1
|
Gaine SP, Sharma G, Tower-Rader A, Botros M, Kovell L, Parakh A, Wood MJ, Harrington CM. Multimodality Imaging in the Detection of Ischemic Heart Disease in Women. J Cardiovasc Dev Dis 2022; 9:350. [PMID: 36286302 PMCID: PMC9604786 DOI: 10.3390/jcdd9100350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022] Open
Abstract
Women with coronary artery disease tend to have a worse short and long-term prognosis relative to men and the incidence of atherosclerotic cardiovascular disease is increasing. Women are less likely to present with classic anginal symptoms when compared with men and more likely to be misdiagnosed. Several non-invasive imaging modalities are available for diagnosing ischemic heart disease in women and many of these modalities can also assist with prognostication and help to guide management. Selection of the optimal imaging modality to evaluate women with possible ischemic heart disease is a scenario which clinicians often encounter. Earlier modalities such as exercise treadmill testing demonstrate significant performance variation in men and women, while newer modalities such as coronary CT angiography, myocardial perfusion imaging and cardiac magnetic resonance imaging are highly specific and sensitive for the detection of ischemia and coronary artery disease with greater parity between sexes. Individual factors, availability, diagnostic performance, and female-specific considerations such as pregnancy status may influence the decision to select one modality over another. Emerging techniques such as strain rate imaging, CT-myocardial perfusion imaging and cardiac magnetic resonance imaging present additional options for diagnosing ischemia and coronary microvascular dysfunction.
Collapse
Affiliation(s)
- Sean Paul Gaine
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Garima Sharma
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Albree Tower-Rader
- Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02214, USA
| | - Mina Botros
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Lara Kovell
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Anushri Parakh
- Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Malissa J. Wood
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02214, USA
| | - Colleen M. Harrington
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA
- Corrigan Women’s Heart Health Program, Massachusetts General Hospital, Boston, MA 02214, USA
| |
Collapse
|
2
|
Sex differences in machine learning computed tomography-derived fractional flow reserve. Sci Rep 2022; 12:13861. [PMID: 35974055 PMCID: PMC9381799 DOI: 10.1038/s41598-022-17875-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/02/2022] [Indexed: 11/08/2022] Open
Abstract
Coronary computed tomography angiography (CCTA) derived machine learning fractional flow reserve (ML-FFRCT) can assess the hemodynamic significance of coronary artery stenoses. We aimed to assess sex differences in the association of ML-FFRCT and incident cardiovascular outcomes. We studied a retrospective cohort of consecutive patients who underwent clinically indicated CCTA and single photon emission computed tomography (SPECT). Obstructive stenosis was defined as ≥ 70% stenosis severity in non-left main vessels or ≥ 50% in the left main coronary. ML-FFRCT was computed using a machine learning algorithm with significant stenosis defined as ML-FFRCT < 0.8. The primary outcome was a composite of death or non-fatal myocardial infarction (D/MI). Our study population consisted of 471 patients with mean (SD) age 65 (13) years, 53% men, and multiple comorbidities (78% hypertension, 66% diabetes, 81% dyslipidemia). Compared to men, women were less likely to have obstructive stenosis by CCTA (9% vs. 18%; p = 0.006), less multivessel CAD (4% vs. 6%; p = 0.25), lower prevalence of ML-FFRCT < 0.8 (39% vs. 44%; p = 0.23) and higher median (IQR) ML-FFRCT (0.76 (0.53-0.86) vs. 0.71 (0.47-0.84); p = 0.047). In multivariable adjusted models, there was no significant association between ML-FFRCT < 0.8 and D/MI [Hazard Ratio 0.82, 95% confidence interval (0.30, 2.20); p = 0.25 for interaction with sex.]. In a high-risk cohort of symptomatic patients who underwent CCTA and SPECT testing, ML-FFRCT was higher in women than men. There was no significant association between ML-FFRCT and incident mortality or MI and no evidence that the prognostic value of ML-FFRCT differs by sex.
