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Tehrani DM, Seto AH. Is Coronary Physiology Assessment Valid in Special Circumstances?: Aortic Stenosis, Atrial Fibrillation, Left Ventricular Hypertrophy, and Other. Cardiol Clin 2024; 42:21-29. [PMID: 37949537 DOI: 10.1016/j.ccl.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) provide an important clinical tool to evaluate the hemodynamic significance of coronary lesions. However, these indices have major limitations. As these indices are meant to be surrogates of coronary flow, clinical scenarios such as aortic stenosis (with increased end-systolic and end-diastolic pressures) or atrial fibrillation (with significant beat-to-beat cardiac output variability) can have significant effect on the accuracy and reliability of these hemodynamic indices. Here, we provide a comprehensive evaluation of the pitfalls, limitations, and strengths of FFR and NHPRs in common clinical scenarios paired with coronary artery disease.
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Affiliation(s)
- David M Tehrani
- Ronald Reagan UCLA Medical Center, 650 Charles East Young Drive South, CHS A2-237, Los Angeles, CA 90095-1679, USA.
| | - Arnold H Seto
- Long Beach Veterans Administration Medical Center, 5901 East 7th Street, 111C, Long Beach, CA 90822, USA. https://twitter.com/arnoldseto
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2
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Wang HY, Zhang R, Dou K, Huang Y, Xie L, Qiao Z, Zou T, Guan C, Song L, Yang W, Wu Y, Tu S, Wijns W, Xu B. Left main bifurcation stenting: impact of residual ischaemia on cardiovascular mortality. Eur Heart J 2023; 44:4324-4336. [PMID: 37188864 PMCID: PMC10627280 DOI: 10.1093/eurheartj/ehad318] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/17/2023] Open
Abstract
AIMS The present study sought to determine the rate and prognostic implications of post-procedural physiologically significant residual ischemia according to Murray law-based quantitative flow ratio (μQFR) after left main (LM) bifurcation percutaneous coronary intervention (PCI). METHODS AND RESULTS Consecutive patients undergoing LM bifurcation stenting at a large tertiary care center between January 2014 and December 2016 with available post-PCI μQFR were included. Physiologically significant residual ischemia was defined by post-PCI μQFR values ≤0.80 in the left anterior descending (LAD) or left circumflex artery (LCX). The primary outcome was 3-year cardiovascular death. The major secondary outcome was 3-year bifurcation-oriented composite endpoint (BOCE). Among 1170 included patients with analyzable post-PCI μQFR, 155 (13.2%) had residual ischemia in either LAD or LCX. Patients with vs. those without residual ischemia had a higher risk of 3-year cardiovascular mortality [5.4% vs. 1.3%; adjusted hazard ratio (HR) 3.20, 95% confidence interval (CI): 1.16-8.80]. The 3-year risk of BOCE was significantly higher in the residual ischemia group (17.8% vs. 5.8%; adjusted HR 2.79, 95% CI: 1.68-4.64), driven by higher incidence of the composite of cardiovascular death and target bifurcation-related myocardial infarction (14.0% vs. 3.3%; adjusted HR 4.06, 95% CI: 2.22-7.42). A significant, inverse association was observed between continuous post-PCI μQFR and the risk of clinical outcomes (per 0.1 μQFR decrease, HR of cardiovascular death 1.27, 95% CI: 1.00-1.62; HR of BOCE 1.29, 95% CI: 1.14-1.47). CONCLUSION After angiographically successful LM bifurcation PCI, residual ischemia assessed by μQFR was identified in 13.2% of patients and was associated with higher risk of 3-year cardiovascular death, indicating the superior prognostic value of post-PCI physiological assessment.
