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Vasiljevs D, Kakurina N, Pontaga N, Kokina B, Osipovs V, Sorokins N, Pikta S, Trusinskis K, Lejnieks A. Culprit versus Complete Revascularization during the Initial Intervention in Patients with Acute Coronary Syndrome Using a Virtual Treatment Planning Tool: Results of a Single-Center Pilot Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020270. [PMID: 36837471 PMCID: PMC9967361 DOI: 10.3390/medicina59020270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/12/2023] [Accepted: 01/27/2023] [Indexed: 02/01/2023]
Abstract
Background and Objectives: The revascularization strategy for percutaneous coronary intervention (PCI) in patients with multivessel (MV) acute coronary syndrome (ACS) remains controversial. Certain gaps in the evidence are related to the optimal timing of non-culprit lesion revascularization and the utility of instantaneous wave-free ratio (iFR) in the management of MV ACS intervention. The major benefits of iFR utilization in MV ACS patients in one-stage complete revascularization are: (1) the possibility to virtually plan the PCI, both the location and the extension of the necessary stenting to achieve the prespecified final hemodynamic result; (2) the opportunity to validate the final hemodynamic result of the PCI, both in culprit artery and all non-culprit arteries and (3) the value of obliviating the uncomfortable, costly, time consuming and sometimes deleterious effects from Adenosine, as there is no requirement for administration. Thus, iFR use fosters the achievement of physiologically appropriate complete revascularization in MV ACS patients during acute hospitalization. Materials and Methods: This pilot study was aimed to test the feasibility of a randomized trial research protocol as well as to assess patient safety signals of co-registration iFR-guided one-stage complete revascularization compared with that of standard staged angiography-guided PCI in de novo patients with MV ACS. This was a single-center, prospective, randomized, open-label clinical trial consecutively screening patients with ACS for MV disease. The intervention strategy of interest was iFR-guided physiologically complete one-stage revascularization, in which the virtual PCI planning of non-culprit lesions and the intervention itself were performed in one stage directly following treatment of the culprit lesion and other critical stenosis of more than ninety percent. Seventeen patients were recruited and completed the 3-month follow-up. Results: Index PCI duration was significantly longer while the volume of contrast media delivered in index PCI was significantly greater in the iFR-guided group than in the angiography-guided group (119.4 ± 40.7 vs. 47 ± 15.5 min, p = 0.004; and 360 ± 97.9 vs. 192.5 ± 52.8 mL, p = 0.003). There were no significant differences in PCI-related major adverse cardiovascular events (MACE) between the groups during acute hospitalization and at 3-months follow-up. One-stage iFR-guided PCI requires fewer PCI attempts until complete revascularization than does angiography-guided staged PCI. Conclusions: Complete revascularization with the routine use of the virtual planning tool in one-stage iFR-guided PCI is a feasible practical strategy in an everyday Cath lab environment following the protocol designed for the study. No statistically significant safety signals were documented in the number of PCI related MACE during the 3-month follow-up.
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Affiliation(s)
- Deniss Vasiljevs
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
- Correspondence: ; Tel.: +371-6544-0858
| | - Natalja Kakurina
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Natalja Pontaga
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Baiba Kokina
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
| | - Vladimirs Osipovs
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Nikolajs Sorokins
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Sergejs Pikta
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Karlis Trusinskis
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Str., LV-1002 Riga, Latvia
| | - Aivars Lejnieks
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
- Riga East Clinical University Hospital, 2 Hipokrata Str., LV-1038 Riga, Latvia
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2
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Calculation of Intracoronary Pressure-Based Indexes with JLabChart. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12073448] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The Fractional Flow Reserve (FFR) and instantaneous wave-Free Ratio (iFR) have been proposed and clinically validated to measure the pressure gradient across coronary stenoses. They provide quantitative information on stenosis severity. Both are used in coronary revascularization procedures to measure intracoronary pressure giving quantitative information to evaluate coronary diseases during angiographic procedures. We designed and implemented a tool able to acquire and measure iFR and FFR supporting the physicians studying and treating patients in interventional cardiology laboratories. We designed an extensive case study to assess the performance of the tool in (i) acquiring pressure signals from blood pressure measurement systems; (ii) calculating FFR and iFR; and (iii) filtering out extra-beats signals during realtime signal analysis phases. The tool, named JLabChart, is available online. We tested it on two sets of data for a total of 600 cycles from 201 pressure measurements performed on 65 patients, from the Interventional Cardiology Unit of Magna Graecia University. The recognition of cardiac cycles and keypoint of the pressure curve was effective in 100% of cases for proximal (aortic) pressure and in 99.2% for distal pressure. The FFR calculated by JLabChart had an excellent correlation (Rp=0.960; p<0.001) with the FFR values obtained through the commercial systems. Similar results were obtained with iFR (Rp=0.998; p<0.001). Finally, the tool measurement results were compared with a commercial tool proving JLabChart’s efficiency with real cases. It was also compared with measurements performed on synthetic vessels and stenosis designed using the Comsol commercial tool. JLabChart is able to provide reliable measurements of FFR and iFR indexes used to support decisions on interventional procedures. It represents a valuable open source support system that can be used in an interventional cardiology laboratory.
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Wienemann H, Meyer A, Mauri V, Baar T, Adam M, Baldus S, Halbach M. Comparison of Resting Full-Cycle Ratio and Fractional Flow Reserve in a German Real-World Cohort. Front Cardiovasc Med 2022; 8:744181. [PMID: 35004875 PMCID: PMC8740550 DOI: 10.3389/fcvm.2021.744181] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/30/2021] [Indexed: 01/10/2023] Open
Abstract
Objective: The aim of this study was to evaluate non-hyperemic resting pressure ratios (NHPRs), especially the novel “resting full-cycle ratio” (RFR; lowest pressure distal to the stenosis/aortic pressure during the entire cardiac cycle), compared to the gold standard fractional flow reserve (FFR) in a “real-world” setting. Methods: The study included patients undergoing coronary pressure wire studies at one German University Hospital. No patients were excluded based on any baseline or procedural characteristics, except for insufficient quality of traces. The diagnostic performance of four NHPRs vs. FFR ≤ 0.80 was tested. Morphological characteristics of stenoses were analyzed by quantitative coronary angiography. Results: 617 patients with 712 coronary lesions were included. RFR showed a significant correlation with FFR (r = 0.766, p < 0.01). Diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of RFR were 78% (95% confidence interval = 75; 81), 72% (65; 78), 81% (77; 84), 63% (57; 69), and 86% (83; 89). Relevant predictors for discordance of RFR ≤ 0.89/FFR > 0.8 were LAD lesions, peripheral artery disease, age, female sex and non-focal stenoses. Predictors for discordance of RFR > 0.89/FFR ≤ 0.8 included non-LCX lesions, percent diameter stenosis and previous percutaneous coronary intervention in the target vessel. RFR and all other NHPRs were highly correlated with each other. Conclusion: All NHPRs have a similar correlation with the gold standard FFR and may facilitate the acceptance and implementation of physiological assessments of lesion severity. However, we found ~20% discordant results between NHPRs and FFR in our “all-comers” German cohort.