Collapse
|
3
|
Wang Z, Yin H, Jing W, Sun H, Ru M, Zhang S, Wang Y. Application of CT coronary flow reserve fraction based on deep learning in coronary artery diagnosis of coronary heart disease complicated with diabetes mellitus. Neural Comput Appl 2022. [DOI: 10.1007/s00521-021-06070-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
4
|
Aleksandric S, Banovic M, Beleslin B. Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis. Front Cardiovasc Med 2022; 9:849032. [PMID: 35360024 PMCID: PMC8961810 DOI: 10.3389/fcvm.2022.849032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/16/2022] [Indexed: 01/10/2023] Open
Abstract
More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.
Collapse
Affiliation(s)
- Srdjan Aleksandric
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- *Correspondence: Srdjan Aleksandric
| | - Marko Banovic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
5
|
Measurement of Plaque Characteristics Using Coronary Computed Tomography Angiography: Achieving High Interobserver Performance. CJC Open 2021; 4:189-196. [PMID: 35198936 PMCID: PMC8843959 DOI: 10.1016/j.cjco.2021.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background Coronary computed tomography angiography (CCTA) is used to assess plaque characteristics, remodelling, and progression and regression. Few papers address standard operating procedures that ensure achievement of high interobserver reproducibility. Moreover, assessment of coronary artery bypass grafts has not been reported. Methods A training set of images was created of native coronary segments, spanning the full range of atheromatous disease from normal to severe, excluding totally occluded segments, and including segments with or without calcification (n = 24) and completely normal-appearing bypass grafts (n = 16). Three observers used a validated software program during a training phase to establish standard operating procedures and then to achieve high intraobserver performance based on Pearson’s correlation coefficient. Subsequently, interobserver variability for the laboratory as a whole was determined with a focus on measures of plaque volume, low- attenuation plaque (LAP), mixed plaque (MP), and calcified plaque (CP). Results We found no substantive differences in analytical issues between grafts and native vessels and emphasize the aggregated data. The range of mean total plaque percent was approximately 55% of total vessel volume with maximal interobserver mean absolute differences of 2% or less. Percent of LAP, MP, and CP demonstrated interobserver standard errors of 1% to 2% and interobserver mean absolute differences of 0% to 1%. Pearson’s correlations were all highly significant and ranged from 0.969 to 0.999. Conclusions CCTA provides a rich diversity of measures of atherosclerosis in coronary and bypass segments that are highly reproducible with experience and adherence to standard operating procedures.
Collapse
|
6
|
Early Feasibility of Automated Artificial Intelligence Angiography Based Fractional Flow Reserve Estimation. Am J Cardiol 2021; 139:8-14. [PMID: 33058806 DOI: 10.1016/j.amjcard.2020.10.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 12/12/2022]
Abstract
Despite the evidence of improved patients' outcome, fractional flow reserve (FFR) is underused in current everyday practice. We aimed to evaluate the feasibility of a novel automated artificial intelligence angiography-based FFR software (AutocathFFR) as a decision supporting tool for interventional cardiologists. AutocathFFR was performed on angiographic images of patients who underwent coronary angiography with a pressure wire FFR measurement. Sensitivity and specificity for detection of FFR cut-off of 0.8 were calculated. Thirty-one patients were included in the present study, with a mean age of 64 ± 10 years, 80% were males, 32% patients had diabetes, 39% had previous percutaneous coronary intervention. The left anterior descending artery was the target vessel in 80% of patients. Automatic lesion detection was successful in all of the lesions with FFR value of ≤0.8. The sensitivity of AutocathFFR for predicting a wire based FFR ≤0.8 was 88% and the specificity for FFR >0.8 was 93%, with a positive predictive value of 94% and negative predictive value of 87%, indicating an accuracy level of 90% and area under the curve of 0.91. AutocathFFR has excellent accuracy in prediction of wire based FFR and is a promising technology that may facilitate appropriate decision and treatment choices for coronary artery disease patients.