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Affiliation(s)
- Hao-Yu Wang
- Cardiometabolic Medicine Center, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
- State Key Laboratory of Cardiovascular Disease, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Rui Zhang
- Cardiometabolic Medicine Center, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
- State Key Laboratory of Cardiovascular Disease, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Kefei Dou
- Cardiometabolic Medicine Center, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
- State Key Laboratory of Cardiovascular Disease, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
- National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital Chinese Academy of Medical Sciences, A 12 Langshan Rd, Nanshan District, Shenzhen 518057, China
| | - Yunfei Huang
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Lihua Xie
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Zheng Qiao
- Cardiometabolic Medicine Center, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
- State Key Laboratory of Cardiovascular Disease, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Tongqiang Zou
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Changdong Guan
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Lei Song
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Weixian Yang
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Yongjian Wu
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, University of Galway, Galway, Ireland
| | - Bo Xu
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, A 167 Beilishi Rd, Xicheng District, Beijing 100037, China
- National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital Chinese Academy of Medical Sciences, A 12 Langshan Rd, Nanshan District, Shenzhen 518057, China
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3
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Mehta CR, Naeem A, Patel Y. Cardiac Computed Tomography Angiography in CAD Risk Stratification and Revascularization Planning. Diagnostics (Basel) 2023; 13:2902. [PMID: 37761268 PMCID: PMC10530183 DOI: 10.3390/diagnostics13182902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
PURPOSE OF REVIEW Functional stress testing is frequently used to assess for coronary artery disease (CAD) in symptomatic, stable patients with low to intermediate pretest probability. However, patients with highly vulnerable plaque may have preserved luminal patency and, consequently, a falsely negative stress test. Cardiac computed tomography angiography (CCTA) has emerged at the forefront of primary prevention screening and has excellent agency in ruling out obstructive CAD with high negative predictive value while simultaneously characterizing nonobstructive plaque for high-risk features, which invariably alters risk-stratification and pre-procedural decision making. RECENT FINDINGS We review the literature detailing the utility of CCTA in its ability to risk-stratify patients with CAD based on calcium scoring as well as high-risk phenotypic features and to qualify the functional significance of stenotic lesions. SUMMARY Calcium scores ≥ 100 should prompt consideration of statin and aspirin therapy. Spotty calcifications < 3 mm, increased non-calcified plaque > 4 mm3 per mm of the vessel wall, low attenuation < 30 HU soft plaque and necrotic core with a rim of higher attenuation < 130 HU, and a positive remodeling index ratio > 1.1 all confer additive risk for acute plaque rupture when present. Elevations in the perivascular fat attenuation index > -70.1 HU are a strong predictor of all-cause mortality and can further the risk stratification of patients in the setting of a non-to-minimal plaque burden. Lastly, a CT-derived fractional flow reserve (FFRCT) < 0.75 or values from 0.76 to 0.80 in conjunction with additional risk factors is suggestive of flow-limiting disease that would benefit from invasive testing. The wealth of information available through CCTA can allow clinicians to risk-stratify patients at elevated risk for an acute ischemic event and engage in advanced revascularization planning.
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Affiliation(s)
- Chirag R. Mehta
- Department of Cardiology, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA (Y.P.)
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4
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Escaned J, Berry C, De Bruyne B, Shabbir A, Collet C, Lee JM, Appelman Y, Barbato E, Biscaglia S, Buszman PP, Campo G, Chieffo A, Colleran R, Collison D, Davies J, Giacoppo D, Holm NR, Jeremias A, Paradies V, Piróth Z, Raposo L, Roguin A, Rudolph T, Sarno G, Sen S, Toth GG, Van Belle E, Zimmermann FM, Dudek D, Stefanini G, Tarantini G. Applied coronary physiology for planning and guidance of percutaneous coronary interventions. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the European Society of Cardiology. EUROINTERVENTION 2023; 19:464-481. [PMID: 37171503 PMCID: PMC10436072 DOI: 10.4244/eij-d-23-00194] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/23/2023] [Indexed: 05/13/2023]
Abstract
The clinical value of fractional flow reserve and non-hyperaemic pressure ratios are well established in determining an indication for percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD). In addition, over the last 5 years we have witnessed a shift towards the use of physiology to enhance procedural planning, assess post-PCI functional results, and guide PCI optimisation. In this regard, clinical studies have reported compelling data supporting the use of longitudinal vessel analysis, obtained with pressure guidewire pullbacks, to better understand how obstructive CAD contributes to myocardial ischaemia, to establish the likelihood of functionally successful PCI, to identify the presence and location of residual flow-limiting stenoses and to predict long-term outcomes. The introduction of new functional coronary angiography tools, which merge angiographic information with fluid dynamic equations to deliver information equivalent to intracoronary pressure measurements, are now available and potentially also applicable to these endeavours. Furthermore, the ability of longitudinal vessel analysis to predict the functional results of stenting has played an integral role in the evolving field of simulated PCI. Nevertheless, it is important to have an awareness of the value and challenges of physiology-guided PCI in specific clinical and anatomical contexts. The main aim of this European Association of Percutaneous Cardiovascular Interventions clinical consensus statement is to offer up-to-date evidence and expert opinion on the use of applied coronary physiology for procedural PCI planning, disease pattern recognition and post-PCI optimisation.
