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Zhu Y, Zhou G, Yang L, Liu K, Xie Y, Yang WY, Dai Q. Predictive value of intravascular ultrasound for the function of intermediate coronary lesions. BMC Cardiovasc Disord 2023; 23:457. [PMID: 37710160 PMCID: PMC10500773 DOI: 10.1186/s12872-023-03489-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/01/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Intravascular ultrasound (IVUS) can provide detailed coronary anatomic parameters. The purpose of our study was to evaluate the parameters measured by IVUS for the prediction of intermediate coronary lesions function by referencing quantitative fraction ratio (QFR) ≤ 0.80 (vs. > 0.80). METHODS Eighty four cases with 92 intermediate coronary lesions in vessels with a diameter ≥ 2.50 mm were enrolled. Paired assessment of IVUS and cQFR was available, and vessels with cQFR ≤ 0.8 were considered the positive reference standard. Logistic regression was used to select model variables by a maximum partial likelihood estimation test and receiver operating characteristic curve (ROC) analysis to evaluate the diagnostic value of different indices. RESULTS Plaque burden (PB) and lesion length (LL) of IVUS were independent risk factors for the function of coronary lesions. The predictive probability P was derived from the combined PB and LL model. The area under the curve (AUC) of PB, (minimum lumen area) MLA, and LL and the predicted probability P are 0.789,0.732,0731, and 0.863, respectively (P < 0.01). The AUC of the predicted probability P was the biggest among them; the prediction accuracy of cQFR ≤ 0.8 was 84.8%, and the sensitivity of the diagnostic model was 0.826, specificity was 0. 725, and P < 0.01. CONCLUSION PB and LL of IVUS were independent risk factors influencing the function of intermediate coronary lesions. The model combining the PB and LL may predict coronary artery function better than any other single parameter.
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Affiliation(s)
- Yajuan Zhu
- Department of Cardiology, Shanghai General Hospital of Nanjing Medical University, No.100, Haining Rd, Hongkou District, Shanghai, 200080, China
| | - Guowei Zhou
- Department of Cardiology, Shanghai General Hospital of Shanghai Jiao Tong University School of Medicine, No.100, Haining Rd, Hongkou District, Shanghai, 200080, China
| | - Lei Yang
- Department of Emergency, Shanghai General Hospital of Shanghai Jiao Tong University School of Medicine, No.100, Haining Rd, Hongkou District, Shanghai, 200080, China
| | - Keng Liu
- Menghai County People's Hospital, Xishuangbanna, Yunnan Province, China
| | - Yuning Xie
- School of Oral Medicine, Nanjing Medical University, No.1, Shanghai RD, Nanjing City, Jiangsu Province, China
| | - Wen-Yi Yang
- Department of Cardiology, Shanghai General Hospital of Shanghai Jiao Tong University School of Medicine, No.100, Haining Rd, Hongkou District, Shanghai, 200080, China.
| | - Qiuyan Dai
- Department of Cardiology, Shanghai General Hospital of Nanjing Medical University, No.100, Haining Rd, Hongkou District, Shanghai, 200080, China.
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Litmanovich D, Hurwitz Koweek LM, Ghoshhajra BB, Agarwal PP, Bourque JM, Brown RKJ, Davis AM, Fuss C, Johri AM, Kligerman SJ, Malik SB, Maroules CD, Meyersohn NM, Vasu S, Villines TC, Abbara S. ACR Appropriateness Criteria® Chronic Chest Pain-High Probability of Coronary Artery Disease: 2021 Update. J Am Coll Radiol 2022; 19:S1-S18. [PMID: 35550795 DOI: 10.1016/j.jacr.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
Abstract
Management of patients with chronic chest pain in the setting of high probability of coronary artery disease (CAD) relies heavily on imaging for determining or excluding presence and severity of myocardial ischemia, hibernation, scarring, and/or the presence, site, and severity of obstructive coronary lesions, as well as course of management and long-term prognosis. In patients with no known ischemic heart disease, imaging is valuable in determining and documenting the presence, extent, and severity of obstructive coronary narrowing and presence of myocardial ischemia. In patients with known ischemic heart disease, imaging findings are important in determining the management of patients with chronic myocardial ischemia and can serve as a decision-making tool for medical therapy, angioplasty, stenting, or surgery. This document summarizes the recent growing body of evidence on various imaging tests and makes recommendations for imaging based on the available data and expert opinion. This document is focused on epicardial CAD and does not discuss the microvascular disease as the cause for CAD. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Diana Litmanovich
- Harvard Medical School, Boston, Massachusetts; and Chief, Cardiothoracic imaging Section, Beth Israel Deaconess Medical Center.