Collapse
|
7
|
Fairbairn TA, Dobson R, Hurwitz-Koweek L, Matsuo H, Norgaard BL, Rønnow Sand NP, Nieman K, Bax JJ, Pontone G, Raff G, Chinnaiyan KM, Rabbat M, Amano T, Kawasaki T, Akasaka T, Kitabata H, Binukrishnan S, Rogers C, Berman D, Patel MR, Douglas PS, Leipsic J. Sex Differences in Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve: Lessons From ADVANCE. JACC Cardiovasc Imaging 2020; 13:2576-2587. [PMID: 32861656 DOI: 10.1016/j.jcmg.2020.07.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study is to determine the management and clinical outcomes of patients investigated with coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) according to sex. BACKGROUND Women are underdiagnosed with conventional ischemia testing, have lower rates of obstructive coronary artery disease (CAD) at invasive coronary angiography (ICA), yet higher mortality compared to men. Whether FFRCT improves sex-based patient management decisions compared to CCTA alone is unknown. METHODS Subjects with symptoms and CAD on CCTA were enrolled (2015 to 2017). Demographics, symptom status, CCTA anatomy, coronary volume to myocardial mass ratio (V/M), lowest FFRCT values, and management plans were captured. Endpoints included reclassification rate between CCTA and FFRCT management plans, incidence of ICA demonstrating obstructive CAD (≥50% stenosis) and revascularization rates. RESULTS A total of 4,737 patients (n = 1,603 females, 33.8%) underwent CCTA and FFRCT. Women were older (age 68 ± 10 years vs. 65 ± 10 years; p < 0.0001) with more atypical symptoms (41.5% vs. 33.9%; p < 0.0001). Women had less obstructive CAD (65.4% vs. 74.7%; p < 0.0001) at CCTA, higher FFRCT (0.76 ± 0.10 vs. 0.73 ± 0.10; p < 0.0001), and lower likelihood of positive FFRCT ≤ 0.80 for the same degree stenosis (p < 0.0001). A positive FFRCT ≤0.80 resulted in equal referral to ICA (n = 510 [54.5%] vs. n = 1,249 [56.5%]; p = 0.31), but more nonobstructive CAD (n = 208 [32.1%] vs. n = 354 [24.5%]; p = 0.0003) and less revascularization (n = 294 [31.4%] vs. n = 800 [36.2%]; p < 0.0001) in women, unless the FFRCT was ≤0.75 where revascularization rates were similar (n = 253 [41.9%] vs. n = 715 [46.4%]; p = 0.06). Women have a higher V/M ratio (26.17 ± 7.58 mm3/g vs. 24.76 ± 7.22 mm3/g; p < 0.0001) that is associated with higher FFRCT independent of degree stenosis (p < 0.001). Predictors of revascularization included stenosis severity, FFRCT, symptoms, and V/M ratio (p < 0.001) but not female sex (p = 0.284). CONCLUSIONS FFRCT differs between the sexes, as women have a higher FFRCT for the same degree of stenosis. In FFRCT-positive CAD, women have less obstructive CAD at ICA and less revascularization, which is associated with higher V/M ratio. The findings suggest that CAD and FFRCT variations by sex need specific interpretation as these differences may affect therapeutic decision making and clinical outcomes. (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care [ADVANCE]; NCT02499679).
Collapse
Affiliation(s)
| | - Rebecca Dobson
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Hitoshi Matsuo
- Wakayama Medical University, Wakayama, Japan; Gifu Heart Center, Gifu, Japan
| | | | | | - Koen Nieman
- Stanford University Medical Center, Palo Alto, California, USA
| | - Jeroen J Bax
- Leiden University Medical Center, Leiden, the Netherlands
| | - Gianluca Pontone
- Centro Cardiologico Monzino, IRCCS, University of Milan, Milan, Italy
| | - Gilbert Raff
- William Beaumont Hospital, Royal Oaks, Michigan, USA
| | | | - Mark Rabbat
- Loyola University Medical Center, Maywood, Illinois, USA
| | | | | | | | | | | | | | - Daniel Berman
- Cedars Sinai Medical Centre, Beverly Hills, California, USA
| | - Manesh R Patel
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
8
|
Kim SH, Kang SH, Chung WY, Yoon CH, Park SD, Nam CW, Kwon KH, Doh JH, Byun YS, Bae JW, Youn TJ, Chae IH. Validation of the diagnostic performance of 'HeartMedi V.1.0', a novel CT-derived fractional flow reserve measurement, for patients with coronary artery disease: a study protocol. BMJ Open 2020; 10:e037780. [PMID: 32690748 PMCID: PMC7375628 DOI: 10.1136/bmjopen-2020-037780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/12/2020] [Accepted: 06/05/2020] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Coronary CT angiography (CCTA) is widely used for non-invasive coronary artery evaluation, but it is limited in identifying the nature of functional characteristics