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Affiliation(s)
- Javier Escaned
- Hospital Clínico San Carlos IdISCC, Complutense University of Madrid, Madrid, Spain
| | - Colin Berry
- Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Center Hospital, Lausanne, Switzerland
| | - Asad Shabbir
- Hospital Clínico San Carlos IdISCC, Complutense University of Madrid, Madrid, Spain
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yolande Appelman
- Amsterdam UMC, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Cona, Italy
| | - Piotr P Buszman
- Andrzej Frycz Modrzewski Kraków University, Kraków, Poland
- American Heart of Poland, Ustroń, Poland
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Cona, Italy
| | - Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Róisín Colleran
- Cardiovascular Research Institute Dublin and Department of Cardiology, Mater Private Network, Dublin, Ireland
- School of Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Damien Collison
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Justin Davies
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Daniele Giacoppo
- Cardiovascular Research Institute Dublin and Department of Cardiology, Mater Private Network, Dublin, Ireland
- Department of Cardiology, Alto Vicentino Hospital, Santorso, Italy
- ISAResearch, German Heart Centre Munich, Munich, Germany
| | - Niels R. Holm
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Zsolt Piróth
- Gottsegen National Cardiovascular Center, Budapest, Hungary
| | - Luís Raposo
- Unidade de Intervenção Cardiovascular, Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Ariel Roguin
- Hillel Yaffe Medical Center, Hadera, Israel
- Faculty of Medicine, Technion, Haifa, Israel
| | - Tanja Rudolph
- Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen, Germany
| | - Giovanna Sarno
- Cardiology, Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Sayan Sen
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Gabor G Toth
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Eric Van Belle
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Institut Coeur Poumon, Lille, France
- Department of Cardiology, Institut Pasteur de Lille, Lille, France
| | | | - Dariusz Dudek
- Interventional Cardiology Unit, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Giuseppe Tarantini
- Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
- University of Padua Medical School, Padua, Italy
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5
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Pellegrini D, Ielasi A, Tespili M, Guagliumi G, De Luca G. Percutaneous Treatment of Left Main Disease: A Review of Current Status. J Clin Med 2023; 12:4972. [PMID: 37568374 PMCID: PMC10419939 DOI: 10.3390/jcm12154972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/13/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Percutaneous treatment of the left main coronary artery is one of the most challenging scenarios in interventional cardiology, due to the large portion of myocardium at risk the technical complexity of treating a complex bifurcation with large branches. Our aim is to provide un updated overview of the current indications for percutaneous treatment of the left main, the different techniques and the rationale underlying the choice for provisional versus upfront two-stent strategies, intravascular imaging and physiology guidance in the management of left main disease, and the role of mechanical support devices in complex high-risk PCI.
