claude Bernard LYON 1, Faculté de Médecine de Lyon Est., 8 avenue Rockefeller, 69008, Lyon, France
| | - Laurence Bontemps
- Centre de Medicine Nucléaire, Hôpital Louis Pradel, 28, Avenue Doyen Lépine, 69500, Bron, France
- Université Claude Bernard LYON 1, Faculté de Médecine de Lyon Est., 8 avenue Rockefeller, 69008, Lyon, France
| | - Marc Janier
- Centre de Medicine Nucléaire, Hôpital Louis Pradel, 28, Avenue Doyen Lépine, 69500, Bron, France
- Université Claude Bernard LYON 1, Faculté de Médecine de Lyon Est., 8 avenue Rockefeller, 69008, Lyon, France
| | - Christian Scheiber
- Centre de Medicine Nucléaire, Hôpital Louis Pradel, 28, Avenue Doyen Lépine, 69500, Bron, France
- Université Claude Bernard LYON 1, Faculté de Médecine de Lyon Est., 8 avenue Rockefeller, 69008, Lyon, France
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Prasad S, Harikrishnan S, Sanjay G, Abhilash SP, Bijulal S, Krishna Kumar MN, Tharakan J, Ajit Kumar VK. Clinical Outcomes of patients with coronary artery disease who underwent FFR evaluation of intermediate coronary lesionS- COFFRS study. Indian Heart J 2016; 69:499-504. [PMID: 28822518 PMCID: PMC5560872 DOI: 10.1016/j.ihj.2016.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 11/23/2016] [Accepted: 12/12/2016] [Indexed: 11/29/2022] Open
Abstract
Background We undertook this study to validate the impact of FFR-guided coronary interventions among Indian patients, which is not readily available as of date. Our patients differ from their western counterparts, both in terms of risk profile (younger, more metabolic syndrome, lipid rich diet) as well as their coronary size. Methods We retrospectively evaluated 282 patients with intermediate stenosis in their coronary arteries, who underwent FFR to assess the functional severity of the lesion. There were 3 groups: Group 1–FFR > 0.8 and kept on medical follow-up; Group 2–FFR ≤ 0.8 and underwent revascularisation; and Group 3–FFR ≤ 0.8 and refused to undergo revascularization. 281(99.6%) patients had regular follow-up in our clinic. Results Median age-57 years (range = 28–78). Males = 230, 90 patients were in Group 1, 175 in group 2 (PCI in 144 & CABG in 31) and 17 in group 3. Median follow-up of patients was 17.9 months (2 to 56 months). Three patients(3.4%) in Group 1 had MACE (1 STEMI, 2 UA); 4 patients (2.3%) in Group 2 had Non-STE-ACS; 7 patients (41%) in Group 3 had MACE (3 deaths with acute LVF, 2 NSTEMI, 2 STEMI) Conclusion In our experience, MACE events were not higher in patients with FFR > 0.8 and kept under medical therapy and were similarly lower in patients with FFR ≤0.8 and underwent revascularisation (p = 0.73). Also MACE events were higher in patients with FFR ≤ 0.8 and did not undergo revascularisation compared to other two appropriately treated groups (p = 0.03). FFR based revascularization decision appears to be a safe strategy in Indian patients.
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Affiliation(s)
- Srinivasa Prasad
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, India
| | - S Harikrishnan
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, India
| | - G Sanjay
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, India.