that cause ischaemia. Recent computational fluid dynamic (CFD) techniques applied to CCTA images permit non-invasive computation of fractional flow reserve (FFR), a measure of lesion-specific ischaemia. However, this technology has limitations, such as long computational time and the need for expensive equipment, which hinder widespread use. METHODS AND ANALYSIS This study is a prospective, multicentre, comparative and confirmatory trial designed to evaluate the diagnostic performance of HeartMedi V.1.0, a novel CT-derived FFR measurement for the detection of haemodynamically significant coronary artery stenoses identified by CCTA, based on invasive FFR as a reference standard. The invasive FFR values ≤0.80 will be considered haemodynamically significant. The study will enrol 184 patients who underwent CCTA, invasive coronary angiography and invasive FFR. Computational FFR (c-FFR) will be analysed by CFD techniques using a lumped parameter model based on vessel length method. Blinded core laboratory interpretation will be performed for CCTA, invasive coronary angiography, invasive FFR and c-FFR. The primary objective of the study is to compare the area under the receiver-operator characteristic curve between c-FFR and CCTA to non-invasively detect the presence of haemodynamically significant coronary stenosis. The secondary endpoints include diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value and correlation of c-FFR with invasive FFR. ETHICS AND DISSEMINATION The study has ethic approval from the ethics committee of Seoul National University Bundang Hospital (E-1709/420-001) and informed consent will be obtained for all enrolled patients. The result will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER KCT0002725; Pre-results.
Collapse
Affiliation(s)
- Soo-Hyun Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, The Republic of Korea
| | - Si-Hyuck Kang
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, The Republic of Korea
| | - Woo-Young Chung
- Department of Internal Medicine, Seoul Metropolitan Boramae Hospital, Dongjak-gu, Seoul, The Republic of Korea
| | - Chang-Hwan Yoon
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, The Republic of Korea
| | - Sang-Don Park
- Division of Cardiology, Department of Internal Medicine, Inha University Hospital, Incheon, The Republic of Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, The Republic of Korea
| | - Ki-Hwan Kwon
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, The Republic of Korea
| | - Joon-Hyung Doh
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, The Republic of Korea
| | - Young-Sup Byun
- Division of Cardiology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, The Republic of Korea
| | - Jang-Whan Bae
- Department of Internal Medicine, College of Medicine, Chungbuk National University, Cheongju, The Republic of Korea
| | - Tae-Jin Youn
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, The Republic of Korea
| | - In-Ho Chae
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, The Republic of Korea
| |
Collapse
|
9
|
Heseltine TD, Murray SW, Ruzsics B, Fisher M. Latest Advances in Cardiac CT. Eur Cardiol 2020; 15:1-7. [PMID: 32180833 PMCID: PMC7066830 DOI: 10.15420/ecr.2019.14.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 08/07/2019] [Indexed: 12/18/2022] Open
Abstract
Recent rapid technological advancements in cardiac CT have improved image quality and reduced radiation exposure to patients. Furthermore, key insights from large cohort trials have helped delineate cardiovascular disease risk as a function of overall coronary plaque burden and the morphological appearance of individual plaques. The advent of CT-derived fractional flow reserve promises to establish an anatomical and functional test within one modality. Recent data examining the short-term impact of CT-derived fractional flow reserve on downstream care and clinical outcomes have been published. In addition, machine learning is a concept that is being increasingly applied to diagnostic medicine. Over the coming decade, machine learning will begin to be integrated into cardiac CT, and will potentially make a tangible difference to how this modality evolves. The authors have performed an extensive literature review and comprehensive analysis of the recent advances in cardiac CT. They review how recent advances currently impact on clinical care and potential future directions for this imaging modality.