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Affiliation(s)
- Dario Pellegrini
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Alfonso Ielasi
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Maurizio Tespili
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Giulio Guagliumi
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Giuseppe De Luca
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
- Division of Cardiology, AOU “Policlinico G. Martino”, Via Consolare Valeria, 1, 98124 Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, Piazza Pugliatti, 1, 98122 Messina, Italy
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6
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Ilic I, Timcic S, Odanovic N, Otasevic P, Collet C. Serial stenosis assessment-can we rely on invasive coronary physiology. Front Cardiovasc Med 2023; 10:1172906. [PMID: 37200979 PMCID: PMC10185833 DOI: 10.3389/fcvm.2023.1172906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/07/2023] [Indexed: 05/20/2023] Open
Abstract
Atherosclerosis is a widespread disease affecting coronary arteries. Diffuse atherosclerotic disease affects the whole vessel, posing difficulties in determining lesion significance by angiography. Research has confirmed that revascularization guided by invasive coronary physiology indices improves patients' prognosis and quality of life. Serial lesions can be a diagnostic challenge because the measurement of functional stenosis significance using invasive physiology is influenced by a complex interplay of factors. The use of fractional flow reserve (FFR) pullback provides a trans-stenotic pressure gradient (ΔP) for each of the lesions. The strategy of treating the lesion with greater ΔP first and then reevaluating another lesion has been advocated. Similarly, non-hyperemic indices can be used to assess the contribution of each stenosis and predict the effect of lesion treatment on physiology indices. Pullback pressure gradient (PPG) integrates physiological variables of coronary pressure along the epicardial vessel and characteristics of discrete and diffuse coronary stenoses into a quantitative index that can be used to guide revascularization. We proposed an algorithm that integrates FFR pullbacks and calculates PPG to determine individual lesion importance and to guide intervention. Computer modeling of the coronaries and the use of non-invasive FFR measurement together with mathematical algorithms for fluid dynamics can make predictions of lesion significance in serial stenoses easier and provide practical solutions for treatment. All these strategies need to be validated before widespread clinical use.
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Affiliation(s)
- Ivan Ilic
- Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Medical School, University of Belgrade, Belgrade, Serbia
- Correspondence: Ivan Ilic
| | - Stefan Timcic
- Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | | | - Petar Otasevic
- Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Medical School, University of Belgrade, Belgrade, Serbia
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
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7
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Tehrani DM, Seto AH. Is Coronary Physiology Assessment Valid in Special Circumstances?: Aortic Stenosis, Atrial Fibrillation, Left Ventricular Hypertrophy, and Other. Interv Cardiol Clin 2023; 12:21-29. [PMID: 36372459 DOI: 10.1016/j.iccl.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) provide an important clinical tool to evaluate the hemodynamic significance of coronary lesions. However, these indices have major limitations. As these indices are meant to be surrogates of coronary flow, clinical scenarios such as aortic stenosis (with increased end-systolic and end-diastolic pressures) or atrial fibrillation (with significant beat-to-beat cardiac output variability) can have significant effect on the accuracy and reliability of these hemodynamic indices. Here, we provide a comprehensive evaluation of the pitfalls, limitations, and strengths of FFR and NHPRs in common clinical scenarios paired with coronary artery disease.
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Affiliation(s)
- David M Tehrani
- Ronald Reagan UCLA Medical Center, 650 Charles East Young Drive South, CHS A2-237, Los Angeles, CA 90095-1679, USA.