| | - Lynne M Hurwitz Koweek
- Panel Chair, Duke University Medical Center, Durham, North Carolina; Panel Chair ACR AUG committee
| | - Brian B Ghoshhajra
- Panel Vice-Chair, Division Chief, Cardiovascular Imaging, Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Prachi P Agarwal
- Division Director of Cardiothoracic Radiology and Co-Director of Congenital Cardiovascular MR Imaging, University of Michigan, Ann Arbor, Michigan
| | - Jamieson M Bourque
- Medical Director of Nuclear Cardiology and the Stress Laboratory, University of Virginia Health System, Charlottesville, Virginia; Nuclear cardiology expert
| | - Richard K J Brown
- University of Michigan Health System, Ann Arbor, Michigan; and Vice Chair of Clinical Operations, Department of Radiology and Imaging Sciences, University of Utah
| | - Andrew M Davis
- The University of Chicago Medical Center, Chicago, Illinois; American College of Physicians; and Associate Vice-Chair for Quality, Department of Medicine, University of Chicago
| | - Cristina Fuss
- Oregon Health & Science University, Portland, Oregon; SCCT Member of the Board; Section Chief Cardiothoracic Imaging Department of Diagnostic Radiology, Oregon Health & Science University; ABR OLA Cardiac Committee; and NASCI Program Vice-Chair
| | - Amer M Johri
- Queen's University, Kingston, Ontario, Canada; Cardiology Expert; and ASE Board Member
| | | | - Sachin B Malik
- Division Chief Thoracic and Cardiovascular Imaging, Director of Cardiac MRI, Director of MRI, VA Palo Alto Health Care System, Palo Alto, California and Stanford University, Stanford, California
| | | | - Nandini M Meyersohn
- Fellowship Program Director, Massachusetts General Hospital, Boston, Massachusetts
| | - Sujethra Vasu
- Director, Cardiac MRI and Cardiac CT, Wake Forest University Health Sciences, Winston Salem, North Carolina; Society for Cardiovascular Magnetic Resonance
| | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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Fernández-Peregrina E, Ahmad H, Mintz GS, Garcia-Garcia HM. When coronary imaging and physiology are discordant, how best to manage coronary lesions? An appraisal of the clinical evidence. Catheter Cardiovasc Interv 2022; 99:2008-2015. [PMID: 35373887 DOI: 10.1002/ccd.30186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/16/2022] [Accepted: 03/19/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Discordant physiology and anatomy may occur when nonsevere angiographic stenosis has positive physiology as well as the opposite situation. AIM To underline the reasons behind the discrepancy in physiology and anatomy and to summarize the information that coronary imaging may add to physiology. METHODS A review of the published literature on physiology and intravascular imaging assessment of intermediate lesions was carried out. RESULTS The limitations of angiography, the possibility of an underlying diffuse disease, the presence of a "grey zone" in both techniques, the amount of myocardial mass that subtends the stenosis, and plaque vulnerability may play a role in such discrepancy. Intracoronary imaging has a poor diagnostic accuracy compared to physiology. However, it may add information about plaque vulnerability that might be useful in deciding whether to treat or not a certain lesion. CONCLUSIONS Coronary revascularization is recommended for patients with ischemia based on physiology. Intracoronary imaging adds information on plaque vulnerability and can help on the decision whether to revascularize or not a lesion.
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Affiliation(s)
- Estefania Fernández-Peregrina
- Division of Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Huzaifa Ahmad
- Division of Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Gary S Mintz
- Division of Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Hector M Garcia-Garcia
- Division of Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
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Tufaro V, Safi H, Torii R, Koo BK, Kitslaar P, Ramasamy A, Mathur A, Jones DA, Bajaj R, Erdoğan E, Lansky A, Zhang J, Konstantinou K, Little CD, Rakhit R, Karamasis GV, Baumbach A, Bourantas CV. Wall shear stress estimated by 3D-QCA can predict cardiovascular events in lesions with borderline negative fractional flow reserve. Atherosclerosis 2021; 322:24-30. [PMID: 33706080 DOI: 10.1016/j.atherosclerosis.2021.02.