Collapse
Affiliation(s)
| | - Scott W Murray
- Royal Liverpool University Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | | | - Michael Fisher
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
- Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Liverpool, UK
| |
Collapse
|
10
|
Fujimoto S, Giannopoulos AA, Kumamaru KK, Matsumori R, Tang A, Kato E, Kawaguchi Y, Takamura K, Miyauchi K, Daida H, Rybicki FJ, Mitsouras D. The transluminal attenuation gradient in coronary CT angiography for the detection of hemodynamically significant disease: can all arteries be treated equally? Br J Radiol 2018; 91:20180043. [PMID: 29589976 DOI: 10.1259/bjr.20180043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Results of the use of the transluminal attenuation gradient (TAG) at coronary CT angiography (CCTA) to predict hemodynamically significant disease vary widely. This study tested whether diagnostic performance of TAG to predict fractional flow reserve (FFR) ≤ 0.8 is improved when applied separately to subsets of coronary arteries that carry similar physiological flow. METHODS 28 patients with 64 × 0.5 mm CCTA and invasive FFR in ≥1 major coronary artery were retrospectively evaluated. Two readers assessed TAG in each artery. The receiver operating characteristic (ROC) area under the curve (AUC) was used to assess the diagnostic performance of TAG to detect hemodynamically significant disease following a clinical use rule [negative: FFR > 0.8 or ≤ 25% diameter stenosis (DS) at invasive catheter angiography; positive: FFR ≤ 0.8 or ≥ 90% DS at invasive catheter angiography]. ROC AUC was compared for all arteries pooled together, vs separately for arteries carrying similar physiological flow (Group 1: all left anterior descending plus right-dominant left circumflex; Group 2: right-dominant RCA plus left/co-dominant left circumflex). RESULTS Of the 84 arteries, 30 had FFR measurements, 30 had ≤25% DS and 13 had ≥90% DS. 11 arteries with 26-89% DS and no FFR measurement were excluded. TAG interobserver reproducibility was excellent (Pearson r = 0.954, Bland-Altman bias: 0.224 Hounsfield unit cm-1). ROC AUC to detect hemodynamically significant disease was higher when considering arteries separately (Group 1 AUC = 0.841, p = 0.039; Group 2 AUC = 0.840, p = 0.188), than when pooling all arteries together (AUC = 0.661). CONCLUSION Incorporating information on the physiology of coronary flow via the particular vessel interrogated and coronary dominance may improve the accuracy of TAG, a simple measurement that can be quickly performed at the time of CCTA interpretation to detect hemodynamically significant stenosis in individual coronary arteries. Advances in knowledge: The interpretation of TAG may benefit by incorporating information regarding which coronary artery is being interrogated.
Collapse
Affiliation(s)
- Shinichiro Fujimoto
- 1 Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine , Tokyo , Japan
| | - Andreas A Giannopoulos
- 2 Department of Radiology, Applied Imaging Science Laboratory, Brigham and Women's Hospital, Harvard Medical School , Boston, MA , USA.,3 Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich , Zurich , Switzerland
| | - Kanako K Kumamaru
- 2 Department of Radiology, Applied Imaging Science Laboratory, Brigham and Women's Hospital, Harvard Medical School , Boston, MA , USA.,4 Department of Radiology, Juntendo University Graduate School of Medicine , Tokyo , Japan
| | - Rie Matsumori
- 1 Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine , Tokyo , Japan
| | - Anji Tang
- 2 Department of Radiology, Applied Imaging Science Laboratory, Brigham and Women's Hospital, Harvard Medical School , Boston, MA , USA
| | - Etsuro Kato
- 1 Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine , Tokyo , Japan
| | - Yuko Kawaguchi
- 1 Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine , Tokyo , Japan
| | - Kazuhisa Takamura
- 1 Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine , Tokyo , Japan
| | - Katsumi Miyauchi
- 1 Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine , Tokyo , Japan
| | - Hiroyuki Daida
- 1 Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine , Tokyo , Japan
| | - Frank J Rybicki
- 5 The Ottawa Hospital Research Institute , Ottawa, ON , Canada.,6 Department of Radiology, The University of Ottawa , Ottawa, ON , Canada
| | - Dimitris Mitsouras
- 2 Department of Radiology, Applied Imaging Science Laboratory, Brigham and Women's Hospital, Harvard Medical School , Boston, MA , USA.,5 The Ottawa Hospital Research Institute , Ottawa, ON , Canada.,7 Department of Biochemistry, Microbiology and Immunology, The University of Ottawa , Ottawa, ON , Canada
| |
Collapse
|
11
|
Raggi P, Mancini GBJ. Myocardial perfusion with single-photon emission computed tomography, multidetector computed tomography, or neither? J Nucl Cardiol 2017; 24:1722-1724. [PMID: 27189172 DOI: 10.1007/s12350-016-0528-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 04/26/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Suite 4A7.050, 8440 - 112 Street, Edmonton, AB, T6G 2B7, Canada.