| | - S P Abhilash
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, India
| | - S Bijulal
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, India
| | - M N Krishna Kumar
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, India
| | - Jaganmohan Tharakan
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, India
| | - V K Ajit Kumar
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, India
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Safi M, Karimlu MR, Khaheshi I, Ataeinia B. Concordance between myocardial perfusion scan assessed by SPECT and fractional flow reserve findings for detection of significant ischemia. Egypt Heart J 2016. [DOI: 10.1016/j.ehj.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Hussain ST, Chiribiri A, Morton G, Bettencourt N, Schuster A, Paul M, Perera D, Nagel E. Perfusion cardiovascular magnetic resonance and fractional flow reserve in patients with angiographic multi-vessel coronary artery disease. J Cardiovasc Magn Reson 2016; 18:44. [PMID: 27430288 PMCID: PMC4949877 DOI: 10.1186/s12968-016-0263-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/29/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Perfusion cardiovascular magnetic resonance (CMR) and fractional flow reserve (FFR) are emerging as the most accurate tools for the assessment of myocardial ischemia noninvasively or in the catheter laboratory. However, there is limited data comparing CMR and FFR in patients with multi-vessel disease. This study aims to evaluate the correlation between myocardial ischemia detected by CMR with FFR in patients with multivessel coronary disease at angiography. METHODS AND RESULTS Forty-one patients (123 vascular territories) with angiographic 2- or 3-vessel coronary artery disease (visual stenosis >50 %) underwent high-resolution adenosine stress perfusion CMR at 1.5 T and FFR measurement. An FFR value of <0.75 was considered significant. On a per patient basis, CMR and FFR detected identical ischemic territories in 19 patients (46 %) (mean number of territories 0.7+/-0.7 in both (p = 1.0)). On a per vessel basis, 89 out of 123 territories demonstrated concordance between the CMR and FFR results (72 %). In 34 % of the study population, CMR resulted in fewer ischemic territories than FFR; in 12 % CMR resulted in more ischemic territories than FFR. There was good concordance between the two methods to detect myocardial ischemia on a per-patient (k =0.658 95 % CI 0.383-0.933) level and moderate concordance on a per-vessel (k = 0.453 95 % CI 0.294-0.612) basis. CONCLUSIONS There is good concordance between perfusion CMR and FFR for the identification of myocardial ischemia in patients with multi-vessel disease. However, some discrepancy remains and at this stage it is unclear whether CMR underestimates or FFR overestimates the number of ischemic segments in multi-vessel disease.
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Affiliation(s)
- Shazia T. Hussain
- />Papworth Hospital NHS trust, Papworth Everard, Papworth Everard, Cambridgeshire UK
- />Cardiology Department, Papworth Hospital, Papworth Everard, CB23 3RE UK
| | - Amedeo Chiribiri
- />King’s College London BHF Centre of Excellence, NIHR Biomedical Research Centre and Welcome Trust and EPSRC Medical Engineering Centre at Guy’s and St. Thomas’ NHS Foundation Trust, Division of Imaging Sciences, The Rayne Institute, London, UK
| | | | - Nuno Bettencourt
- />Centro Hospitalar de Vila Nova de Gaia/Espinho, EPE, Vila Nova de Gaia, Portugal
| | - Andreas Schuster
- />Department of Cardiology and Pulmonology and German Centre for Cardiovascular Research, Göttingen, Germany
| | - Matthias Paul
- />Luzerner Kantonsspital, 6000 Luzern 16, Switzerland
| | - Divaka Perera
- />King’s College London BHF Centre of Excellence, NIHR Biomedical Research Centre at Guy’s and St. Thomas’ NHS Foundation Trust, Cardiovascular Division, The Rayne Institute, London, UK
| | - Eike Nagel
- />DZHK Centre for Cardiovascular Imaging, University Hospital Frankfurt/Main, Frankfurt/Main, Germany
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Nakahara T, Iwabuchi Y, Murakami K. Diagnostic Performance of 3D Bull’s Eye Display of SPECT and Coronary CTA Fusion. JACC Cardiovasc Imaging 2016; 9:703-11. [DOI: 10.1016/j.jcmg.2015.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 09/02/2015] [Accepted: 09/03/2015] [Indexed: 11/29/2022]
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Mohdnazri SR, Keeble TR, Sharp AS. Fractional Flow Reserve: Does a Cut-off Value add Value? Interv Cardiol 2016; 11:17-26. [PMID: 29588700 DOI: 10.15420/icr.2016:7:2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Fractional flow reserve (FFR) has been shown to improve outcomes when used to guide percutaneous coronary intervention (PCI). There have been two proposed cut-off points for FFR. The first was derived by comparing FFR against a series of non-invasive tests, with a value of ≤0.75 shown to predict a positive ischaemia test. It was then shown in the DEFER study that a vessel FFR value of ≥0.75 was associated with safe deferral of PCI. During the validation phase, a 'grey zone' for FFR values of between 0.76 and 0.80 was demonstrated, where a positive non-invasive test may still occur, but sensitivity and specificity were sub-optimal. Clinical judgement was therefore advised for values in this range. The FAME studies then moved the FFR cut-off point to ≤0.80, with a view to predicting outcomes. The ≤0.80 cut-off point has been adopted into clinical practice guidelines, whereas the lower value of ≤0.75 is no longer widely used. Here, the authors discuss the data underpinning these cut-off values and the practical implications for their use when using FFR guidance in PCI.