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS There is some evidence of the implications of wall shear stress (WSS) derived from three-dimensional quantitative coronary angiography (3D-QCA) models in predicting adverse cardiovascular events. This study investigates the efficacy of 3D-QCA-derived WSS in detecting lesions with a borderline negative fractional flow reserve (FFR: 0.81-0.85) that progressed and caused events. METHODS In this retrospective cohort study, we identified 548 patients who had at least one lesion with an FFR 0.81-0.85 and complete follow-up data; 293 lesions (286 patients) with suitable angiographic characteristics were reconstructed using a dedicated 3D-QCA software and included in the analysis. In the reconstructed models blood flow simulation was performed and the value of 3D-QCA variables and WSS distribution in predicting events was examined. The primary endpoint of the study was the composite of cardiac death, target lesion related myocardial infarction or clinically indicated target lesion revascularization. RESULTS During a median follow-up of 49.4 months, 37 events were reported. Culprit lesions had a greater area stenosis [(AS), 66.1% (59.5-72.3) vs 54.8% (46.5-63.2), p<0.001], smaller minimum lumen area [(MLA), 1.66 mm2 (1.45-2.30) vs 2.10 mm2 (1.69-2.70), p=0.011] and higher maximum WSS [9.0 Pa (5.10-12.46) vs 5.0 Pa (3.37-7.54), p < 0.001] than those that remained quiescent. In multivariable analysis, AS [hazard ratio (HR): 1.06, 95% confidence interval (CI): 1.03-1.10, p=0.001] and maximum WSS (HR: 1.08, 95% CI: 1.02-1.14, p=0.012) were the only independent predictors of the primary endpoint. Lesions with an increased AS (≥58.6%) that were exposed to high WSS (≥7.69Pa) were more likely to progress and cause events (27.8%) than those with a low AS exposed to high WSS (7.4%) or those exposed to low WSS that had increased (12.8%) or low AS (2.7%, p<0.001). CONCLUSIONS This study for the first time highlights the potential value of 3D-QCA-derived WSS in detecting, among lesions with a borderline negative FFR, those that cause cardiovascular events.
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Affiliation(s)
- Vincenzo Tufaro
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Hannah Safi
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Institute of Cardiovascular Sciences, University College London, London, UK
| | - Ryo Torii
- Department of Mechanical Engineering, University College London, London, UK
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Centre, Seoul National University Hospital, Seoul, South Korea
| | - Pieter Kitslaar
- Division of Image Processing, Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands; Medis Medical Imaging Systems Bv, Leiden, the Netherlands
| | - Anantharaman Ramasamy
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Anthony Mathur
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Daniel A Jones
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Retesh Bajaj
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Emrah Erdoğan
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Department of Cardiology, Van Yüzüncü Yıl University, Van, Turkey
| | - Alexandra Lansky
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK; Yale University School of Medicine, New Haven, CT, USA
| | - Jinlong Zhang
- Department of Internal Medicine and Cardiovascular Centre, Seoul National University Hospital, Seoul, South Korea
| | | | - Callum D Little
- Department of Cardiology, Royal Free London NHS Trust, London, UK
| | - Roby Rakhit
- Department of Cardiology, Royal Free London NHS Trust, London, UK
| | | | - Andreas Baumbach
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK; Yale University School of Medicine, New Haven, CT, USA
| | - Christos V Bourantas
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK; Institute of Cardiovascular Sciences, University College London, London, UK.
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Impact of diabetes mellitus on the relationship between a Poiseuille-based index and fractional flow reserve in intermediate coronary lesions. Coron Artery Dis 2021; 32:632-638. [PMID: 33534242 DOI: 10.1097/mca.0000000000001024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The ratio of lesion length (LL) to the fourth power of minimal lumen diameter (MLD) (LL/MLD4) is a Poiseuille-based index with good diagnostic accuracy for the detection of coronary lesions with abnormal fractional flow reserve (FFR). We aimed to evaluate the impact of diabetes mellitus (DM) on its performance in intermediate coronary stenoses. METHODS We performed quantitative coronary angiography and simultaneous FFR measurement in 324 patients (234 non-DM and 90 DM) with 335 coronary lesions. The area under the receiver-operating characteristic curve (AUC) for angiographic parameters was determined, using an FFR value ≤0.80 to indicate the physiological significance of coronary stenoses. RESULTS In the non-DM group, FFR was significantly related to percent diameter stenosis (%DS) (R = -0.238) and LL/MLD4 ratio (R = -0.301; P < 0.001 for both). In the DM group, there was no correlation between %DS and FFR, whereas a close-to-threshold correlation was observed for the LL/MLD4 ratio (R = -0.205; P = 0.048). The AUC of LL/MLD4 ratio was significantly different between non-diabetic and diabetic subjects (0.738 vs. 0.540; P = 0.024). Moreover, the LL/MLD4 ratio showed higher AUCs than %DS (0.738 vs. 0.635; P = 0.017) and LL (0.738 vs. 0.634; P = 0.024) in non-diabetic population but this superiority did not exist in diabetic population. CONCLUSION We showed good diagnostic accuracy of LL/MLD4 ratio for identifying ischemic lesions in patients without DM. However, there was an impaired performance in diabetic patients and thus FFR measurement is essential to determine their hemodynamic status.