| | - Arnold H Seto
- Long Beach Veterans Administration Medical Center, 5901 East 7th Street, 111C, Long Beach, CA 90822, USA. https://twitter.com/arnoldseto
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8
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Milzi A, Dettori R, Lubberich RK, Burgmaier K, Marx N, Reith S, Burgmaier M. Quantitative Flow Ratio Is Related to Anatomic Left Main Stem Lesion Parameters as Assessed by Intravascular Imaging. J Clin Med 2022; 11:jcm11206024. [PMID: 36294345 PMCID: PMC9604622 DOI: 10.3390/jcm11206024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/29/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Previously, an association between anatomic left main stem (LMS) lesion parameters, as described by intravascular ultrasound (IVUS) and fractional flow reserve (FFR), was shown. Quantitative flow ratio (QFR) is a novel, promising technique which can assess functional stenosis relevance based only on angiography. However, as little is known about the relationship between anatomic LMS parameters and QFR, it was thus investigated in this study. Methods: In 53 patients with LMS disease, we tested the association between anatomic assessment using OCT (n = 28) or IVUS (n = 25) on the one hand and functional assessment as determined by QFR on the other hand. LMS-QFR was measured using a dedicated approach, averaging QFR over left anterior descending (LAD) and circumflex (LCX) and manually limiting segment of interest to LMS. Results: The minimal luminal area of the LMS (LMS-MLA) as measured by intravascular imaging showed a consistent correlation with QFR (R = 0.61, p < 0.001). QFR could predict a LMS-MLA < 6 mm2 with very good diagnostic accuracy (AUC 0.919) and a LMS-MLA < 4.5 mm2 with good accuracy (AUC 0.798). Similar results were obtained for other stenosis parameters. Conclusions: QFR might be a valuable tool to assess LMS disease. Further studies focusing on patient outcomes are needed to further validate the effectiveness of this approach.
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Affiliation(s)
- Andrea Milzi
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
- Correspondence: ; Tel.: +49-241-8036098
| | - Rosalia Dettori
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Richard Karl Lubberich
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Kathrin Burgmaier
- Department of Pediatrics, Faculty of Medicine, University of Cologne, University Hospital of Cologne, 50931 Cologne, Germany
- Faculty of Applied Healthcare Science, Deggendorf Institute of Technology, 94469 Deggendorf, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Sebastian Reith
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Mathias Burgmaier
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
- Faculty of Applied Healthcare Science, Deggendorf Institute of Technology, 94469 Deggendorf, Germany
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9
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Ge Z, Gao XF, Zhan JJ, Chen SL. Coronary Bifurcation Lesions. Interv Cardiol Clin 2022; 11:405-417. [PMID: 36243486 DOI: 10.1016/j.iccl.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) for the treatment of coronary bifurcation lesions (CBLs) is still technically demanding, mainly because of higher rates of both acute and chronic complication as compared with non-CBLs. Although provisional stenting (PS) is considered as the preferred strategy for most of the CBLs, a systematic two-stent technique (double kissing [DK] crush) should be considered in patients with complex left main (LM)-CBLs or non-LM-CBLs stratified by the DEFINITION criteria. Intracoronary imaging and/or physiologic evaluation should be used to optimize CBLs intervention. PCI with DES for the treatment of CBLs is technically demanding, mainly because of higher rates of both acute and chronic complication as compared with non-CBLs. PS is a default strategy for most of the CBLs. Double kissing (DK) crush is associated with better clinical outcomes compared with PS in patients with complex LM-CBLs or non-LM-CBLs stratified by the DEFINITION criteria. Intracoronary imaging and/or physiologic evaluation are useful tools to guide the treatment of CBLs. The use of drug-coated balloons in CBLs needs further data to support the clinical benefits.
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Affiliation(s)
- Zhen Ge
- Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, Jiangsu, China
| | - Xiao-Fei Gao
- Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, Jiangsu, China
| | - Jun-Jie Zhan
- Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, Jiangsu, China.
| | - Shao-Liang Chen
- Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, Jiangsu, China.
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10
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Dąbrowski EJ, Kożuch M, Dobrzycki S. Left Main Coronary Artery Disease-Current Management and Future Perspectives. J Clin Med 2022; 11:jcm11195745. [PMID: 36233613 PMCID: PMC9573137 DOI: 10.3390/jcm11195745] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
Due to its anatomical features, patients with an obstruction of the left main coronary artery (LMCA) have an increased risk of death. For years, coronary artery bypass grafting (CABG) has been considered as a gold standard for revascularization. However, notable advancements in the field of percutaneous coronary intervention (PCI) led to its acknowledgement as an important treatment alternative, especially in patients with low and intermediate anatomical complexity. Although recent years brought several random clinical trials that investigated the safety and efficacy of the percutaneous approach in LMCA, there are still uncertainties regarding optimal revascularization strategies. In this paper, we provide a comprehensive review of state-of-the-art diagnostic and treatment methods of LMCA disease, focusing on percutaneous methods.