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Affiliation(s)
- Shah R Mohdnazri
- The Essex Cardiothoracic Centre, Basildon, UK.,Anglia Ruskin University, Chelmsford, UK
| | - Thomas R Keeble
- The Essex Cardiothoracic Centre, Basildon, UK.,Anglia Ruskin University, Chelmsford, UK
| | - Andrew Sp Sharp
- Royal Devon and Exeter Hospital, Exeter, UK.,University of Exeter, Exeter, UK
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Kober F, Jao T, Troalen T, Nayak KS. Myocardial arterial spin labeling. J Cardiovasc Magn Reson 2016; 18:22. [PMID: 27071861 PMCID: PMC4830031 DOI: 10.1186/s12968-016-0235-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/22/2016] [Indexed: 11/10/2022] Open
Abstract
Arterial spin labeling (ASL) is a cardiovascular magnetic resonance (CMR) technique for mapping regional myocardial blood flow. It does not require any contrast agents, is compatible with stress testing, and can be performed repeatedly or even continuously. ASL-CMR has been performed with great success in small-animals, but sensitivity to date has been poor in large animals and humans and remains an active area of research. This review paper summarizes the development of ASL-CMR techniques, current state-of-the-art imaging methods, the latest findings from pre-clinical and clinical studies, and future directions. We also explain how successful developments in brain ASL and small-animal ASL-CMR have helped to inform developments in large animal and human ASL-CMR.
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Affiliation(s)
- Frank Kober
- />Aix-Marseille Université, CNRS CRMBM UMR 7339, Centre de Résonance Magnétique Biologique et Médicale, Marseille, France
| | - Terrence Jao
- />Department of Biomedical Engineering, University of Southern California, Los Angeles, California USA
| | - Thomas Troalen
- />Aix-Marseille Université, CNRS CRMBM UMR 7339, Centre de Résonance Magnétique Biologique et Médicale, Marseille, France
| | - Krishna S. Nayak
- />Department of Biomedical Engineering, University of Southern California, Los Angeles, California USA
- />Ming Hsieh Department of Electrical Engineering, University of Southern California, Los Angeles, California USA
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Polte CL, Burck I, Gjertsson P, Lomsky M, Nekolla SG, Nagel E. Cardiac Positron Emission Tomography: a Clinical Perspective. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-016-9371-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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van Nunen LX, Zimmermann FM, Tonino PAL, Barbato E, Baumbach A, Engstrøm T, Klauss V, MacCarthy PA, Manoharan G, Oldroyd KG, Ver Lee PN, Van't Veer M, Fearon WF, De Bruyne B, Pijls NHJ. Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomised controlled trial. Lancet 2015; 386:1853-60. [PMID: 26333474 DOI: 10.1016/s0140-6736(15)00057-4] [Citation(s) in RCA: 393] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) study, fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) improved outcome compared with angiography-guided PCI for up to 2 years of follow-up. The aim in this study was to investigate whether the favourable clinical outcome with the FFR-guided PCI in the FAME study persisted over a 5-year follow-up. METHODS The FAME study was a multicentre trial done in Belgium, Denmark, Germany, the Netherlands, Sweden, the UK, and the USA. Patients (aged ≥ 18 years) with multivessel coronary artery disease were randomly assigned to undergo angiography-guided PCI or FFR-guided PCI. Before randomisation, stenoses requiring PCI were identified on the angiogram. Patients allocated to angiography-guided PCI had revascularisation of all identified stenoses. Patients allocated to FFR-guided PCI had FFR measurements of all stenotic arteries and PCI was done only if FFR was 0·80 or less. No one was masked to treatment assignment. The primary endpoint was major adverse cardiac events at 1 year, and the data for the 5-year follow-up are reported here. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00267774. FINDINGS After 5 years, major adverse cardiac events occurred in 31% of patients (154 of 496) in the angiography-guided group versus 28% (143 of 509 patients) in the FFR-guided group (relative risk 0·91, 95% CI 0·75-1·10; p=0·31). The number of stents placed per patient was significantly higher in the angiography-guided group than in the FFR-guided group (mean 2·7 [SD 1·2] vs 1·9 [1·3], p<0·0001). INTERPRETATION The results confirm the long-term safety of FFR-guided PCI in patients with multivessel disease. A strategy of FFR-guided PCI resulted in a significant decrease of major adverse cardiac events for up to 2 years after the index procedure. From 2 years to 5 years, the risks for both groups developed similarly. This clinical outcome in the FFR-guided group was achieved with a lower number of stented arteries and less resource use. These results indicate that FFR guidance of multivessel PCI should be the standard of care in most patients. FUNDING St Jude Medical, Friends of the Heart Foundation, and Medtronic.