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Ramasamy A, Chen Y, Zanchin T, Jones DA, Rathod K, Jin C, Onuma Y, Zhang YJ, Amersey R, Westwood M, Ozkor M, O’Mahony C, Lansky A, Crake T, Serruys PW, Mathur A, Baumbach A, Bourantas CV. Optical coherence tomography enables more accurate detection of functionally significant intermediate non-left main coronary artery stenoses than intravascular ultrasound: A meta-analysis of 6919 patients and 7537 lesions. Int J Cardiol 2020; 301:226-234. [DOI: 10.1016/j.ijcard.2019.09.067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/19/2019] [Accepted: 09/25/2019] [Indexed: 01/18/2023]
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7
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Song HG, Kang SJ, Mintz GS. Value of intravascular ultrasound in guiding coronary interventions. Echocardiography 2018; 35:520-533. [DOI: 10.1111/echo.13837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Hae Geun Song
- Department of Cardiology; DeltaHealth Hospital; Shanghai China
| | - Soo-Jin Kang
- Department of Cardiology; Asan Medical Center; University of Ulsan College of Medicine; Seoul South Korea
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8
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Shaheen M, Mokarrab M, Youssef A, Aref M, Abushouk AI, Elmaraezy A, Almasswary A. Physiological evaluation of the provisional side-branch intervention strategy for bifurcation lesions using instantaneous wave-free ratio. Indian Heart J 2018; 70 Suppl 3:S254-S258. [PMID: 30595269 PMCID: PMC6309120 DOI: 10.1016/j.ihj.2018.01.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 01/10/2023] Open
Abstract
Background The provisional side-branch intervention strategy remains the gold standard approach for repair of coronary bifurcation lesions. We performed this study to evaluate the clinical and functional outcomes of using the instantaneous wave-free ratio (iFR) for physiological assessment in provisional side-branch repair of bifurcation lesions. Methods Fifty patients with coronary bifurcation lesions were equally divided into two groups: (I) an iFR-guided side-branch intervention group and (II) a conventional group, in which the operator selected a different interventional method. After the procedure, we performed a six-month follow-up for postoperative ejection fraction (EF) and clinical cardiac outcomes. Results Our results showed that the iFR measurement procedure was technically feasible in bifurcation lesions, with no procedural-related complications. Moreover, measuring iFR significantly predicted the side-branch percent stenosis after stenting of the main branch (r = −0.81, p < 0.0001). Compared to the conventional group, the iFR-guided group showed a significantly shorter procedural time (MD = −14.6 min, 95% CI [−27.7, −1.4]) and hospital stay duration (MD = −0.92 days, 95% CI [−1.6, −0.28]). However, no significant differences were recorded between the iFR-guided and conventional groups in terms of postoperative EF (p = 0.9), six-month heart failure class (p = 0.89), or post-interventional angina (p = 0.066). Conclusion Using iFR for physiological assessment during the provisional side-branch intervention strategy can reduce the procedural time and length of hospital stay in patients with bifurcation lesions. Larger trials should compare the clinical outcomes of iFR to other physiological assessment methods such as the fractional flow reserve (FFR) in patients with coronary bifurcation lesions. ClinicalTrials.gov number: NCT02785510
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Affiliation(s)
- Mohamed Shaheen
- Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Moustafa Mokarrab
- Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ali Youssef
- Department of Cardiology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Mansour Aref
- Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Ahmed Elmaraezy
- Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt; NovaMed Medical Research Association, Cairo, Egypt
| | - Adel Almasswary
- Department of Cardiology, Aseer Central Hospital, Abha, Saudi Arabia
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Papafaklis MI, Mavrogiannis MC, Siogkas PK, Lakkas LS, Katsouras CS, Fotiadis DI, Michalis LK. Functional assessment of lesion severity without using the pressure wire: coronary imaging and blood flow simulation. Expert Rev Cardiovasc Ther 2017; 15:863-877. [PMID: 28902523 DOI: 10.1080/14779072.2017.1379899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Michail I. Papafaklis
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
- Michailideion Cardiac Center, Medical School, University of Ioannina, Ioannina, Greece
| | | | - Panagiotis K. Siogkas
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science, University of Ioannina, Ioannina, Greece
| | - Lampros S. Lakkas
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Dimitrios I. Fotiadis
- Michailideion Cardiac Center, Medical School, University of Ioannina, Ioannina, Greece
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science, University of Ioannina, Ioannina, Greece
| | - Lampros K. Michalis
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
- Michailideion Cardiac Center, Medical School, University of Ioannina, Ioannina, Greece
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Song HG, Kang SJ. Current Clinical Applications of Intravascular Ultrasound in Coronary Artery Disease. CURRENT CARDIOVASCULAR IMAGING REPORTS 2017. [DOI: 10.1007/s12410-017-9424-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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de Araújo Gonçalves P, Hideo-Kajita A, Garcia-Garcia HM. Impact of plaque characteristics on the degree of functional stenosis. Cardiovasc Diagn Ther 2017; 7:219-226. [PMID: 28540216 DOI: 10.21037/cdt.2017.04.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Coronary CT angiography (CCTA) is mainly regarded as a gatekeeper for invasive coronary angiography, in face of its widely recognized value to noninvasively rule out significant coronary stenosis. Nevertheless, it is also increasingly recognized that this noninvasive modality can depict several atherosclerotic plaque features and quantify total coronary plaque burden. This opens a new field for cardiac CT, since these atherosclerotic features beyond stenosis severity have been correlated with the degree of functional significance, and are the focus of the present manuscript. Although recently acknowledged and documented in CCTA studies, the relation between plaque burden and functional significance has been previously described using several intracoronary imaging modalities, which are also reviewed in the manuscript, to help put in perspective the relation between anatomy and function in coronary artery disease.