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Affiliation(s)
- Hendrik Wienemann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Annika Meyer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Victor Mauri
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Till Baar
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Matti Adam
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Stephan Baldus
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Marcel Halbach
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
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Sabatino J, De Rosa S, Leo I, Strangio A, Spaccarotella C, Polimeni A, Sorrentino S, Di Salvo G, Indolfi C. Prediction of Significant Coronary Artery Disease Through Advanced Echocardiography: Role of Non-invasive Myocardial Work. Front Cardiovasc Med 2021; 8:719603. [PMID: 34504879 PMCID: PMC8421730 DOI: 10.3389/fcvm.2021.719603] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/29/2021] [Indexed: 12/28/2022] Open
Abstract
Background: Non-invasive prediction of critical coronary artery stenosis (CAST) in patients with coronary artery disease (CAD) is challenging. Strain parameters can often capture an impairment of regional longitudinal function; however, they are load dependent. A novel non-invasive method to estimate Myocardial Work (MW) has been recently proposed, showing a strong correlation with invasive work measurements. Our aim was to investigate the ability of non-invasive MW to predict the ischaemic risk area underlying a CAST. Methods and Results: The study population comprises 80 individuals: 50 patients with CAST and 30 controls (CTRL). Echocardiography recordings were obtained before coronary angiography to measure global longitudinal strain (GLS), Myocardial Work Index (MWI), Myocardial Constructive Work (MCW), Myocardial Wasted work (MWW), Myocardial Work Efficiency (MWE). Global MWI (p = 0.048), MWE (p < 0.001), and MCW (p = 0.048) at baseline were significantly reduced in patients with CAST compared to controls (p < 0.05). Regional MWE within the myocardial segments underlying the CAST, but not LS, was significantly reduced compared to non-target segments (p < 0.001). At ROC analysis, the diagnostic performance to predict CAST for regional MWE (AUC = 0.920, p < 0.001) was higher compared to both regional post-systolic shortening index (PSI) (AUC = 0.600, p = 0.129) and regional LS (AUC = 0.546, p = 0.469). Conclusions: Non-invasive estimation of MW work indices is able to predict a CAST before invasive angiography.
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Affiliation(s)
- Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy.,Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Isabella Leo
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Antonio Strangio
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Carmen Spaccarotella
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Giovanni Di Salvo
- Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy.,Mediterranea Cardiocentro, Naples, Italy
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5
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Niccoli G, Morrone D, De Rosa S, Montone RA, Polimeni A, Aimo A, Mancone M, Muscoli S, Pedrinelli R, Indolfi C. The central role of invasive functional coronary assessment for patients with ischemic heart disease. Int J Cardiol 2021; 331:17-25. [PMID: 33529656 DOI: 10.1016/j.ijcard.2021.01.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/05/2021] [Accepted: 01/15/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Giampaolo Niccoli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Medicine, University of Parma, Parma, Italy.
| | - Doralisa Morrone
- Division of Cardiology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Salvatore De Rosa
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Polimeni
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy
| | - Alberto Aimo
- Division of Cardiology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Massimo Mancone
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Saverio Muscoli
- Department of Medicine, 'Tor Vergata' University of Rome, Rome, Italy
| | - Roberto Pedrinelli
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy
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6
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Scarsini R, Terentes-Printzios D, De Maria GL, Ribichini F, Banning A. Why, When and How Should Clinicians Use Physiology in Patients with Acute Coronary Syndromes? ACTA ACUST UNITED AC 2020; 15:e05. [PMID: 32577130 PMCID: PMC7301203 DOI: 10.15420/icr.2019.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/13/2020] [Indexed: 12/14/2022]
Abstract
Current data support the use of coronary physiology in patients with acute coronary syndrome (ACS). In patients with ST-elevation MI, the extent of myocardial damage and microvascular dysfunction create a complex conundrum to assimilate when considering clinical management and risk stratification. In this setting, the index of microcirculatory resistance emerged as an accurate tool to identify patients at risk of suboptimal myocardial reperfusion after primary percutaneous coronary intervention who may benefit from novel adjunctive therapies. In the context of non-ST-elevation ACS, coronary physiology should be carefully interpreted and often integrated with intracoronary imaging, especially in cases of ambiguous culprit lesion. Conversely, the functional assessment of bystander coronary disease is favoured by the available evidence, aiming to achieve complete revascularisation. Based on everyday clinical scenarios, the authors illustrate the available evidence and provide recommendations for the functional assessment of infarct-related artery and non-culprit lesions in patients with ACS.
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Affiliation(s)
- Roberto Scarsini
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK.,Division of Cardiology, Department of Medicine, University of Verona Verona, Italy
| | | | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona Verona, Italy
| | - Adrian Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK.,Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford Oxford, UK
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7
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Clarke JRD, Duarte Lau F, Zarich SW. Determining the Significance of Coronary Plaque Lesions: Physiological Stenosis Severity and Plaque Characteristics. J Clin Med 2020; 9:jcm9030665. [PMID: 32131474 PMCID: PMC7141262 DOI: 10.3390/jcm9030665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 01/10/2023] Open
Abstract
The evaluation of coronary lesions has evolved in recent years. Physiologic-guided revascularization (particularly with pressure-derived fractional flow reserve (FFR)) has led to superior outcomes compared to traditional angiographic assessment. A greater importance, therefore, has been placed on the functional significance of an epicardial lesion. Despite the improvements in the limitations of angiography, insights into the relationship between hemodynamic significance and plaque morphology at the lesion level has shown that determining the implications of epicardial lesions is rather complex. Investigators have sought greater understanding by correlating ischemia quantified by FFR with plaque characteristics determined on invasive and non-invasive modalities. We review the background of the use of these diagnostic tools in coronary artery disease and discuss the implications of analyzing physiological stenosis severity and plaque characteristics concurrently.
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Affiliation(s)
- John-Ross D. Clarke
- Department of Internal Medicine, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA;
- Correspondence: or ; Tel.: +1-203-260-4510
| | - Freddy Duarte Lau
- Department of Internal Medicine, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA;
| | - Stuart W. Zarich
- The Heart and Vascular Institute, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA;
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8
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Adenosine-Free Indexes vs. Fractional Flow Reserve for Functional Assessment of Coronary Stenoses: Systematic Review and Meta-Analysis. Int J Cardiol 2020; 299:93-99. [DOI: 10.1016/j.ijcard.2019.07.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 06/30/2019] [Accepted: 07/09/2019] [Indexed: 01/10/2023]
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9
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Ihdayhid AR, Koh JS, Ramzy J, Kumar A, Michail M, Brown A, Samady H. The Role of Fractional Flow Reserve and Instantaneous Wave-Free Ratio Measurements in Patients with Acute Coronary Syndrome. Curr Cardiol Rep 2019; 21:159. [PMID: 31768835 DOI: 10.1007/s11886-019-1233-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The role of fractional flow reserve to guide revascularization in patients with stable angina is well established. The instantaneous wave-free ratio (iFR) is an emerging adenosine-free resting index that is non-inferior to FFR and has potential to streamline the functional evaluation of coronary artery disease. The feasibility and utility of intracoronary physiology in patients with acute coronary syndrome (ACS) is unclear. This review will discuss the physiological principles and validity of using FFR and iFR in patients presenting with ACS. We will also provide an overview of the available evidence for their role in guiding revascularization in this patient group. RECENT FINDINGS The use of intracoronary physiology in culprit lesions of patients presenting with STEMI is not recommended and its accuracy is uncertain in patients with NSTEMI. In contrast, the physiological assessment of non-culprit vessels with FFR and IFR is a reliable measure of lesion-specific ischemia. Recent studies have demonstrated that FFR-guided revascularization of non-culprit lesions improves clinical outcomes although the role of iFR in this patient cohort is unknown. Physiology-guided revascularization of non-culprit ACS lesions improves clinical outcomes. Future studies investigating the complementary role of plaque morphology, biomechanics, and systemic inflammation may provide clinicians with a more comprehensive framework to guide treatment decisions.