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Affiliation(s)
- Lokien X van Nunen
- Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Frederik M Zimmermann
- Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Pim A L Tonino
- Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Emanuele Barbato
- Cardiovascular Center Aalst, Onze Lieve Vrouw Ziekenhuis, Aalst, Belgium; Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Andreas Baumbach
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Thomas Engstrøm
- Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Volker Klauss
- Medizinische Poliklinik, Campus-Innenstadt, University Hospital, Munich, Germany
| | | | | | | | - Peter N Ver Lee
- Northeast Cardiology Associates and Eastern Maine Medical Center, Bangor, ME, USA
| | - Marcel Van't Veer
- Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - William F Fearon
- Stanford University Medical Center and Palo Alto VA Health Care Systems, Stanford, CA, USA
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouw Ziekenhuis, Aalst, Belgium
| | - Nico H J Pijls
- Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.
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Kidambi A, Sourbron S, Maredia N, Motwani M, Brown JM, Nixon J, Everett CC, Plein S, Greenwood JP. Factors associated with false-negative cardiovascular magnetic resonance perfusion studies: A Clinical evaluation of magnetic resonance imaging in coronary artery disease (CE-MARC) substudy. J Magn Reson Imaging 2015; 43:566-73. [PMID: 26285057 PMCID: PMC4762538 DOI: 10.1002/jmri.25032] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 08/01/2015] [Accepted: 08/04/2015] [Indexed: 12/28/2022] Open
Abstract
Purpose To examine factors associated with false‐negative cardiovascular magnetic resonance (MR) perfusion studies within the large prospective Clinical Evaluation of MR imaging in Coronary artery disease (CE‐MARC) study population. Myocardial perfusion MR has excellent diagnostic accuracy to detect coronary heart disease (CHD). However, causes of false‐negative MR perfusion studies are not well understood. Materials and Methods CE‐MARC prospectively recruited patients with suspected CHD and mandated MR, myocardial perfusion scintigraphy, and invasive angiography. This subanalysis identified all patients with significant coronary stenosis by quantitative coronary angiography (QCA) and MR perfusion (1.5T, T1‐weighted gradient echo), using the original blinded image read. We explored patient and imaging characteristics related to false‐negative or true‐positive MR perfusion results, with reference to QCA. Multivariate regression analysis assessed the likelihood of false‐negative MR perfusion according to four characteristics: poor image quality, triple‐vessel disease, inadequate hemodynamic response to adenosine, and Duke jeopardy score (angiographic myocardium‐at‐risk score). Results In all, 265 (39%) patients had significant angiographic disease (mean age 62, 79% male). Thirty‐five (5%) had false‐negative and 230 (34%) true‐positive MR perfusion. Poor MR perfusion image quality, triple‐vessel disease, and inadequate hemodynamic response were similar between false‐negative and true‐positive groups (odds ratio, OR [95% confidence interval, CI]: 4.1 (0.82–21.0), P = 0.09; 1.2 (0.20–7.1), P = 0.85, and 1.6 (0.65–3.8), P = 0.31, respectively). Mean Duke jeopardy score was significantly lower in the false‐negative group (2.6 ± 1.7 vs. 5.4 ± 3.0, OR 0.34 (0.21–0.53), P < 0.0001). Conclusion False‐negative cardiovascular MR perfusion studies are uncommon, and more common in patients with lower angiographic myocardium‐at‐risk. In CE‐MARC, poor image quality, triple‐vessel disease, and inadequate hemodynamic response were not significantly associated with false‐negative MR perfusion. J. MAGN. RESON. IMAGING 2016;43:566–573.
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Affiliation(s)
- Ananth Kidambi
- Multidisciplinary Cardiovascular Research Centre & the Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - Neil Maredia
- Multidisciplinary Cardiovascular Research Centre & the Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Manish Motwani
- Multidisciplinary Cardiovascular Research Centre & the Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Julia M Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Jane Nixon
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Colin C Everett
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre & the Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre & the Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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29
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Hung OY, Samady H, Anderson HV. Appropriate use criteria: lessons from Japan. JACC Cardiovasc Interv 2015; 7:1010-3. [PMID: 25234673 DOI: 10.1016/j.jcin.2014.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 06/19/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Olivia Y Hung
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Habib Samady
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - H Vernon Anderson
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at Houston, Houston, Texas.