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Affiliation(s)
- Pedro de Araújo Gonçalves
- Department of Cardiology and Radiology, Hospital da Luz, Lisbon, Portugal.,Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Carnaxide, Lisbon, Portugal.,Chronic Diseases Research Center - Nova Medical School, Lisbon, Portugal
| | - Alexandre Hideo-Kajita
- Division of Interventional Cardiology, MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, DC, USA
| | - Hector Manuel Garcia-Garcia
- Division of Interventional Cardiology, MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, DC, USA
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12
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Cutoff Value and Long-Term Prediction of Clinical Events by FFR Measured Immediately After Implantation of a Drug-Eluting Stent in Patients With Coronary Artery Disease. JACC Cardiovasc Interv 2017; 10:986-995. [DOI: 10.1016/j.jcin.2017.02.012] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/14/2017] [Accepted: 02/14/2017] [Indexed: 11/18/2022]
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13
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Angiographic underestimation of disease severity in the left anterior descending artery: a fractional flow reserve analysis. Coron Artery Dis 2017; 27:556-60. [PMID: 27385481 DOI: 10.1097/mca.0000000000000407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES This study compared the prevalence of angiographic underestimation of left anterior descending artery (LAD) lesions with non-LAD lesions. BACKGROUND Coronary angiography cannot assess the functional severity of a coronary stenosis. Previous studies suggested that lesions of the LAD are more often angiographically underestimated, but evidence is limited. MATERIALS AND METHODS Fractional flow reserve (FFR) was performed in 335 coronary lesions (187 LAD lesions and 148 non-LAD lesions). A visually estimated diameter stenosis of at least 70% was considered functionally significant. An FFR value of up to 0.80 was considered significant. Multivariable analyses were carried out. RESULTS Angiographically, LAD lesions as well as non-LAD lesions were considered functionally significant in 29% (P=0.94). FFR showed significant stenosis of the LAD in 52% compared with 24% in non-LAD lesions (P<0.001). Underestimation was observed in 30% of LAD lesions compared with 11% in non-LAD lesions (P<0.001). The adjusted odds ratio for underestimation in LAD lesions in comparison with non-LAD lesions was 3.48 (95% confidence interval 1.89-6.41; P<0.001). CONCLUSION Underestimation of the functional severity of a coronary stenosis is more common in LAD lesions. FFR should be performed more often for intermediate stenosis of the LAD.
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14
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Chu M, Dai N, Yang J, Westra J, Tu S. A systematic review of imaging anatomy in predicting functional significance of coronary stenoses determined by fractional flow reserve. Int J Cardiovasc Imaging 2017; 33:975-990. [PMID: 28265791 DOI: 10.1007/s10554-017-1085-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 01/28/2017] [Indexed: 01/06/2023]
Abstract
Fractional flow reserve (FFR) is the current gold standard to assess the physiological significance of coronary stenoses. With the development of coronary imaging techniques, several anatomic parameters have been investigated in vivo and their associations with FFR have been studied. The aim of this review is to summarize the accuracy of anatomic parameters derived by the present coronary imaging techniques including invasive coronary angiography, coronary computed tomography angiography, intravascular ultrasound and optical coherence tomography, in predicting a significant FFR. The impact of patient characteristics, lesion locations, variability of FFR and imaging resolution on the predictive ability are discussed.
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Affiliation(s)
- Miao Chu
- Biomedical Instrument Institute, School of Biomedical Engineering, Med-X Research Institute, Shanghai Jiao Tong University, No. 1954, Hua Shan Road, Shanghai, 200030, China
| | - Neng Dai
- Cardiovascular Department, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Junqing Yang
- The 3rd Division of Cardiology, Department of Cardiology, Guangdong General Hospital, Guangdong Provincial Cardiovascular Institute, Guangdong Academy of Medical Sciences, No.106, 2nd Zhongshan Road, Yuexiu district, Guangzhou, Guangdong, 510080, China.