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Affiliation(s)
- Abdul Rahman Ihdayhid
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia
| | - Jin-Sin Koh
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road, Suite F606, Atlanta, GA, 30322, USA
| | - John Ramzy
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia
| | - Arnav Kumar
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road, Suite F606, Atlanta, GA, 30322, USA
| | - Michael Michail
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia.,Institute of Cardiovascular Science, University College London, London, UK
| | - Adam Brown
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia
| | - Habib Samady
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea. .,Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road, Suite F606, Atlanta, GA, 30322, USA.
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10
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Carson JM, Roobottom C, Alcock R, Nithiarasu P. Computational instantaneous wave-free ratio (IFR) for patient-specific coronary artery stenoses using 1D network models. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2019; 35:e3255. [PMID: 31469943 PMCID: PMC7003475 DOI: 10.1002/cnm.3255] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/22/2019] [Accepted: 08/21/2019] [Indexed: 05/05/2023]
Abstract
In this work, we estimate the diagnostic threshold of the instantaneous wave-free ratio (iFR) through the use of a one-dimensional haemodynamic framework. To this end, we first compared the computed fractional flow reserve (cFFR) predicted from a 1D computational framework with invasive clinical measurements. The framework shows excellent promise and utilises minimal patient data from a cohort of 52 patients with a total of 66 stenoses. The diagnostic accuracy of the cFFR model was 75.76%, with a sensitivity of 71.43%, a specificity of 77.78%, a positive predictive value of 60%, and a negative predictive value of 85.37%. The validated model was then used to estimate the diagnostic threshold of iFR. The model determined a quadratic relationship between cFFR and the ciFR. The iFR diagnostic threshold was determined to be 0.8910 from a receiver operating characteristic curve that is in the range of 0.89 to 0.9 that is normally reported in clinical studies.
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Affiliation(s)
- Jason M. Carson
- Zienkiewicz Centre for Computational Engineering, College of EngineeringSwansea UniversitySwanseaUK
- Data Science Building, Swansea University Medical SchoolSwansea UniversitySwanseaUK
- HDR UK Wales and Northern IrelandHealth Data Research UKLondonUK
| | - Carl Roobottom
- Derriford Hospital and Peninsula Medical SchoolPlymouth Hospitals NHS TrustPlymouthUK
| | - Robin Alcock
- Derriford Hospital and Peninsula Medical SchoolPlymouth Hospitals NHS TrustPlymouthUK
| | - Perumal Nithiarasu
- Zienkiewicz Centre for Computational Engineering, College of EngineeringSwansea UniversitySwanseaUK
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11
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De Rosa S, Polimeni A, De Velli G, Conte M, Sorrentino S, Spaccarotella C, Mongiardo A, Sabatino J, Contarini M, Indolfi C. Reliability of Instantaneous Wave-Free Ratio (iFR) for the Evaluation of Left Main Coronary Artery Lesions. J Clin Med 2019; 8:jcm8081143. [PMID: 31370353 PMCID: PMC6724021 DOI: 10.3390/jcm8081143] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 07/20/2019] [Accepted: 07/30/2019] [Indexed: 01/10/2023] Open
Abstract
The assessment of the left main coronary artery (LMCA) by coronary angiography has several limitations. The fractional flow reserve (FFR) is useful for the functional evaluation of LMCA stenoses. The instantaneous wave-free ratio (iFR), a resting index, was developed to simplify functional coronary assessment. However, its performance for LMCA stenoses has yet to be explored. The iFR was measured at rest, and the FFR was measured under maximal hyperemia. We calculated that a sample size of 90 lesions would have provided 90% power at a 5% significance level to detect an Area Under the Curve (AUC) < 0.7 for the iFR to identify FFR-positive stenoses. A total of 91 measurements were performed on angiographically intermediate LMCA stenoses at three centers. The comparison between the iFR and the FFR showed a significant correlation (r = 0.67, p < 0.001). At receiver operating characteristic (ROC) analysis, the iFR revealed a good diagnostic performance when compared to the FFR (AUC = 0.84; p < 0.001). A classification agreement between the iFR and the FFR was recorded in 81% of cases. The left ventricular ejection fraction (LVEF) was an independent predictor of the discrepancy between the FFR and iFR values (p = 0.040). The present study is the first demonstrating that the assessment of LMCA stenoses with the instantaneous wave-free ratio is a reliable adenosine-free alternative to classic fractional flow reserve. If confirmed in larger populations, these findings could be of relevance for real world daily practice.
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Affiliation(s)
- Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | | | | | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Carmen Spaccarotella
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Annalisa Mongiardo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | | | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy.
- URT-CNR, Magna Graecia University, 88100 Catanzaro, Italy.
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12
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De Rosa S, Polimeni A, Petraco R, Davies JE, Indolfi C. Diagnostic Performance of the Instantaneous Wave-Free Ratio: Comparison With Fractional Flow Reserve. Circ Cardiovasc Interv 2019; 11:e004613. [PMID: 29326150 DOI: 10.1161/circinterventions.116.004613] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 11/16/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aim of the present study was to perform a meta-analysis of all available studies comparing the instantaneous wave-free ratio (iFR) with fractional flow reserve (FFR). METHODS AND RESULTS Published trials comparing the iFR with FFR were searched for in PubMed, Google Scholar, and Scopus electronic databases. A total of 23 studies were available for the analysis, including 6381 stenoses. First, a meta-analysis of all studies was performed exploring the correlation between FFR and iFR. Interestingly, we found good correlation (0.798 [0.78-0.82]) between the 2 indices (P<0.001). In addition, to evaluate the diagnostic performance of iFR to identify FFR-positive coronary stenoses, we performed an additional meta-analysis, summarizing the results of receiver operating characteristics analyses from individual studies reporting the area under the curve. Summing the results of these studies, we found that iFR has a good diagnostic performance for the identification of FFR-positive stenoses (area under the curve=0.88 [0.86-0.90]; P<0.001). Furthermore, our search results included 5 studies that compared iFR and FFR to a third independent reference standard. Interestingly, no significant differences between iFR and FFR were reported in those studies. CONCLUSIONS The present meta-analysis shows that iFR significantly correlates with standard FFR and shows a good diagnostic performance in identifying FFR-positive coronary stenoses. Finally, iFR and FFR have similar diagnostic efficiency for detection of ischemia-inducing stenoses when tested against a third comparator.