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30
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Pattanshetty DJ, Bhat PK, Gandhi S, Pillai DP, Aneja A. Comparing stress testing and fractional flow reserve to evaluate presence, location and extent of ischemia in coronary artery disease. Indian Heart J 2015; 67:50-5. [PMID: 25820051 DOI: 10.1016/j.ihj.2015.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 02/09/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND FFR provides an accurate and reproducible assessment of the functional severity of coronary stenosis. Whereas stress testing remains the preferred initial modality for assessment of ischemia, there is limited data comparing it with FFR. We sought to determine the correlation between cardiac stress testing and coronary fractional flow reserve (FFR) measurement for assessing the presence, location, and burden of myocardial ischemia in patients referred for evaluation of coronary artery disease (CAD). METHODS Over 5-year study period, of the 5420 consecutive coronary angiograms that were screened, 326 patients had FFR measurements. Of these, 96 patients with FFR measurements who had a preceding stress test (stress echocardiography [SE] or myocardial perfusion imaging [MPI]) within a year were included. RESULTS Of the 96 patients, there were 46 (48%) men and 50 (52%) women with a mean age of 61 ± 10 years. SE was performed in 57 (59.3%) and MPI in 32 (40.7%) of patients. FFR was ≤0.79 in 54 (56%) patients. Stress testing had low sensitivity (55%) and specificity (47%) compared to FFR. The concordance between FFR and stress testing was low for both presence (k=0.03) and location (k=0.05) of the ischemic territory. The number of ischemic vascular territories was correctly estimated in only 39% of the stress tests. SE was more likely to overestimate and MPI more likely to underestimate extent of ischemia. CONCLUSIONS In patients referred for evaluation of CAD, there was poor correlation between stress testing and FFR. A prospective study comparing these two modalities with FFR is needed.
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Affiliation(s)
| | - Pradeep K Bhat
- Case Western Reserve University, MetroHealth Campus, Cleveland, OH, USA
| | - Sanjay Gandhi
- Case Western Reserve University, MetroHealth Campus, Cleveland, OH, USA
| | - Dilip P Pillai
- Case Western Reserve University, MetroHealth Campus, Cleveland, OH, USA
| | - Ashish Aneja
- Case Western Reserve University, MetroHealth Campus, Cleveland, OH, USA.
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31
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Ko SM, Hwang HK, Kim SM, Cho IH. Multi-modality imaging for the assessment of myocardial perfusion with emphasis on stress perfusion CT and MR imaging. Int J Cardiovasc Imaging 2015; 31 Suppl 1:1-21. [PMID: 25809387 DOI: 10.1007/s10554-015-0645-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/16/2015] [Indexed: 01/29/2023]
Abstract
High-quality and non-invasive diagnostic tools for assessing myocardial ischemia are necessary for therapeutic decisions regarding coronary artery disease. Myocardial perfusion has been studied using myocardial contrast echo perfusion, single-photon emission computed tomography, positron emission tomography, cardiovascular magnetic resonance, and, more recently, computed tomography. The addition of coronary computed tomography angiography to myocardial perfusion imaging improves the specificity and overall diagnostic accuracy of detecting the hemodynamic significance of coronary artery stenosis. This study reviews the benefits, limitations, and imaging findings of various imaging modalities for assessing myocardial perfusion, with particular emphasis on stress perfusion computed tomography and cardiovascular magnetic resonance imaging.
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Affiliation(s)
- Sung Min Ko
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-ro, Hwayang-dong, Gwangjin-gu, Seoul, 143-729, Korea,
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32
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Sachdeva R. Effect of revascularization of chronic total occlusion on tandem stenoses in a "donor" artery. Tex Heart Inst J 2014; 41:547-50. [PMID: 25425993 DOI: 10.14503/thij-13-3569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The presence, severity, and extent of ischemia predict the outcome of coronary artery disease. Indeed the extent of myocardial ischemia and viability determines the value of revascularization in coronary stenosis after acute myocardial infarction. In multivessel coronary artery disease, noninvasive methods for the evaluation of ischemia are often inadequate to guide percutaneous coronary intervention. It is a common misperception that revascularization might not benefit a myocardial segment in the chronic total occlusion distribution when that segment is supplied by well-developed collateral vessels, because severe ischemia is unlikely to be present under these circumstances. An 82-year-old man presented with acute coronary syndrome, tandem stenoses in a "donor" artery, and a chronic total occlusion of the right coronary artery. We present a rationale for using fractional flow reserve to determine the existence of ischemia and to aid in deciding the best approach to the treatment of that ischemia.