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Med-X Research Institute, Shanghai Jiao Tong University, No. 1954, Hua Shan Road, Shanghai, 200030, China.
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Intravascular ultrasound-guided drug-eluting stent implantation. Cardiovasc Interv Ther 2016; 32:1-11. [DOI: 10.1007/s12928-016-0438-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 10/30/2016] [Indexed: 10/20/2022]
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16
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Jang JS, Shin HC, Bae JS, Jin HY, Seo JS, Yang TH, Kim DK, Cho KI, Kim BH, Park YH, Je HG, Kim DS. Diagnostic Performance of Intravascular Ultrasound-Derived Minimal Lumen Area to Predict Functionally Significant Non-Left Main Coronary Artery Disease: a Meta-Analysis. Korean Circ J 2016; 46:622-631. [PMID: 27721852 PMCID: PMC5054173 DOI: 10.4070/kcj.2016.46.5.622] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 11/04/2015] [Accepted: 12/08/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention frequently results in unnecessary stenting due to the low positive predictive value of IVUS-derived minimal lumen area (MLA) for identification of functionally significant coronary stenosis. We appraised the diagnostic accuracy of IVUS-derived MLA compared with the fractional flow reserve (FFR) to assess intermediate coronary stenosis. SUBJECTS AND METHODS We searched MEDLINE and Cochrane databases for studies using IVUS and FFR methods to establish the best MLA cut-off values to predict significant non-left main coronary artery stenosis. Summary estimates were obtained using a random-effects model. RESULTS The 17 studies used in our analysis enrolled 3920 patients with 4267 lesions. The weighted overall mean MLA cut-off value was 2.58 mm2. The pooled MLA sensitivity that predicted functionally significant coronary stenosis was 0.75 (confidence interval [CI]: 0.72 to 0.77) and the specificity was 0.66 (CI: 0.64 to 0.68). The positive likelihood ratio (LR) was 2.33 (CI: 2.06 to 2.63) and LR (-) was 0.33 (CI: 0.26 to 0.42). The pooled diagnostic odds ratio (DOR) was 7.53 (CI: 5.26 to 10.76) and the area under the summary receiver operating characteristic curve for all the trials was 0.782 with a Q point of 0.720. Meta-regression analysis demonstrated that an FFR cut-off point of 0.75 was associated with a four times higher diagnostic accuracy compared to that of 0.80 (relative DOR: 3.92; 95% CI: 1.25 to 12.34). CONCLUSION IVUS-derived MLA has limited diagnostic accuracy and needs careful interpretation to correlate with functionally significant non-left main coronary artery stenosis.
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Affiliation(s)
- Jae-Sik Jang
- Division of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea
| | - Ho-Cheol Shin
- Division of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea
| | - Jong Seok Bae
- Department of Neurology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Han-Young Jin
- Division of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea
| | - Jeong-Sook Seo
- Division of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea
| | - Tae-Hyun Yang
- Division of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea
| | - Dae-Kyeong Kim
- Division of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea
| | - Kyoung-Im Cho
- Division of Cardiology, Kosin University Medical Center, Busan, Korea
| | - Bo-Hyun Kim
- Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Yong Hyun Park
- Division of Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung-Gon Je
- Department of Cardiovascular Surgery, Busan National University Yangsan Hospital, Yangsan, Korea
| | - Dong-Soo Kim
- Division of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea
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Cho YK, Nam CW, Han JK, Koo BK, Doh JH, Ben-Dor I, Waksman R, Pichard A, Murata N, Tanaka N, Lee CH, Gonzalo N, Escaned J, Costa MA, Kubo T, Akasaka T, Hu X, Wang JA, Yang HM, Yoon MH, Tahk SJ, Yoon HJ, Chung IS, Hur SH, Kim KB. Usefulness of combined intravascular ultrasound parameters to predict functional significance of coronary artery stenosis and determinants of mismatch. EUROINTERVENTION 2016; 11:163-70. [PMID: 26093837 DOI: 10.4244/eijv11i2a30] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Efficacy of combined intravascular ultrasound (IVUS) parameters in functional significance prediction and discrepancy between IVUS and fractional flow reserve (FFR) have not been well defined. This study therefore aimed to: 1) evaluate the diagnostic accuracy of combined IVUS parameters, namely minimal lumen area (MLA) and percent plaque burden (%PB), in functional significance prediction of coronary artery