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Affiliation(s)
- Salvatore De Rosa
- From the Division of Cardiology, Department of Medical and Surgical Sciences (S.D.R., A.P., C.I.) and URT-CNR of IFC (C.I.), Magna Graecia University, Catanzaro, Italy; and National Heart and Lung Institute, Imperial College London, United Kingdom (R.P., J.E.D.)
| | - Alberto Polimeni
- From the Division of Cardiology, Department of Medical and Surgical Sciences (S.D.R., A.P., C.I.) and URT-CNR of IFC (C.I.), Magna Graecia University, Catanzaro, Italy; and National Heart and Lung Institute, Imperial College London, United Kingdom (R.P., J.E.D.)
| | - Ricardo Petraco
- From the Division of Cardiology, Department of Medical and Surgical Sciences (S.D.R., A.P., C.I.) and URT-CNR of IFC (C.I.), Magna Graecia University, Catanzaro, Italy; and National Heart and Lung Institute, Imperial College London, United Kingdom (R.P., J.E.D.)
| | - Justin E Davies
- From the Division of Cardiology, Department of Medical and Surgical Sciences (S.D.R., A.P., C.I.) and URT-CNR of IFC (C.I.), Magna Graecia University, Catanzaro, Italy; and National Heart and Lung Institute, Imperial College London, United Kingdom (R.P., J.E.D.)
| | - Ciro Indolfi
- From the Division of Cardiology, Department of Medical and Surgical Sciences (S.D.R., A.P., C.I.) and URT-CNR of IFC (C.I.), Magna Graecia University, Catanzaro, Italy; and National Heart and Lung Institute, Imperial College London, United Kingdom (R.P., J.E.D.).
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Meta-Analysis of Diagnostic Performance of Instantaneous Wave-Free Ratio versus Quantitative Flow Ratio for Detecting the Functional Significance of Coronary Stenosis. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5828931. [PMID: 31119175 PMCID: PMC6500690 DOI: 10.1155/2019/5828931] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 03/24/2019] [Accepted: 04/03/2019] [Indexed: 01/10/2023]
Abstract
Background Fractional flow reserve (FFR), as a functional measurement of coronary stenosis, is recommended for guiding revascularization in intermediate coronary lesions. However, it still remains underutilized for potential reasons including time consumption, costs, or contraindications associated with adenosine administration. Here we performed this meta-analysis to assess the diagnostic performance of two adenosine-free indices, instantaneous wave free-ratio (iFR), and quantitative flow ratio (QFR) in evaluating coronary stenosis severity with FFR as the reference standard. Methods PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to include relevant studies with the diagnostic accuracy of iFR or QFR referenced to FFR. A bivariate model was applied to pool diagnostic parameters. We used Cochran's Q test and I2 index to assess heterogeneity and identify the potential source of heterogeneity by meta-regression. Results A total of 8213 lesions from 28 studies (19 for iFR and 9 for QFR) were included in this meta-analysis. The pooled sensitivity and specificity were 0.79 (95% CI, 0.75 to 0.83) and 0.85 (95% CI, 0.82 to 0.87) for iFR and 0.90 (95% CI, 0.84 to 0.93) and 0.88 (95% CI, 0.86 to 0.90) for QFR, respectively. Significantly higher sensitivity and specificity were observed in the bivariate analysis for QFR than for iFR (P < 0.001 for both). The area under summary receiver-operating curve of iFR and QFR was 0.89 (95% CI, 0.86 to 0.92) and 0.92 (95% CI, 0.89 to 0.94). Conclusion Evidence suggests that both of the two indices have good performance in detecting functional ischemia of coronary arteries and QFR might be a promising method without requiring the pressure wire. Further application of QFR may potentially provide important information to clinicians in the assessment of coronary lesions.
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Indolfi C, De Rosa S, Mongiardo A, Yasuda M, Torella D, Spaccarotella C. The everlasting dispute between coronary bypass and angioplasty in patients with multivessels coronary artery disease: results of the SYNTAX II study. Eur Heart J Suppl 2019; 21:B55-B56. [PMID: 30948949 PMCID: PMC6439918 DOI: 10.1093/eurheartj/suz019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ciro Indolfi
- Cardiology Unit, UOC Cardiologia Emodinamica ed UTICRT CNR di IFC Università degli Studi Magna Graecia di Catanzaro, Italy
| | - Salvatore De Rosa
- Cardiology Unit, UOC Cardiologia Emodinamica ed UTICRT CNR di IFC Università degli Studi Magna Graecia di Catanzaro, Italy
| | - Annalisa Mongiardo
- Cardiology Unit, UOC Cardiologia Emodinamica ed UTICRT CNR di IFC Università degli Studi Magna Graecia di Catanzaro, Italy
| | - Masakazu Yasuda
- Cardiology Unit, UOC Cardiologia Emodinamica ed UTICRT CNR di IFC Università degli Studi Magna Graecia di Catanzaro, Italy
| | - Daniele Torella
- Cardiology Unit, UOC Cardiologia Emodinamica ed UTICRT CNR di IFC Università degli Studi Magna Graecia di Catanzaro, Italy
| | - Carmen Spaccarotella
- Cardiology Unit, UOC Cardiologia Emodinamica ed UTICRT CNR di IFC Università degli Studi Magna Graecia di Catanzaro, Italy
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Coronary Physiology in the Cardiac Catheterization Laboratory. J Clin Med 2019; 8:jcm8020255. [PMID: 30781631 PMCID: PMC6406799 DOI: 10.3390/jcm8020255] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/09/2019] [Accepted: 02/14/2019] [Indexed: 01/10/2023] Open
Abstract
Coronary angiography has been the principle modality for assessing the severity of atherosclerotic coronary artery disease for several decades. However, there is a complex relationship between angiographic coronary stenosis and the presence or absence of myocardial ischemia. Recent technological advances now allow for the assessment of coronary physiology in the catheterization laboratory at the time of diagnostic coronary angiography. Early studies focused on coronary flow reserve (CFR) but more recent work has demonstrated the physiologic accuracy and prognostic value of the fractional flow reserve (FFR) and instantaneous wave free ratio (iFR) for the assessment of coronary artery disease. These measurements have been validated in large multi-center clinical trials and have become indispensable tools for guiding revascularization in the cardiac catheterization laboratory. The physiological assessment of chest pain in the absence of epicardial coronary artery disease involves coronary thermodilution to obtain the index of microcirculatory resistance (IMR) or Doppler velocity measurement to determine the coronary flow velocity reserve (CFVR). Physiology-based coronary artery assessment brings "personalized medicine" to the catheterization laboratory and allows cardiologists and referring providers to make decisions based on objective findings and evidence-based treatment algorithms. The purpose of this review is to describe the theory, technical aspects, and relevant clinical trials related to coronary physiology assessment for an intended audience of general medical practitioners.