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33
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Kamiya K, Sakakibara M, Asakawa N, Yamada S, Yoshitani T, Iwano H, Komatsu H, Naya M, Chiba S, Yamada S, Manabe O, Kikuchi Y, Oyama-Manabe N, Oba K, Tsutsui H. Cardiac magnetic resonance performs better in the detection of functionally significant coronary artery stenosis compared to single-photon emission computed tomography and dobutamine stress echocardiography. Circ J 2014; 78:2468-76. [PMID: 25109426 DOI: 10.1253/circj.cj-13-1454] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Fractional flow reserve (FFR) measured on catheterization is now widely used for the diagnosis of functional myocardial ischemia in patients with coronary artery disease (CAD). FFR, however, is invasive and carries potential procedural complications. Therefore, the aim of this study was to compare the diagnostic capability in functionally significant stenosis identified on FFR, between cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI), single-photon emission computed tomography MPI (SPECT-MPI), and dobutamine stress echocardiography (DSE) in patients with CAD. METHODS AND RESULTS A total of 25 patients who had at least 1 angiographic stenosis ≥50% on coronary angiography was studied. CMR-MPI, SPECT-MPI and DSE were done before FFR measurement. FFR was measured in all 3 major epicardial coronary arteries. Out of 71 vascular territories excluding 4 territories due to inadequate imaging, 29 (41%) had FFR <0.80. The sensitivity of CMR-MPI was significantly higher than that of SPECT-MPI and DSE (P=0.02 and P=0.001, respectively). The area under the receiver operating characteristic curve (AUC) for CMR-MPI (AUC, 0.92) was significantly greater than for SPECT-MPI (AUC, 0.73; P=0.006) and DSE (AUC, 0.69; P<0.001). CONCLUSIONS CMR-MPI performed well in the detection of functionally significant stenosis defined according to FFR, and had the highest diagnostic sensitivity among the 3 modalities tested in patients with CAD.
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Affiliation(s)
- Kiwamu Kamiya
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
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35
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SPECT myocardial perfusion versus fractional flow reserve for evaluation of functional ischemia: A meta analysis. Eur J Radiol 2014; 83:951-956. [DOI: 10.1016/j.ejrad.2014.02.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 02/13/2014] [Accepted: 02/17/2014] [Indexed: 01/23/2023]
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Affiliation(s)
- William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA
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37
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Iwasaki K. Myocardial ischemia is a key factor in the management of stable coronary artery disease. World J Cardiol 2014; 6:130-9. [PMID: 24772253 PMCID: PMC3999333 DOI: 10.4330/wjc.v6.i4.130] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/16/2013] [Accepted: 03/03/2014] [Indexed: 02/07/2023] Open
Abstract
Previous studies demonstrated that coronary revascularization, especially percutaneous coronary intervention (PCI), does not significantly decrease the incidence of cardiac death or myocardial infarction in patients with stable coronary artery disease. Many studies using myocardial perfusion imaging (MPI) showed that, for patients with moderate to severe ischemia, revascularization is the preferred therapy for survival benefit, whereas for patients with no to mild ischemia, medical therapy is the main choice, and revascularization is associated with increased mortality. There is some evidence that revascularization in patients with no or mild ischemia is likely to result in worsened ischemia, which is associated with increased mortality. Studies using fractional flow reserve (FFR) demonstrate that ischemia-guided PCI is superior to angiography-guided PCI, and the presence of ischemia is the key to decision-making for PCI. Complementary use of noninvasive MPI and invasive FFR would be important to compensate for each method's limitations. Recent studies of appropriateness criteria showed that, although PCI in the acute setting and coronary bypass surgery are properly performed in most patients, PCI in the non-acute setting is often inappropriate, and stress testing to identify myocardial ischemia is performed in less than half of patients. Also, some studies suggested that revascularization in an inappropriate setting is not associated with improved prognosis. Taken together, the presence and the extent of myocardial ischemia is a key factor in the management of patients with stable coronary artery disease, and coronary revascularization in the absence of myocardial ischemia is associated with worsened prognosis.
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Affiliation(s)
- Kohichiro Iwasaki
- Kohichiro Iwasaki, Department of Cardiology, Okayama Kyokuto Hospital, Okayama 703-8265, Japan
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38
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Yokota S, Ottervanger JP, Mouden M, Timmer JR, Knollema S, Jager PL. Prevalence, location, and extent of significant coronary artery disease in patients with normal myocardial perfusion imaging. J Nucl Cardiol 2014; 21:284-90. [PMID: 24469846 DOI: 10.1007/s12350-013-9837-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/27/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND False-negative myocardial perfusion imaging (MPI) can by due to left main (LM) or three-vessel disease causing "balanced ischemia". However, so far prevalence of LM or three-vessel-disease in patients with normal MPI is unclear. We assessed prevalence, location, and extent of significant coronary artery disease (CAD) in patients with normal MPI. METHODS Between 2006 and 2010, 256 patients with normal MPI who had invasive angiography because of persisting or worsening of the same initial symptoms were studied. Significant CAD was defined as stenosis > 70% or LM > 50%. RESULTS A total of 93 patients (36%) had significant CAD. Significant CAD was observed more frequently in males, higher age and those with typical angina complaints. Significant LM disease was present in 7%, three-vessel disease in 10%, two-vessel disease in 22%, and single vessel disease (not left main) in 61%. In those with single vessel disease, the location was the LAD in 40%, the RCA in 30%, and the LCX in 30%. CONCLUSIONS In selected patients with normal MPI, one-third had significant CAD. The majority of these patients had single vessel disease (not left main). LM or three vessel disease, causing "balanced ischemia", is a less common cause of false-negative MPI.