stenosis; and 2) define factors that affect the relation between FFR value and IVUS parameters. METHODS AND RESULTS At 11 international centres, IVUS and FFR measurements were concurrently performed in 945 major epicardial coronary artery lesions (886 patients). Functional significance was defined as FFR ≤0.8. MLA and FFR correlated weakly (r=0.289, p<0.001). Diagnostic accuracy of MLA ≤4.0 mm2, %PB >70% and their combination were 50%, 47% and 51%, respectively, with similar area under the curve (AUC) of 0.561, 0.511 and 0.516, respectively. The best cut-off values (BCV) were MLA ≤3.0 mm2 and %PB >75%, with accuracy of 60% for MLA, 50% for %PB and 56% for their combination, and AUC of 0.618, 0.511 and 0.533, respectively. MLA BCV ≤3.0 mm2 had higher predictive power than %PB BCV >75% or their combination. Independent predictors of functional significance were male gender (odds ratio 1.76 [95% confidence interval: 1.19-2.62]), left ventricular ejection fraction (LVEF, 0.98 [0.96-0.99]), LAD lesion (2.52 [1.73-3.67]), reference vessel diameter (0.60 [0.41-0.86]), lesion length (1.04 [1.02-1.06]) and MLA (0.79 [0.69-0.92]). False negative lesion incidence was 24.4% in association with race (for Asians, 0.391 [0.219-0.698]), LAD lesion (2.677 [1.709-4.191]) and LVEF (0.977 [0.957-0.997]). False positive lesion incidence was 17.0% in association with non-LAD lesion (2.444 [1.620-3.686]). CONCLUSIONS Combined IVUS parameters did not improve the accuracy of functional significance prediction. Discrepancy between IVUS and FFR, which was not rare, should be taken into account in clinical decision making.
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Affiliation(s)
- Yun-Kyeong Cho
- Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
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18
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Borren N, Maas AHEM, Ottervanger JP. Stop invasive coronary angiography as the gold standard for the diagnosis of stable angina! Interv Cardiol 2015. [DOI: 10.2217/ica.15.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Lee PH, Ahn JM, Park SJ. Update on percutaneous intervention for left main coronary artery stenosis. Expert Rev Cardiovasc Ther 2015; 13:933-43. [PMID: 26159652 DOI: 10.1586/14779072.2015.1065730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Percutaneous coronary intervention (PCI) using drug-eluting stents (DES) is currently considered as a viable alternative to coronary artery bypass graft surgery (CABG) for selected patients with left main coronary artery disease. The updated results of the landmark randomized trials comparing CABG versus PCI demonstrated comparable 5-year outcomes and are in line with the current guidelines that designate PCI as a reasonable treatment in this disease subset. Given that the completed randomized trials did not include contemporary DESs, the upcoming results of the ongoing trials evaluating the performance of new-generation DES compared with CABG (such as the EXCEL trial), may further help to clarify the current role and future recommendations of PCI for left main coronary artery disease. Apart from the recent stent technology, further improvements in outcomes after PCI may be possible when it is used with an integrated approach that combines functional concepts for decision-making, adjunctive imaging support and optimal pharmacotherapies.
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Affiliation(s)
- Pil Hyung Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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20
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Ouyang F, Chen M, Yi T, Wu M, Peng H, Huang H, Huang H, Zhou S. Successful percutaneous coronary intervention for multivessel stenosis complicated by a huge coronary artery fistula with the combined physiology and intracoronary anatomy techniques. Int J Cardiol 2015; 192:70-1. [PMID: 26000465 DOI: 10.1016/j.ijcard.2015.05.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 05/06/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Fan Ouyang
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China; Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
| | - Mingxian Chen
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ting Yi
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
| | - Mingxing Wu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
| | - Huibing Peng
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
| | - Haobo Huang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
| | - He Huang
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China; Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China.
| | - Shenghua Zhou
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China.