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Mo X, Yan F, Zhang B. Molecular Ultrasound Monitoring of Early Artery Injury After Carotid Balloon Angioplasty. Front Pharmacol 2019; 9:1569. [PMID: 30740054 PMCID: PMC6355681 DOI: 10.3389/fphar.2018.01569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/24/2018] [Indexed: 12/26/2022] Open
Abstract
Cardiovascular intervention is a common treatment procedure for many cardiovascular diseases. But restenosis often occurs after these procedures, greatly discounting their long-term therapeutic effects. Early detection of endothelial denudation is helpful for the diagnosis and prevention of restenosis. Here, we fabricated targeted microbubbles by conjugating anti-collagen IV antibodies to the surface of biotinylated microbubbles (MBColIV) and applied them for ultrasound molecular imaging of endothelial injury at early stage. Our results showed that the MBColIV, with a typical multi-peak particle distribution, was successfully constructed, which was confirmed by Alexa Fluor® 555-labeled secondary antibody. Ex vivo adhesion of microbubbles revealed that MBColIV can effectively and specially bind to the surface of balloon-injured carotid artery. The in vivo animal experiments showed ultrasound molecular imaging signals from carotid artery-injured rats administrated with MBColIV were significantly higher than those administrated with isotype control microbubbles. Histological staining of the left carotid common artery revealed that collagen IV was obviously exposed after endothelium denudation in balloon-injured artery. In conclusion, our current study provides an effective approach to detect vascular injury at the early stage and a potential platform for image-guided therapy to vascular injury.
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Affiliation(s)
- Xinhai Mo
- Department of Ultrasound in Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fei Yan
- Paul C. Lauterbur Research Center for Biomedical Imaging, Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Bo Zhang
- Department of Ultrasound in Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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Raja DC, Subban V, Mathew R, Abdullakutty J, Joseph J, George J, Chandra S, Livingston N, Nair SG, Janakiraman E, Kalidoss L, Mullasari AS. Comparison of resting and adenosine-free pressure indices with adenosine-induced hyperemic fractional flow reserve in intermediate coronary lesions. Indian Heart J 2019; 71:74-79. [PMID: 31000187 PMCID: PMC6477165 DOI: 10.1016/j.ihj.2018.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/11/2018] [Accepted: 11/25/2018] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Fractional flow reserve (FFR) using adenosine has been the gold standard in the functional assessment of intermediate coronary stenoses in the catheterization laboratory. We aim to study the correlation of adenosine-free indices such as whole cycle Pd/Pa [the ratio of mean distal coronary pressure (Pd) to the mean pressure observed in the aorta (Pa)], instantaneous wave-free ratio (iFR), and contrast-induced submaximal hyperemia (cFFR) with FFR. METHODS This multicenter, prospective, observational study included patients with stable angina or acute coronary syndrome (>48 h since onset) with discrete intermediate coronary lesions (40-70% diameter stenosis). All patients underwent assessment of whole cycle Pd/Pa, iFR, cFFR, and FFR. We then evaluated the correlation of these indices with FFR and assessed the diagnostic efficiencies of them against FFR ≤0.80. RESULTS Of the 103 patients from three different centers, 83 lesions were included for analysis. The correlation coefficient (r value) of whole cycle Pd/Pa, iFR, and cFFR in relation to FFR were +0.84, +0.77, and +0.70 (all p values < 0.001), respectively, and the c-statistic against FFR ≤0.80 were 0.92 (0.86-0.98), 0.89(0.81-0.97), and 0.91 (0.85-0.97) (all p values < 0.001), respectively. The best cut-off values identified by receiver-operator characteristic curve for whole cycle Pd/Pa, iFR, and cFFR were 0.94, 0.90, and 0.88, respectively, for an FFR ≤0.80. By the concept of "adenosine-free zone" (iFR = 0.86-0.93), 59% lesions in this study would not require adenosine. CONCLUSION All the three adenosine-free indices had good correlation with FFR. There is no difference in the diagnostic accuracies among the indices in functional evaluation of discrete intermediate coronary stenoses. However, further validation is needed before adoption of adenosine-free pressure parameters into clinical practice.
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Affiliation(s)
- Deep Chandh Raja
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, Tamilnadu, India
| | - Vijayakumar Subban
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, Tamilnadu, India
| | - Rony Mathew
- Department of Cardiology, Lisie Heart Institute, Lisie Hospitals, Kochi, India
| | - Jabir Abdullakutty
- Department of Cardiology, Lisie Heart Institute, Lisie Hospitals, Kochi, India
| | - Jo Joseph
- Department of Cardiology, Lisie Heart Institute, Lisie Hospitals, Kochi, India
| | - Jimmy George
- Department of Cardiology, Lisie Heart Institute, Lisie Hospitals, Kochi, India
| | - Subash Chandra
- Department of Cardiology, Manipal Hospitals, Bengaluru, Karnataka, India
| | - Nandhini Livingston
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, Tamilnadu, India
| | - Shyam G Nair
- Philips Health Systems, Philips India Limited, India
| | - Ezhilan Janakiraman
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, Tamilnadu, India
| | - Latchumanadhas Kalidoss
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, Tamilnadu, India
| | - Ajit Sankaradas Mullasari
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, Tamilnadu, India.
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Baumann S, Chandra L, Skarga E, Renker M, Borggrefe M, Akin I, Lossnitzer D. Instantaneous wave-free ratio (iFR ®) to determine hemodynamically significant coronary stenosis: A comprehensive review. World J Cardiol 2018; 10:267-277. [PMID: 30622685 PMCID: PMC6314882 DOI: 10.4330/wjc.v10.i12.267] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/23/2018] [Accepted: 11/26/2018] [Indexed: 02/06/2023] Open
Abstract
Coronary angiography is considered to be the gold standard in the morphological evaluation of coronary artery stenosis. The morphological assessment of the severity of a coronary lesion is very subjective. Thus, the invasive fractional flow reserve (FFR) measurement represents the current standard for estimation of the hemodynamic significance of coronary artery stenosis. The FFR-guided revascularization strategy was initially classified as a Class-IA-recommendation in the 2014 European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization. Both the Deferral vs Performance of Percutaneous Coronary Intervention of Functionally Non-Significant Coronary Stenosis and Flow Reserve vs Angiography for Multivessel Evaluation studies showed no treatment advantage for hemodynamically insignificant stenoses. With the help of FFR (and targeted interventions), clinical results could be improved; however, the use in clinical practice is still limited due to the need of adenosine administration and a significant prolongation of the length of the procedure. Instantaneous wave-free ratio (iFR®) is a new innovative approach for the determination of the hemodynamic significance of coronary stenosis, which can be obtained at rest without the use of vasodilators. Regarding the periprocedural complications as well as prognosis, iFR® showed non-inferiority to FFR in the SWEDEHEART and DEFINE-FLAIR trials. Furthermore, iFR®, enhanced by iFR®-pullback, provides the possibility to display the iFR®-change over the course of the vessel to create a hemodynamic map.