| | - G B John Mancini
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
12
|
Lee KE, Ryu AJ, Shin ES, Shim EB. Physiome approach for the analysis of vascular flow reserve in the heart and brain. Pflugers Arch 2017; 469:613-628. [PMID: 28353154 DOI: 10.1007/s00424-017-1961-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/02/2017] [Accepted: 02/20/2017] [Indexed: 01/10/2023]
Abstract
This work reviews the key aspects of coronary and neurovascular flow reserves with an emphasis on physiomic modeling characteristics by the use of a variety of numerical approaches. First, we explain the definition of fractional flow reserve (FFR) in coronary artery and introduce its clinical significance. Then, computational researches for obtaining FFR are reviewed, and their clinical outcomes are compared. In the case of cerebrovascular reserve (CVR), in spite of substantial progress in the simulation of cerebral hemodynamics, only a few computational studies exist. Thus, we discuss the limitations of CVR simulation study and suggest the challenging issue to overcome these. Also, the future direction of physiomic researches for the flow reserves in coronary arteries and cerebral arteries is described. Also, we introduce a machine learning algorithm trained by the existing physiomic simulation data of flow reserve and suggest a prospective research direction related to this.
Collapse
Affiliation(s)
- Kyung Eun Lee
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Kangwondaehak-gil, Chuncheon-si, Kangwon-do, 200-701, Republic of Korea
| | - Ah-Jin Ryu
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Kangwondaehak-gil, Chuncheon-si, Kangwon-do, 200-701, Republic of Korea
| | - Eun-Seok Shin
- Department of Cardiology, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Eun Bo Shim
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Kangwondaehak-gil, Chuncheon-si, Kangwon-do, 200-701, Republic of Korea.
| |
Collapse
|
13
|
Eftekhari A, Min J, Achenbach S, Marwan M, Budoff M, Leipsic J, Gaur S, Jensen JM, Ko BS, Christiansen EH, Kaltoft A, Bøtker HE, Jensen JF, Nørgaard BL. Fractional flow reserve derived from coronary computed tomography angiography: diagnostic performance in hypertensive and diabetic patients. Eur Heart J Cardiovasc Imaging 2016; 18:1351-1360. [DOI: 10.1093/ehjci/jew209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/11/2016] [Indexed: 12/14/2022] Open
|
14
|
Niederer SA, Smith NP. Using physiologically based models for clinical translation: predictive modelling, data interpretation or something in-between? J Physiol 2016; 594:6849-6863. [PMID: 27121495 PMCID: PMC5134392 DOI: 10.1113/jp272003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 03/13/2016] [Indexed: 02/02/2023] Open
Abstract
Heart disease continues to be a significant clinical problem in Western society. Predictive models and simulations that integrate physiological understanding with patient information derived from clinical data have huge potential to contribute to improving our understanding of both the progression and treatment of heart disease. In particular they provide the potential to improve patient selection and optimisation of cardiovascular interventions across a range of pathologies. Currently a significant proportion of this potential is still to be realised. In this paper we discuss the opportunities and challenges associated with this realisation. Reviewing the successful elements of model translation for biophysically based models and the emerging supporting technologies, we propose three distinct modes of clinical translation. Finally we outline the challenges ahead that will be fundamental to overcome if the ultimate goal of fully personalised clinical cardiac care is to be achieved.