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Affiliation(s)
- Shu Yokota
- Department of Cardiology, Isala Klinieken, Dokter Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
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Elgendy IY, Conti CR, Bavry AA. Fractional flow reserve: an updated review. Clin Cardiol 2014; 37:371-80. [PMID: 24652785 DOI: 10.1002/clc.22273] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 02/18/2014] [Indexed: 01/10/2023] Open
Abstract
Revascularization of ischemia-producing coronary lesions is widely used in the management of coronary artery disease. However, some coronary lesions appear significant on the conventional angiogram when they are truly non-flow limiting. For this reason, it is becoming increasingly important to determine the coronary physiology. Fractional flow reserve (FFR) has emerged as a useful tool to determine the lesions that require revascularization. Measurement of FFR during invasive coronary angiography now has a class IA indication from the European Society of Cardiology for identifying hemodynamically significant coronary lesions when noninvasive evidence of myocardial ischemia is unavailable. Current data on FFR can be broadly classified into studies that compare the diagnostic accuracy of FFR measurement compared with other noninvasive modalities and studies that test treatment strategies of patients with intermediate coronary stenoses using a threshold value for FFR and that have clinical outcomes as endpoints. In this review, we will discuss the concept of FFR, current evidence supporting its usage, and future perspectives.
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Affiliation(s)
- Islam Y Elgendy
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida
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40
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Abstract
Cornerstones in the treatment of coronary artery disease (CAD) are medical therapy and coronary revascularization. In acute settings (ST-elevation myocardial infarction and non-ST-elevation myocardial infarction), percutaneous coronary intervention (PCI) has proven to improve prognosis. The optimal treatment of stable CAD is subject to great controversy. By using fractional flow reserve to guide PCI, it is possible to stent only those lesions that induce myocardial ischemia. This review aims to reflect on the use of FFR-guided PCI in stable CAD.
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Myocardial perfusion imaging with a cadmium zinc telluride-based gamma camera versus invasive fractional flow reserve. Eur J Nucl Med Mol Imaging 2013; 41:956-62. [DOI: 10.1007/s00259-013-2630-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 11/06/2013] [Indexed: 11/25/2022]
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Wada T, Hirata K, Shiono Y, Orii M, Shimamura K, Ishibashi K, Tanimoto T, Yamano T, Ino Y, Kitabata H, Yamaguchi T, Kubo T, Imanishi T, Akasaka T. Coronary flow velocity reserve in three major coronary arteries by transthoracic echocardiography for the functional assessment of coronary artery disease: a comparison with fractional flow reserve. Eur Heart J Cardiovasc Imaging 2013; 15:399-408. [DOI: 10.1093/ehjci/jet168] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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43
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Diagnostic performance of computed tomography coronary angiography to detect and exclude left main and/or three-vessel coronary artery disease. Eur Radiol 2013; 23:2934-43. [DOI: 10.1007/s00330-013-2935-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 05/16/2013] [Indexed: 10/26/2022]
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Wasilewski J, Mirota K, Hawranek M, Poloński L. Invasive and non-invasive fractional flow reserve index in validation of hemodynamic severity of intracoronary lesions. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2013; 9:160-9. [PMID: 24570710 PMCID: PMC3915971 DOI: 10.5114/pwki.2013.35452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Revised: 03/25/2013] [Accepted: 04/22/2013] [Indexed: 01/17/2023] Open
Abstract
This review discusses visual and functional evaluation of the hemodynamic significance of the degree of stenosis in coronary angiography, with respect to the indications for revascularization. The concept of the coronary flow reserve is defined, and the theoretical assumptions of the invasive measurement of the fractional flow reserve (FFR) are presented. In the following part, the publication describes the basic steps of numerical stimulations in terms of computational fluid dynamics (CFD) in calculating the fractional flow reserve based on computed tomography (CT) coronary angiography (FFRCT). The numerical FFRCT estimation in correlation with invasive measurements, as well as benefits deriving from FFRCT in the diagnosis of coronary artery disease, is presented in the example of the multicentre prospective DISCOVER-FLOW trial and the DeFACTO project. The CDF method enables to obtain hemodynamic significance of stenosis solely from the coronary anatomy vizualized by CT angiography. The calculation of FFRCT increases the diagnostic reliability of coronary flow reserve estimations. It contributes to the improvement in patients' qualification for contrast coronarography. If the accuracy of FFRCT is confirmed in clinical practice, and the time required for computational processing is shortened, it may turn out that the algorithms of coronary heart disease diagnosis will be verified and it will be to a greater extent based on the CT results.