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Affiliation(s)
- Stefan Baumann
- First Department of Medicine-Cardiology, University Medical Center Mannheim, Mannheim, Germany and DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim 68167, Baden-Württemberg, Germany.
| | - Leonard Chandra
- First Department of Medicine-Cardiology, University Medical Center Mannheim, Mannheim, Germany and DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim 68167, Baden-Württemberg, Germany
| | - Elizaveta Skarga
- First Department of Medicine-Cardiology, University Medical Center Mannheim, Mannheim, Germany and DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim 68167, Baden-Württemberg, Germany
| | - Matthias Renker
- Department of Cardiology, Kerckhoff-Klinik GmbH, Bad Nauheim 61231, Hesse, Germany
| | - Martin Borggrefe
- First Department of Medicine-Cardiology, University Medical Center Mannheim, Mannheim, Germany and DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim 68167, Baden-Württemberg, Germany
| | - Ibrahim Akin
- First Department of Medicine-Cardiology, University Medical Center Mannheim, Mannheim, Germany and DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim 68167, Baden-Württemberg, Germany
| | - Dirk Lossnitzer
- First Department of Medicine-Cardiology, University Medical Center Mannheim, Mannheim, Germany and DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim 68167, Baden-Württemberg, Germany
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Hand Laser Perfusion Imaging to Assess Radial Artery Patency: A Pilot Study. J Clin Med 2018; 7:jcm7100319. [PMID: 30279350 PMCID: PMC6210442 DOI: 10.3390/jcm7100319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 12/15/2022] Open
Abstract
Objectives: To test a novel diagnostic technique to assess radial artery perfusion after transradial catheterization. Background: Despite being mostly asymptomatic, radial artery occlusion (RAO) is not a benign complication, and its diagnosis is frequently missed because it requires time-consuming diagnostic testing. We developed a novel operator-independent diagnostic test to assess RAO after coronary procedures through a transradial access (TRA) by means of hand Laser Perfusion Imaging (LPI). Methods: One hundred patients were evaluated before and after TRA by means of the LPI. A radial perfusion index (RPI) was calculated as the ratio between the total perfusion measured during ulnar occlusion and total basal perfusion. Vascular Duplex scan (VDS) was used as the standard of reference to assess the artery patency. Results: LPI correctly identified RAO in 100% of cases. Post-procedural RPI was 0.89 ± 0.13 in patients with radial patency vs. 0.15 ± 0.04 in patients with RAO (p < 0.001). In line with these results, ROC analysis showed an excellent diagnostic performance of the LPI, that correctly identified all RAO cases (Area Under the Curve, AUC = 1.0; p < 0.001), with an optimal diagnostic cutoff at 0.2 RPI. Conclusions: LPI is a reliable diagnostic technique for RAO, offering the advantages of being quick and simple to perform.
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Indolfi C, Spaccarotella C, Yasuda M, De Rosa S. Climbing the hill of left main coronary artery revascularization: percutaneous coronary intervention or coronary artery bypass graft? J Thorac Dis 2018; 10:576-580. [PMID: 29607115 DOI: 10.21037/jtd.2017.12.116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,URT-CNR of IFC, Department of Medicine, Consiglio Nazionale delle Ricerche, Catanzaro, Italy
| | - Carmen Spaccarotella
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Masakazu Yasuda
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Division of Cardiology, Department of Medicine, Kindai University, Osakasayama, Japan
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
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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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Maini R, Moscona J, Katigbak P, Fernandez C, Sidhu G, Saleh Q, Irimpen A, Samson R, LeJemtel T. Instantaneous wave-free ratio as an alternative to fractional flow reserve in assessment of moderate coronary stenoses: A meta-analysis of diagnostic accuracy studies. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:613-620. [PMID: 29371084 DOI: 10.1016/j.carrev.2017.12.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 12/22/2017] [Accepted: 12/22/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE Fractional flow reserve (FFR) remains underutilized due to practical concerns related to the need for hyperemic agents. These concerns have prompted the study of instantaneous wave-free ratio (iFR), a vasodilator-free index of coronary stenosis. Non-inferior cardiovascular outcomes have been demonstrated in two recent randomized clinic trials. We performed this meta-analysis to provide a necessary update of the diagnostic accuracy of iFR referenced to FFR based on the addition of eight more recent studies and 3727 more lesions. METHODS We searched the PubMed, EMBASE, Central, ProQuest, and Web of Science databases for full text articles published through May 31, 2017 to identify studies addressing the diagnostic accuracy of iFR referenced to FFR≤0.80. The following keywords were used: "instantaneous wave-free ratio" OR "iFR" AND "fractional flow reserve" OR "FFR." RESULTS In total, 16 studies comprising 5756 lesions were identified. Pooled diagnostic accuracy estimates of iFR versus FFR≤0.80 were: sensitivity, 0.78 (95% CI, 0.76-0.79); specificity, 0.83 (0.81-0.84); positive likelihood ratio, 4.54 (3.85-5.35); negative likelihood ratio, 0.28 (0.24-0.32); diagnostic odds ratio, 17.38 (14.16-21.34); area under the summary receiver-operating characteristic curve, 0.87; and an overall diagnostic accuracy of 0.81 (0.78-0.84). CONCLUSIONS In conclusion, iFR showed excellent agreement with FFR as a resting index of coronary stenosis severity without the undesired effects and cost of hyperemic agents. When considering along with its clinical outcome data and ease of application, the diagnostic accuracy of iFR supports its use as a suitable alternative to FFR for physiology-guided revascularization of moderate coronary stenoses. SUMMARY We performed a meta-analysis of the diagnostic accuracy of iFR referenced to FFR. iFR showed excellent agreement with FFR as a resting index of coronary stenosis severity without the undesired effects and cost of hyperemic agents. This supports its use as a suitable alternative to FFR for physiology-guided revascularization of moderate coronary stenoses.
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Affiliation(s)
- Rohit Maini
- Division of Cardiology, Department of Medicine, Tulane University, 1430 Tulane Avenue SL 48, New Orleans, LA 70112, United States.