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11
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Alalawi LH, Dookhan CM, Verghese D, Manubolu VS, Aldana-Bitar J, Lakshmanan S, Ahmad K, Shafter A, Alchokhachi Z, Ghanem A, Golub IS, Budoff M, Roy S. Assessment of left main coronary artery disease: a comparison between invasive and noninvasive. Coron Artery Dis 2022; 33:490-498. [PMID: 35757932 DOI: 10.1097/mca.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Left main coronary artery disease has significant therapeutic as well as prognostic implications. The presence of left main coronary artery stenosis is strongly associated with poor short- and long-term prognoses. Accurate identification of left main stenosis is extremely important since it would be the main factor to guide management. There are several modalities used to determine the presence of atherosclerosis and the degree of stenosis in a left main coronary artery. Newer modalities allow for an accurate evaluation of left main stenosis and atherosclerosis. In this review, we go through different invasive and noninvasive modalities to diagnose left main stenosis, shedding more light into coronary computed tomography angiography, and its accuracy in this specific diagnosis.
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Affiliation(s)
- Luay H Alalawi
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Christina M Dookhan
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dhiran Verghese
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Venkat S Manubolu
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Jairo Aldana-Bitar
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | | | - Khadije Ahmad
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Ahmad Shafter
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Zahra Alchokhachi
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ahmed Ghanem
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Ilana S Golub
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Matthew Budoff
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Sion Roy
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
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12
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Mailey JA, Spence MS. The Contemporary Management of Left Main Coronary Artery Disease. Curr Cardiol Rev 2022; 18:e170621194128. [PMID: 34139985 PMCID: PMC9241110 DOI: 10.2174/1573403x17666210617094735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/23/2020] [Accepted: 03/16/2021] [Indexed: 11/22/2022] Open
Abstract
The 'gold standard' in the management of left main coronary artery disease has historically been coronary artery bypass surgery. Recent innovations in drug-eluting stent technology coupled with the increasing utility of physiology and imaging guidance for procedures have led to an evolving role of percutaneous coronary intervention in left main disease of low and intermediate anatomical complexity. This revascularization modality carries the clear advantage of being less invasive and significantly reduced recovery times. This practice is currently supported by international guidelines, however, it remains a controversial topic in the field of interventional cardiology, and the long-term outcomes of a percutaneous strategy have been questioned. This review describes the current evidence base for the assessment and choice of intervention in left main coronary artery disease. The percutaneous revascularization techniques and use of imaging to optimize procedures and improve clinical outcomes have been discussed.
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Affiliation(s)
| | - Mark S. Spence
- Cardiology Department, Royal Victoria Hospital, Belfast, United Kingdom
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13
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Shekhar S, Mohananey D, Villablanca P, Tyagi S, Crestanello JA, Gil IJN, Ramakrishna H. Revascularization Strategies for Stable Left Main Coronary Artery Disease: Analysis of Current Evidence. J Cardiothorac Vasc Anesth 2021; 36:3370-3378. [PMID: 35115224 DOI: 10.1053/j.jvca.2021.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Divyanshu Mohananey
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Sudhi Tyagi
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Iván J Núñez Gil
- Interventional Cardiology Consultant, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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14
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Abdul-Kafi O, Toole M, Montes-Rivera M, Shroff A, Ardati A. Measure Twice, Cut Once: Adjunctive Physiology and Imaging in Left Main PCI. CURRENT CARDIOVASCULAR IMAGING REPORTS 2021. [DOI: 10.1007/s12410-021-09562-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Assessing left main disease with FFR-CT and its challenges. Int J Cardiovasc Imaging 2021; 37:3309-3311. [PMID: 34487309 DOI: 10.1007/s10554-021-02404-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
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16