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Affiliation(s)
- Jarosław Wasilewski
- 3 Department of Cardiology, Silesian Center for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | | | - Michał Hawranek
- 3 Department of Cardiology, Silesian Center for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Lech Poloński
- 3 Department of Cardiology, Silesian Center for Heart Diseases, Medical University of Silesia, Zabrze, Poland
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van de Hoef TP, Meuwissen M, Escaned J, Davies JE, Siebes M, Spaan JAE, Piek JJ. Fractional flow reserve as a surrogate for inducible myocardial ischaemia. Nat Rev Cardiol 2013; 10:439-52. [DOI: 10.1038/nrcardio.2013.86] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Accuracy of stress myocardial perfusion imaging to diagnose coronary artery disease in end stage liver disease patients. Am J Cardiol 2013; 111:1057-61. [PMID: 23337839 DOI: 10.1016/j.amjcard.2012.12.023] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 12/05/2012] [Accepted: 12/05/2012] [Indexed: 02/08/2023]
Abstract
Patients with end-stage liver disease (ESLD) who also have underlying coronary artery disease (CAD) may be at increased risk for undergoing hemodynamically challenging orthotopic liver transplantation. Noninvasive single-photon emission computed tomographic (SPECT) imaging is often used to determine whether a patient with ESLD has unsuspected CAD. The objective of this study was to determine the accuracy of SPECT imaging for detection of CAD in patients with ESLD. Patients with ESLD who underwent coronary angiography and SPECT imaging before orthotopic liver transplantation were analyzed retrospectively. The predictive accuracy of clinical risk factors was calculated and compared to the results of SPECT imaging. There were 473 SPECT imaging studies. Adenosine SPECT imaging had a sensitivity of 62%, specificity of 82%, positive predictive value of 30%, and negative predictive value of 95% for diagnosing severe CAD. Regadenoson SPECT imaging had a sensitivity of 35%, specificity of 88%, positive predictive value of 23%, and negative predictive value of 93% for diagnosing severe CAD. The accuracy of a standard risk factor analysis showed no statistical difference in predicting CAD compared with adenosine (sensitivity McNemar's p = 0.48, specificity McNemar's p = 1.00) or regadenoson (sensitivity McNemar's p = 0.77, specificity McNemar's p = 1.00) SPECT studies. In conclusion, the 2 pharmaceutical agents had low sensitivity but high specificity for diagnosing CAD. However, because the sensitivity of the test is low, the chances of missing patients with ESLD with CAD is high, making SPECT imaging an inaccurate screening test. A standard risk factor analysis as a predictor for CAD in patients with ESLD is less expensive, has no radiation exposure, and is as accurate as SPECT imaging.
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Cockburn J, Blows L, Williams M, Munir S, de Belder A, Hildick-Smith D, Holmberg S. Fractional flow reserve in the assessment of coronary artery lesions. Br J Hosp Med (Lond) 2013; 73:677-81. [PMID: 23502195 DOI: 10.12968/hmed.2012.73.12.677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
The haemodynamic effect of a coronary artery stenosis is a better predictor of prognosis than anatomical lumen obstruction. Until recently, no individual non-invasive test could provide both accurate coronary anatomy and lesion-specific myocardial ischaemia. However, computer tomography (CT) fractional flow reserve, which can be calculated from a standard CT coronary angiogram, was recently demonstrated to accurately detect and rule out the haemodynamic significance of individual coronary artery stenoses.
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Park SJ, Ahn JM, Kang SJ. Unprotected left main percutaneous coronary intervention: integrated use of fractional flow reserve and intravascular ultrasound. J Am Heart Assoc 2012; 1:e004556. [PMID: 23316329 PMCID: PMC3540662 DOI: 10.1161/jaha.112.004556] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 10/09/2012] [Indexed: 01/25/2023]
Affiliation(s)
- Seung-Jung Park
- Heart Institute, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.
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Sahiner I, Akdemir UO, Kocaman SA, Sahinarslan A, Timurkaynak T, Unlu M. Quantitative evaluation improves specificity of myocardial perfusion SPECT in the assessment of functionally significant intermediate coronary artery stenoses: a comparative study with fractional flow reserve measurements. Ann Nucl Med 2012. [DOI: 10.1007/s12149-012-0666-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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