Collapse
Affiliation(s)
- Steven A. Niederer
- Department of Biomedical Engineering and Imaging SciencesSt Thomas’ HospitalKing's College LondonThe Rayne Institute4th Floor Lambeth WingLondonSE1 7EHUK
| | - Nic P. Smith
- Department of Biomedical Engineering and Imaging SciencesSt Thomas’ HospitalKing's College LondonThe Rayne Institute4th Floor Lambeth WingLondonSE1 7EHUK
- Engineering School Block 1University of AucklandLevel 5, 20 Symonds StreetAuckland101New Zealand
| |
Collapse
|
15
|
Dugas CM, Schussler JM. Advanced technology in interventional cardiology: A roadmap for the future of precision coronary interventions. Trends Cardiovasc Med 2016; 26:466-73. [DOI: 10.1016/j.tcm.2016.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 01/17/2023]
|
16
|
Zhang JM, Zhong L, Luo T, Lomarda AM, Huo Y, Yap J, Lim ST, Tan RS, Wong ASL, Tan JWC, Yeo KK, Fam JM, Keng FYJ, Wan M, Su B, Zhao X, Allen JC, Kassab GS, Chua TSJ, Tan SY. Simplified Models of Non-Invasive Fractional Flow Reserve Based on CT Images. PLoS One 2016; 11:e0153070. [PMID: 27187726 PMCID: PMC4871505 DOI: 10.1371/journal.pone.0153070] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 03/23/2016] [Indexed: 01/10/2023] Open
Abstract
Invasive fractional flow reserve (FFR) is the gold standard to assess the functional coronary stenosis. The non-invasive assessment of diameter stenosis (DS) using coronary computed tomography angiography (CTA) has high false positive rate in contrast to FFR. Combining CTA with computational fluid dynamics (CFD), recent studies have shown promising predictions of FFRCT for superior assessment of lesion severity over CTA alone. The CFD models tend to be computationally expensive, however, and require several hours for completing analysis. Here, we introduce simplified models to predict noninvasive FFR at substantially less computational time. In this retrospective pilot study, 21 patients received coronary CTA. Subsequently a total of 32 vessels underwent invasive FFR measurement. For each vessel, FFR based on steady-state and analytical models (FFRSS and FFRAM, respectively) were calculated non-invasively based on CTA and compared with FFR. The accuracy, sensitivity, specificity, positive predictive value and negative predictive value were 90.6% (87.5%), 80.0% (80.0%), 95.5% (90.9%), 88.9% (80.0%) and 91.3% (90.9%) respectively for FFRSS (and FFRAM) on a per-vessel basis, and were 75.0%, 50.0%, 86.4%, 62.5% and 79.2% respectively for DS. The area under the receiver operating characteristic curve (AUC) was 0.963, 0.954 and 0.741 for FFRSS, FFRAM and DS respectively, on a per-patient level. The results suggest that the CTA-derived FFRSS performed well in contrast to invasive FFR and they had better diagnostic performance than DS from CTA in the identification of functionally significant lesions. In contrast to FFRCT, FFRSS requires much less computational time.