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Riedl KA, Jensen JM, Ko BS, Leipsic J, Grove EL, Mathiassen ON, Bøtker HE, Nørgaard BL. Coronary CT angiography derived FFR in patients with left main disease. Int J Cardiovasc Imaging 2021; 37:3299-3308. [PMID: 34383150 PMCID: PMC8557153 DOI: 10.1007/s10554-021-02371-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/03/2021] [Indexed: 11/24/2022]
Abstract
The presence of left main coronary artery disease (LMCAD) is associated with an unfavorable clinical outcome. The clinical utility of FFRCT testing for non-invasive physiological assessment in LMCAD remains largely unknown. In this single center observational study LMCAD patients were retrospectively identified between November 2015 and December 2017. We evaluated the relationship between LMCAD diameter stenosis and downstream FFRCT values, and the clinical consequences following FFRCT testing in patients with LMCAD. The composite endpoint (all-cause death, myocardial infarction, unplanned revascularization) was determined over a median follow-up of 1.1 years. LMCAD was registered in 432 of 3202 (13%) patients having coronary CTA. FFRCT was prescribed in 213 (49%), while 59 (14%) patients were referred directly to invasive angiography or myocardial perfusion imaging. FFRCT was performed in 195 (45%) patients. LM stenosis severity was inversely related to downstream FFRCT values. In patients with simple LMCAD with stenosis ≥ 50%, > 80% had FFRCT > 0.80 in non-diseased proximal and downstream segments (n = 7). No patients with simple LMCAD and FFRCT > 0.80 (n = 20) suffered an adverse clinical outcome. FFRCT testing in patients with LMCAD is feasible. LM stenosis severity is inversely related to FFRCT value. Patients with LMCAD and FFRCT > 0.80 have favorable clinical outcomes at short-term follow-up. Large-scale studies assessing the clinical utility and safety of deferring invasive catheterization following FFRCT testing in patients with LMCAD are warranted.
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Affiliation(s)
- Katharina A Riedl
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany.
| | - Jesper M Jensen
- Department of Cardiology, Aarhus University Hospital - Skejby, Aarhus, Palle Juul-Jensens Boulevard 69, 8200, Aarhus N, Denmark
| | - Brian S Ko
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, 246 Clayton Rd, Clayton, VIC, 3168, Australia
| | - Jonathon Leipsic
- Department of Radiology, St. Paul's Hospital, University of British Columbia, 1081 Burrard St., Vancouver, BC, V6Z1Y6, Canada
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital - Skejby, Aarhus, Palle Juul-Jensens Boulevard 69, 8200, Aarhus N, Denmark
| | - Ole N Mathiassen
- Department of Cardiology, Aarhus University Hospital - Skejby, Aarhus, Palle Juul-Jensens Boulevard 69, 8200, Aarhus N, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital - Skejby, Aarhus, Palle Juul-Jensens Boulevard 69, 8200, Aarhus N, Denmark
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital - Skejby, Aarhus, Palle Juul-Jensens Boulevard 69, 8200, Aarhus N, Denmark
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17
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Ghorbanniahassankiadeh A, Marks DS, LaDisa JF. Correlation of Computational Instantaneous Wave-Free Ratio With Fractional Flow Reserve for Intermediate Multivessel Coronary Disease. J Biomech Eng 2021; 143:051011. [PMID: 33454732 DOI: 10.1115/1.4049746] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Indexed: 01/14/2023]
Abstract
This study computationally assesses the accuracy of an instantaneous wave-free ratio (iFR) threshold range compared to standard modalities such as fractional flow reserve (FFR) and coronary flow reserve (CFR) for multiple intermediate lesions near the left main (LM) coronary bifurcation. iFR is an adenosine-independent index encouraged for assessment of coronary artery disease (CAD), but different thresholds are debated. This becomes particularly challenging in cases of multivessel disease when sensitivity to downstream lesions is unclear. Idealized LM coronary arteries with 34 different intermediate stenoses were created and categorized (Medina) as single and multiple lesion groups. Computational fluid dynamics modeling was performed with physiologic boundary conditions using an open-source software (simvascular1) to solve the time-dependent Navier-Stokes equations. A strong linear relationship between iFR and FFR was observed among studied models, indicating computational iFR values of 0.92 and 0.93 are statistically equivalent to an FFR of 0.80 in single and multiple lesion groups, respectively. At the clinical FFR value (i.e., 0.8), a triple-lesion group had smaller CFR compared to the single and double lesion groups (e.g., triple = 3.077 versus single = 3.133 and double = 3.132). In general, the effect of additional intermediate downstream lesions (minimum lumen area > 3 mm2) was not statistically significant for iFR and CFR. A computational iFR of 0.92 best predicts an FFR of 0.80 and may be recommended as threshold criteria for computational assessment of LM stenosis following additional validation using patient-specific models.