| | - John Moscona
- Division of Cardiology, Department of Medicine, Tulane University, 1430 Tulane Avenue SL 48, New Orleans, LA 70112, United States
| | - Paul Katigbak
- Division of Cardiology, Department of Medicine, Tulane University, 1430 Tulane Avenue SL 48, New Orleans, LA 70112, United States
| | - Camilo Fernandez
- Division of Precision Medicine, HeartGEN Institute, Boston, MA, United States
| | - Gursukhmandeep Sidhu
- The Wright Center for Graduate Medical Education, Scranton, PA 18503, United States
| | - Qusai Saleh
- Division of Cardiology, Department of Medicine, Tulane University, 1430 Tulane Avenue SL 48, New Orleans, LA 70112, United States
| | - Anand Irimpen
- Division of Cardiology, Department of Medicine, Tulane University, 1430 Tulane Avenue SL 48, New Orleans, LA 70112, United States
| | - Rohan Samson
- Division of Cardiology, Department of Medicine, Tulane University, 1430 Tulane Avenue SL 48, New Orleans, LA 70112, United States
| | - Thierry LeJemtel
- Division of Cardiology, Department of Medicine, Tulane University, 1430 Tulane Avenue SL 48, New Orleans, LA 70112, United States
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Musto C, De Felice F, Rigattieri S, Chin D, Marra A, Nazzaro MS, Cifarelli A, Violini R. Instantaneous wave-free ratio and fractional flow reserve for the assessment of nonculprit lesions during the index procedure in patients with ST-segment elevation myocardial infarction: The WAVE study. Am Heart J 2017; 193:63-69. [PMID: 29129256 DOI: 10.1016/j.ahj.2017.07.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/30/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Functional assessment of non-infarct-related artery lesions during primary percutaneous coronary intervention (PCI) might be useful to avoid revascularization of nonsignificant stenosis and staged procedures, thus reducing hospital stay. We aimed to assess the diagnostic performance of instantaneous wave-free ratio (iFR) as compared with fractional flow reserve (FFR) in this setting. METHODS In the WAVE study, a prospective, observational, single-center registry (NCT02869906), paired iFR and FFR measurements were performed at the level of non-IRA lesions in patients with ST-segment elevation myocardial infarction both during primary PCI and during staged procedures (5-8 days after). RESULTS Paired iFR and FFR measurements were available for 66 non-IRA lesions in 50 patients. The iFR and FFR values of non-IRA lesions did not change significantly between the index and staged procedure. Bland-Altman analysis did not show systematic bias for either iFR or FFR repeated measures. Receiver operating characteristic curve analysis showed high accuracy of iFR to identify positive (≤0.80) FFR measurements in the index procedure with an area under the curve of 0.95. A cutoff of ≤0.89 for iFR in the index procedure had the best combination of sensitivity (95%) and specificity (90%) with positive and negative predictive values of 86% and 97%, respectively. Finally, iFR measured during the index procedure was significantly correlated with FFR (r=0.71, r2=0.51; P<.0001). CONCLUSIONS The WAVE study shows that iFR yields similar diagnostic accuracy to FFR in functional evaluation of non-IRA stenosis in patients with STEMI and multivessel CAD, with the advantage of being adenosine free.
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Affiliation(s)
- Carmine Musto
- Interventional Cardiology Unit-San Camillo Hospital, Rome.
| | | | | | - Diana Chin
- Interventional Cardiology Unit-San Camillo Hospital, Rome
| | - Andrea Marra
- Interventional Cardiology Unit-San Camillo Hospital, Rome
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24
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Baumann S, Schaefer AC, Hohneck A, Mueller K, Becher T, Behnes M, Renker M, Borggrefe M, Akin I, Lossnitzer D. [Instantaneous wave-free ratio (iFR®) in patients with coronary artery disease]. Herz 2017; 43:621-627. [PMID: 28835979 DOI: 10.1007/s00059-017-4608-8] [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: 07/24/2017] [Accepted: 07/24/2017] [Indexed: 02/07/2023]
Abstract
Coronary angiography is considered as the gold standard in the morphological representation of coronary artery stenosis. Coronary angiography is often performed without preprocedural non-invasive proof of ischemia and the assessment of the severity of a coronary lesion by morphology is very subjective. Thus, invasive fractional flow reserve (FFR) measurement represents the current standard for estimation of the hemodynamic relevance of coronary artery stenosis and facilitates decision making for percutaneous coronary intervention (PCI) and stenting. The FFR-guided revascularization strategy has been classified as a class IA recommendation in the 2014 ESC/EACTS guidelines on myocardial revascularization. Both the DEFER and the FAME studies showed no treatment advantage of hemodynamically irrelevant stenosis. By use of FFR (and targeted interventions), clinical results could be improved as well as the procedure costs were reduced; however, the use in clinical practice is still limited due to the need of adenosine administration and a significant prolongation of the procedure. Instantaneous wave-free ratio (iFR®) is a new innovative approach for the determination of the hemodynamic relevance of coronary stenosis which can be obtained at rest without the use of vasodilators. Regarding periprocedural complications as well as prognosis, iFR® showed non-inferiority compared to FFR in the SWEDEHEART and DEFINE-FLAIR trials.
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Affiliation(s)
- S Baumann
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Heidelberg/Mannheim, Heidelberg, Deutschland. .,Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - A C Schaefer
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Heidelberg/Mannheim, Heidelberg, Deutschland
| | - A Hohneck
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Heidelberg/Mannheim, Heidelberg, Deutschland
| | - K Mueller
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Heidelberg/Mannheim, Heidelberg, Deutschland
| | - T Becher
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Heidelberg/Mannheim, Heidelberg, Deutschland
| | - M Behnes
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Heidelberg/Mannheim, Heidelberg, Deutschland
| | - M Renker
- Abteilung für Kardiologie, Kerckhoff-Klinik, Bad Nauheim, Deutschland
| | - M Borggrefe
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Heidelberg/Mannheim, Heidelberg, Deutschland
| | - I Akin
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Heidelberg/Mannheim, Heidelberg, Deutschland
| | - D Lossnitzer
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Heidelberg/Mannheim, Heidelberg, Deutschland
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25
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de Waard G, Di Mario C, Lerman A, Serruys P, van Royen N. Instantaneous wave-free ratio to guide coronary revascularisation: physiological framework, validation and differences from fractional flow reserve. EUROINTERVENTION 2017; 13:450-458. [DOI: 10.4244/eij-d-16-00456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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26
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Niccoli G, Indolfi C, Davies JE. Evaluation of intermediate coronary stenoses in acute coronary syndromes using pressure guidewire. Open Heart 2017; 4:e000431. [PMID: 28761673 PMCID: PMC5515130 DOI: 10.1136/openhrt-2016-000431] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 08/15/2016] [Accepted: 08/30/2016] [Indexed: 01/10/2023] Open
Abstract
Fractional flow reserve (FFR) is increasingly used to guide myocardial revascularisation. However, supporting evidence regarding its use originates from studies that have enrolled mainly patients with stable angina, while patients with acute coronary syndromes (ACS) have not been included. Notably, multifactorial microvascular dysfunction and an increased sympathetic tone in patients with ACS may lead to blunted response to adenosine and false-negative results of FFR due to submaximal hyperaemia. This may raise the possibility of deferring treatment of stenosis that instead would have needed dilatation, thus leaving a residual risk of preventable cardiac events. In this literature review, we aim at summarising laboratory and clinical investigations concerning the use of FFR in culprit and non-culprit lesions in ACS. Furthermore, we will report recent data on instantaneous wave-free ratio, an adenosine-free index of functional stenosis severity, in stable coronary artery disease and in patients with ACS.