Collapse
Affiliation(s)
- Jun-Mei Zhang
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
| | - Liang Zhong
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
- * E-mail:
| | - Tong Luo
- California Medical Innovations Institute, San Diego, CA 92121, United States of America
| | - Aileen Mae Lomarda
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
| | - Yunlong Huo
- Department of Mechanics and Engineering Science, College of Engineering, Peking University, Beijing, 100871, China
| | - Jonathan Yap
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
| | - Soo Teik Lim
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
| | - Ru San Tan
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
| | - Aaron Sung Lung Wong
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
| | - Jack Wei Chieh Tan
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
| | - Khung Keong Yeo
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
| | - Jiang Ming Fam
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
| | - Felix Yung Jih Keng
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
| | - Min Wan
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- School of Information Engineering, Nanchang University, Nanchang, Jiangxi, 330031, China
| | - Boyang Su
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
| | - Xiaodan Zhao
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
| | | | - Ghassan S. Kassab
- California Medical Innovations Institute, San Diego, CA 92121, United States of America
| | - Terrance Siang Jin Chua
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
| | - Swee Yaw Tan
- National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
| |
Collapse
|
17
|
Secchi F, Alì M, Faggiano E, Cannaò PM, Fedele M, Tresoldi S, Di Leo G, Auricchio F, Sardanelli F. Fractional flow reserve based on computed tomography: an overview. Eur Heart J Suppl 2016; 18:E49-E56. [PMID: 28533717 DOI: 10.1093/eurheartj/suw014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Computed tomography coronary angiography (CTCA) is a technique proved to provide high sensitivity and negative predictive value for the identification of anatomically significant coronary artery disease (CAD) when compared with invasive X-ray coronary angiography. While the CTCA limitation of a ionizing radiation dose delivered to patients is substantially overcome by recent technical innovations, a relevant limitation remains the only anatomical assessment of coronary stenoses in the absence of evaluation of their functional haemodynamic significance. This limitation is highly important for those stenosis graded as intermediate at the anatomical assessment. Recently, non-invasive methods based on computational fluid dynamics were developed to calculate vessel-specific fractional flow reserve (FFR) using data routinely acquired by CTCA [computed tomographic fractional flow reserve (CT-FFR)]. Here we summarize methods for CT-FFR and review the evidence available in the literature up to June 26, 2016, including 16 original articles and one meta-analysis. The perspective of CT-FFR may greatly impact on CAD diagnosis, prognostic evaluation, and treatment decision-making. The aim of this review is to describe technical characteristics and clinical applications of CT-FFR, also in comparison with catheter-based invasive FFR, in order to make a cost-benefit balance in terms of clinical management and patient's health.
Collapse
Affiliation(s)
- Francesco Secchi
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, San Donato Milanese, Milan 20097, Italy
| | - Marco Alì
- PhD Course in Integrative Biomedical Research, Università degli Studi di Milano, Via Mangiagalli 31, Milano 20133, Italy
| | - Elena Faggiano
- Computational Mechanics & Advanced Material Group, Department of Civil Engineering and Architecture (DICAr), Università degli Studi di Pavia, Via Ferrata 3, Pavia 27100, Italy
| | - Paola Maria Cannaò
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Via Festa del Perdono 7, Milan 20100, Italy
| | - Marco Fedele
- Computational Mechanics & Advanced Material Group, Department of Civil Engineering and Architecture (DICAr), Università degli Studi di Pavia, Via Ferrata 3, Pavia 27100, Italy
| | - Silvia Tresoldi
- Unit of Diagnostic and Interventional Radiology, Azienda Ospedaliera San Paolo, Via A. di Rudinì 8, Milan 20142, Italy
| | - Giovanni Di Leo
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, San Donato Milanese, Milan 20097, Italy
| | - Ferdinando Auricchio
- Computational Mechanics & Advanced Material Group, Department of Civil Engineering and Architecture (DICAr), Università degli Studi di Pavia, Via Ferrata 3, Pavia 27100, Italy
| | - Francesco Sardanelli
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, San Donato Milanese, Milan 20097, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Morandi 30, San Donato Milanese, Milan 20097, Italy
| |
Collapse
|
18
|
Danad I, Baskaran L, Min JK. Noninvasive Fractional Flow Reserve Derived from Coronary Computed Tomography Angiography for the Diagnosis of Lesion-specific Ischemia. Interv Cardiol Clin 2015; 4:481-489. [PMID: 28581934 DOI: 10.1016/j.iccl.2015.06.008] [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: 06/07/2023]
Abstract
Fractional flow reserve derived from coronary computed tomography angiography (FFRCT) has emerged as a powerful tool for the assessment of flow-limiting coronary stenoses. To date, FFRCT is the only noninvasive imaging modality for the depiction of lesion-specific ischemia and large prospective multicenter studies have established its high diagnostic value. The nature of FFRCT allows the prediction of functional outcome of coronary stenting, which will expand the role of cardiac computed tomography in the evaluation and management of coronary artery disease.
Collapse
Affiliation(s)
- Ibrahim Danad
- Department of Radiology, Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, 413 East 69th Street, New York, NY 10021, USA
| | - Lohendran Baskaran
- Department of Radiology, Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, 413 East 69th Street, New York, NY 10021, USA
| | - James K Min
- Department of Radiology, Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, 413 East 69th Street, New York, NY 10021, USA.
| |
Collapse
|