1
|
Maznyczka A, Rajkumar C, Hobson A, Haworth PA. Effect of coronary tortuosity on invasive physiology. BMJ Case Rep 2022; 15:e249095. [PMID: 35688575 PMCID: PMC9189850 DOI: 10.1136/bcr-2022-249095] [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] [Accepted: 05/26/2022] [Indexed: 11/04/2022] Open
Abstract
We present a case of angina, where extreme coronary tortuosity affected invasive physiology interpretation. Extreme coronary tortuosity may lower fractional flow reserve and instantaneous wave-free ratio. Therefore, invasive physiology can be misleading in this setting, when used to evaluate stenosis significance, or when used post-percutaneous coronary (PCI) intervention for physiology guided stent optimisation.
Collapse
Affiliation(s)
- Annette Maznyczka
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Christopher Rajkumar
- Department of Cardiology, Imperial College London National Heart and Lung Institute, London, UK
| | - Alex Hobson
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Peter Aj Haworth
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| |
Collapse
|
2
|
Yokota S, Borren NM, Ottervanger JP, Mouden M, Timmer JR, Knollema S, Jager PL. Does fractional flow reserve overestimate severity of LAD lesions? J Nucl Cardiol 2020; 27:1306-1313. [PMID: 31044405 DOI: 10.1007/s12350-019-01712-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 03/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Fractional Flow Reserve (FFR) is increasingly used to estimate the severity of coronary stenoses, prior to coronary revascularization. However, it has been suggested that FFR overestimates the severity of Left Anterior Descending (LAD) lesions. Our aim was to verify whether in patients without ischemia on Myocardial Perfusion Imaging, FFR of the LAD is more often abnormal in comparison to FFR of other coronary arteries. METHODS Prospective cohort study of consecutive patients who underwent FFR measurement because of persistent or worsening of angina complaints, within 6 months after normal Myocardial Perfusion Imaging. FFR measurements of a graft or diagonal branch were excluded. A FFR ≤ 0.80 denoted a functionally relevant stenosis. RESULTS In 133 patients, 167 FFR measurements were performed, of which 85 in the LAD. Mean age of the patients was 64.8 ± 10.5 years, 40% were women. There were no differences in baseline characteristics between patients undergoing LAD and non-LAD measurements. An abnormal FFR was observed in 35.3% of the LAD measurements, compared to 9.8% in the non-LAD measurements (P = 0.001). Also after adjusting for age and gender, the FFR remained more frequently abnormal in the LAD with OR 5.2 (95% CI 2.2 to 12.3). Of the abnormal FFR LAD measurements, 70% were visually considered non-obstructive on invasive angiography. CONCLUSIONS In selected patients without ischemia on MPI, FFR measurement of the LAD is significantly more often abnormal. The majority of these patients has no obstructive lesions on invasive angiography. Possibly, FFR overestimates severity of LAD lesions, with risk of unnecessary revascularization.
Collapse
Affiliation(s)
- Shu Yokota
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Nanette M Borren
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
- Department of Nuclear Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Jan Paul Ottervanger
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
| | - Mohamed Mouden
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Jorik R Timmer
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Siert Knollema
- Department of Nuclear Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Pieter L Jager
- Department of Nuclear Medicine, Isala Hospital, Zwolle, The Netherlands
| |
Collapse
|
3
|
Spadaccio C, Glineur D, Barbato E, Di Franco A, Oldroyd KG, Biondi-Zoccai G, Crea F, Fremes SE, Angiolillo DJ, Gaudino M. Fractional Flow Reserve-Based Coronary Artery Bypass Surgery: Current Evidence and Future Directions. JACC Cardiovasc Interv 2020; 13:1086-1096. [PMID: 32222443 DOI: 10.1016/j.jcin.2019.12.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/25/2019] [Accepted: 12/12/2019] [Indexed: 02/08/2023]
Abstract
Fractional flow reserve (FFR) provides an objective measurement of the severity of ischemia caused by coronary stenoses in downstream myocardial regions. Data from the interventional cardiology realm have suggested benefits of a FFR-guided percutaneous coronary intervention (PCI) strategy. Limited evidence is available on the use of FFR to guide coronary artery bypass grafting (CABG). The most recent data have shown that FFR might simplify CABG procedures and optimize patency of arterial grafts without any clear impact on clinical outcomes. The aim of this review was to summarize the available data on FFR-based CABG and discuss the rationale and potential consequences of a switch toward FFR-based surgical revascularization strategy.
Collapse
Affiliation(s)
- Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - David Glineur
- Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Italy
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Keith G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Stephen E Fremes
- Schulich Heart Centre, Division of Cardiac Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Dominick J Angiolillo
- Department of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
| |
Collapse
|
4
|
Miao Z, Liebeskind DS, Lo W, Liu L, Pu Y, Leng X, Song L, Xu X, Jia B, Gao F, Mo D, Sun X, Liu L, Ma N, Wang B, Wang Y, Wang Y. Fractional Flow Assessment for the Evaluation of Intracranial Atherosclerosis: A Feasibility Study. INTERVENTIONAL NEUROLOGY 2016; 5:65-75. [PMID: 27610123 DOI: 10.1159/000444333] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Current studies on endovascular intervention for intracranial atherosclerosis select patients based on luminal stenosis. Coronary studies demonstrated that fractional flow measurements assess ischemia better than anatomical stenosis and can guide patient selection for intervention. We similarly postulated that fractional flow can be used to assess ischemic stroke risk. METHODS This was a feasibility study to assess the technical use and safety of applying a pressure guidewire to measure fractional flow across intracranial stenoses. Twenty patients with severe intracranial stenosis were recruited. The percentage of luminal stenosis, distal to proximal pressure ratios (fractional flow) and the fractional flow gradients across the stenosis were measured. Procedural success rate and safety outcomes were documented. RESULTS All 20 patients had successful crossing of stenosis by the pressure guidewire. Ten patients underwent angioplasty, and 5 had stenting performed. There was one perforator stroke, but not related to the use of the pressure wire. For the 13 patients with complete pre- and postintervention data, the mean preintervention stenosis, fractional flow and translesional pressure gradient were 76.2%, 0.66 and 29.9 mm Hg, whilst the corresponding postintervention measurements were 24.7%, 0.88 and 10.9 mm Hg, respectively. Fractional flow (r = -0.530, p = 0.001) and the translesional pressure gradient (r = 0.501, p = 0.002) only had a modest correlation with the luminal stenosis. CONCLUSION Fractional flow measurement by floating a pressure guidewire across the intracranial stenosis was technically feasible and safe in this study. Further studies are needed to validate its use for ischemic stroke risk assessment.
Collapse
Affiliation(s)
- ZhongRong Miao
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - WaiTing Lo
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong, SAR, China
| | - LiPing Liu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - YueHua Pu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - XinYi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - LiGang Song
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - XiaoTong Xu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - BaiXue Jia
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Feng Gao
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - DaPeng Mo
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuan Sun
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lian Liu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ning Ma
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Bo Wang
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - YiLong Wang
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - YongJun Wang
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| |
Collapse
|