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Affiliation(s)
- Giampaolo Niccoli
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences & URT CNR, Magna Graecia University, Catanzaro, Italy
| | - Justin E Davies
- National Heart and Lung Institute, International Centre for Circulatory Health, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
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27
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Cook CM, Ahmad Y, Shun-Shin MJ, Nijjer S, Petraco R, Al-Lamee R, Mayet J, Francis DP, Sen S, Davies JE. Quantification of the Effect of Pressure Wire Drift on the Diagnostic Performance of Fractional Flow Reserve, Instantaneous Wave-Free Ratio, and Whole-Cycle Pd/Pa. Circ Cardiovasc Interv 2016; 9:e002988. [PMID: 27076571 PMCID: PMC4836560 DOI: 10.1161/circinterventions.115.002988] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 02/22/2016] [Indexed: 01/10/2023]
Abstract
Background— Small drifts in intracoronary pressure measurements (±2 mm Hg) can affect stenosis categorization using pressure indices. This has not previously been assessed for fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), and whole-cycle distal pressure/proximal pressure (Pd/Pa) indices. Methods and Results—Four hundred forty-seven stenoses were assessed with FFR, iFR, and whole-cycle Pd/Pa. Cut point values for significance were predefined as ≤0.8, <0.90, and <0.93, respectively. Pressure wire drift was simulated by offsetting the distal coronary pressure trace by ±2 mm Hg. FFR, iFR, and whole-cycle Pd/Pa indices were recalculated and stenosis misclassification quantified. Median (±median absolute deviation) values for FFR, iFR, and whole-cycle Pd/Pa were 0.81 (±0.11), 0.90 (±0.07), and 0.93 (±0.06), respectively. For the cut point of FFR, iFR, and whole-cycle Pd/Pa, 34.6% (155), 50.1% (224), and 62.2% (278) of values, respectively, lay within ±0.05 U. With ±2 mm Hg pressure wire drift, 21% (94), 25% (110), and 33% (148) of the study population were misclassified with FFR, iFR, and whole-cycle Pd/Pa, respectively. Both FFR and iFR had significantly lower misclassification than whole-cycle Pd/Pa (P<0.001). There was no statistically significant difference between the diagnostic performance of FFR and iFR (P=0.125). Conclusions— In a substantial proportion of cases, small amounts of pressure wire drift are enough to cause stenoses to change classification. Whole-cycle Pd/Pa is more vulnerable to such reclassification than FFR and iFR.
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Affiliation(s)
- Christopher M Cook
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom.
| | - Yousif Ahmad
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Matthew J Shun-Shin
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Sukhjinder Nijjer
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Ricardo Petraco
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Rasha Al-Lamee
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Jamil Mayet
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Darrel P Francis
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Sayan Sen
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Justin E Davies
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
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Man W, Hu J, Zhao Z, Zhang M, Wang T, Lin J, Duan Y, Wang L, Wang H, Sun D, Li Y. Diagnostic performance of instantaneous wave-free ratio for the evaluation of coronary stenosis severity confirmed by fractional flow reserve: A PRISMA-compliant meta-analysis of randomized studies. Medicine (Baltimore) 2016; 95:e4774. [PMID: 27603377 PMCID: PMC5023900 DOI: 10.1097/md.0000000000004774] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The instantaneous wave-free ratio (iFR) is a new vasodilator-free index of coronary stenosis severity. The aim of this meta-analysis is to assess the diagnostic performance of iFR for the evaluation of coronary stenosis severity with fractional flow reserve as standard reference. METHODS We searched PubMed, EMBASE, CENTRAL, ProQuest, Web of Science, and International Clinical Trials Registry Platform (ICTRP) for publications concerning the diagnostic value of iFR. We used a random-effects covariate to synthesize the available data of sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-), and diagnostic odds ratio (DOR). Overall test performance was summarized by the summary receiver operating characteristic curve (sROC) and the area under the curve (AUC). RESULTS Eight studies with 1611 subjects were included in the meta-analysis. The pooled sensitivity, specificity, LR+, LR-, and DOR for iFR were respectively 73.3% (70.1-76.2%), 86.4% (84.3-88.3%), 5.71 (4.43-7.37), 0.29 (0.22-0.38), and 20.54 (16.11-26.20). The area under the summary receiver operating characteristic curves for iFR was 0.8786. No publication bias was identified. CONCLUSION The available evidence suggests that iFR may be a new, simple, and promising technology for coronary stenosis physiological assessment.
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Affiliation(s)
| | | | | | | | | | - Jie Lin
- Department of Cardiology, Xijing Hospital
| | - Yu Duan
- Department of Cardiology, Xijing Hospital
| | - Ling Wang
- Department of Health Statistics, Faculty of Preventive Medicine
| | - Haichang Wang
- Department of Cardiology, Tangdu Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China
| | - Dongdong Sun
- Department of Cardiology, Xijing Hospital
- Correspondence: Yan Li, Department of Cardiology, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi’an, Shaanxi 710032, China (e-mail: ); Dongdong Sun, Department of Cardiology, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi’an, Shaanxi 710032, China (e-mail: )
| | - Yan Li
- Department of Cardiology, Xijing Hospital
- Correspondence: Yan Li, Department of Cardiology, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi’an, Shaanxi 710032, China (e-mail: ); Dongdong Sun, Department of Cardiology, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi’an, Shaanxi 710032, China (e-mail: )
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29
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Echavarría-Pinto M, Serruys PW, Garcia-Garcia HM, Broyd C, Cerrato E, Macaya C, Escaned J. Use of intracoronary physiology indices in acute coronary syndromes. Interv Cardiol 2015. [DOI: 10.2217/ica.15.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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30
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Hennigan B, Robertson K, Berry C, Oldroyd K. Is Hyperaemia Essential for Accurate Functional Assessment of Coronary Stenosis Severity? Interv Cardiol 2015; 10:72-78. [PMID: 29588678 PMCID: PMC5808679 DOI: 10.15420/icr.2015.10.2.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 04/20/2015] [Indexed: 01/10/2023] Open
Abstract
Fractional flow reserve (FFR) requires the use of maximal hyperaemia as described in the original preclinical and clinical validation studies and subsequent practice changing randomized controlled trials. A perception that the need for hyperaemia (usually induced with adenosine) was one of the obstacles to more widespread adoption of FFR has led to interest in the use of resting non-hyperaemic indices to assess the functional significance of coronary stenoses. We examine the current evidence base and conclude that resting indices agree with FFR in only 80 % of lesions when a binary cut-off is employed but closer to 90 % when hybrid strategies utilising both resting indices and FFR are utilised. It seems counter intuitive to sacrifice diagnostic accuracy when in most patients and healthcare systems the induction of hyperaemia with adenosine is safe and emminently affordable.
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Affiliation(s)
| | | | - Colin Berry
- Golden Jubilee National Hospital, Clydebank, UK
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Abstract
Pressure-wire technology, most typically fractional flow reserve (FFR), has provided interventional cardiologists with a means of determining the physiological importance of a stenosis during angiography. There has been renewed interest in coronary physiology in the light of guideline recognition, ongoing clinical research and new technologies changing the paradigm of how assessment is performed in the catheter laboratory. We reflect on FFR, with regards the potential effects of changing hemodynamics on FFR and the latest evidence with regards to outcomes. We also review the instantaneous wave-free ratio (iFR), a new pressure-only index, measured at rest, that is under active evaluation in several international randomized controlled trials. We review the accumulated evidence and discuss the important physiological concepts between pressure and flow that underlie the approach to using resting indices. Finally we investigate future developments, including physiological mapping with iFR-Pullback and the potential to predict the hemodynamic effect of stenting.
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