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21
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Vizzari G, Di Giorgio A, Saporito F, Trio O, Versaci F, Andò G. Percutaneous coronary intervention driven by combined use of intracoronary anatomy and physiology. Int J Cardiol 2015; 187:562-4. [DOI: 10.1016/j.ijcard.2015.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
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22
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Chen SL, Ye F, Zhang JJ, Xu T, Tian NL, Liu ZZ, Lin S, Shan SJ, Ge Z, You W, Liu YQ, Qian XS, Li F, Yang S, Kwan TW, Xu B, Stone GW. Randomized Comparison of FFR-Guided and Angiography-Guided Provisional Stenting of True Coronary Bifurcation Lesions: The DKCRUSH-VI Trial (Double Kissing Crush Versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions VI). JACC Cardiovasc Interv 2015; 8:536-46. [PMID: 25819187 DOI: 10.1016/j.jcin.2014.12.221] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 12/01/2014] [Accepted: 12/04/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study sought to compare the outcomes of fractional flow reserve (FFR)-guided and angiography (Angio)-guided provisional side-branch (SB) stenting for true coronary bifurcation lesions. BACKGROUND Angio-guided provisional SB stenting after stenting of the main vessel provides favorable outcomes for the majority of coronary bifurcation lesions. Whether an FFR-guided provisional stenting approach is superior has not been studied. METHODS A total of 320 patients with single Medina 1,1,1 and 0,1,1 coronary bifurcation lesions undergoing stenting with a provisional SB approach were randomly assigned 1:1 to Angio-guided and FFR-guided groups. SB stenting was performed for Thrombolysis In Myocardial Infarction flow grade<3, ostial SB stenosis>70%, or greater than type A dissection after main vessel stenting in the Angio-guided group and for SB-FFR<0.80 in the FFR-guided group. The primary endpoint was the 1-year composite rate of major adverse cardiac events (cardiac death, myocardial infarction, and clinically driven target vessel revascularization). RESULTS Comparing the Angio-guided and FFR-guided groups, treatment of the SB (balloon or stenting) was performed in 63.1% and 56.3% of lesions respectively (p=0.07); stenting of the SB was attempted in 38.1% and 25.9%, respectively (p=0.01); and, when attempted, stenting was successful in 83.6% and 73.3% of SBs, respectively (p=0.01). The 1-year composite major adverse cardiac event rate was 18.1% in both groups (hazard ratio: 0.91, 95% confidence interval: 0.48 to 1.88; p=1.00). The 1-year target vessel revascularization and stent thrombosis rates were 6.9% and 5.6% (p=0.82) and 1.3% and 0.6% (p=0.56) in the Angio-guided and FFR-guided groups, respectively. CONCLUSIONS In this multicenter, randomized trial, angiographic and FFR guidance of provisional SB stenting of true coronary bifurcation lesions provided similar 1-year clinical outcomes. (Randomized Study on DK Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions; ChiCTR-TRC-07000015).
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Affiliation(s)
- Shao-Liang Chen
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China; Collaborative Innovation Center for Cardiovascular Disease Translational Medicine and Clinical Medical Research Center of Jiangsu Province, China.
| | - Fei Ye
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jun-Jie Zhang
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Tian Xu
- Nanjing Heart Center, Nanjing, China
| | | | | | - Song Lin
- Jintan Municipal People's Hospital, Jintan, China
| | - Shou-Jie Shan
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhen Ge
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wei You
- Nanjing Heart Center, Nanjing, China
| | | | | | - Feng Li
- Huainan Oriental General Hospital, Huainan, China
| | - Song Yang
- Yixin People's Hospital, Yixin, China
| | - Tak W Kwan
- Beth Israel Hospital, New York, New York
| | - Bo Xu
- Beijing Fuwai Cardiovascular Hospital, Beijing, China
| | - Gregg W Stone
- Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York.
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23
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Mintz GS. Clinical utility of intravascular imaging and physiology in coronary artery disease. J Am Coll Cardiol 2014; 64:207-22. [PMID: 24530669 DOI: 10.1016/j.jacc.2014.01.015] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 01/02/2014] [Accepted: 01/14/2014] [Indexed: 12/26/2022]
Abstract
Intravascular imaging and physiology techniques and technologies are moving beyond the framework of research to inform clinical decision making. Currently available technologies and techniques include fractional flow reserve; grayscale intravascular ultrasound (IVUS); IVUS radiofrequency tissue characterization; optical coherence tomography, the light analogue of IVUS; and near-infrared spectroscopy that detects lipid within the vessel wall and that has recently been combined with grayscale IVUS in a single catheter as the first combined imaging device. These tools can be used to answer questions that occur during daily practice, including: Is this stenosis significant? Where is the culprit lesion? Is this a vulnerable plaque? What is the likelihood of distal embolization or periprocedural myocardial infarction during stent implantation? How do I optimize acute stent results? Why did thrombosis or restenosis occur in this stent? One of the legacies of coronary angiography is to presume that one technique will answer all of these questions; however, that often has been proved inaccurate in contemporary practice.
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Affiliation(s)
- Gary S Mintz
- Cardiovascular Research Foundation, New York, New York.
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24
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Sen S, Davies J. Can anatomy be used as a surrogate for physiology? The IVUS conundrum. Int J Cardiol 2013; 168:631-2. [PMID: 23647600 DOI: 10.1016/j.ijcard.2013.03.191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 03/31/2013] [Indexed: 01/10/2023]
Affiliation(s)
- Sayan Sen
- Imperial College, 59-61, North Wharf Road, Paddington, London, W21LA, United Kingdom.
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