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Affiliation(s)
- Arash Ghorbanniahassankiadeh
- Department of Biomedical Engineering, Medical College of Wisconsin and Marquette University, 8701 W Watertown Plank Road, Milwaukee, WI 53226
| | - David S Marks
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226
| | - John F LaDisa
- Department of Biomedical Engineering, Medical College of Wisconsin and Marquette University, 8701 W Watertown Plank Road, Milwaukee, WI 53226; Department of Physiology, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226; Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226
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18
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Tomaniak M, Masdjedi K, van Zandvoort LJ, Neleman T, Tovar Forero MN, Vermaire A, Kochman J, Kardys I, den Dekker W, Wilschut J, Diletti R, de Jaegere P, Van Mieghem NM, Zijlstra F, Daemen J. Correlation between 3D-QCA based FFR and quantitative lumen assessment by IVUS for left main coronary artery stenoses. Catheter Cardiovasc Interv 2021; 97:E495-E501. [PMID: 32725862 PMCID: PMC7984347 DOI: 10.1002/ccd.29151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/27/2020] [Accepted: 07/03/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES We aimed to evaluate the feasibility of using three dimensional-quantitative coronary angiography (3D-QCA) based fractional flow reserve (FFR) (vessel fractional flow reserve [vFFR], CAAS8.1, Pie Medical Imaging) and to correlate vFFR values with intravascular ultrasound (IVUS) for the evaluation of intermediate left main coronary artery (LMCA) stenosis. BACKGROUND 3D-QCA derived FFR indices have been recently developed for less invasive functional lesion assessment. However, LMCA lesions were vastly under-represented in first validation studies. METHODS This observational single-center cohort study enrolled consecutive patients with stable angina, unstable angina, or non-ST-segment elevation myocardial infarction and nonostial, intermediate grade LMCA stenoses who underwent IVUS evaluation. vFFR was computed based on two angiograms with optimal LMCA stenosis projection and correlated with IVUS-derived minimal lumen area (MLA). RESULTS A total of 256 patients with intermediate grade LMCA stenosis evaluated with IVUS were screened for eligibility; 147 patients met the clinical inclusion criteria and had a complete IVUS LMCA footage available, of them, 63 patients (63 lesions) underwent 3D-QCA and vFFR analyses. The main reason for screening failure was insufficient quality of the angiogram (51 patients,60.7%). Mean age was 65 ± 11 years, 75% were male. Overall, mean MLA within LMCA was 8.77 ± 3.17 mm2 , while mean vFFR was 0.87 ± 0.09. A correlation was observed between vFFR and LMCA MLA (r = .792, p = .001). The diagnostic accuracy of vFFR ≤0.8 in identifying lesions with MLA < 6.0 mm2 (sensitivity 98%, specificity 71.4%, area under the curve (AUC) 0.95, 95% confidence interval (CI) 0.89-1.00, p = .001) was good. CONCLUSIONS In patients with good quality angiographic visualization of LMCA and available complete LMCA IVUS footage, 3D-QCA based vFFR assessment of LMCA disease correlates well to LMCA MLA as assessed by IVUS.
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Affiliation(s)
- Mariusz Tomaniak
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
- First Department of CardiologyMedical University of WarsawPoland
| | - Kaneshka Masdjedi
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Laurens J van Zandvoort
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Tara Neleman
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Maria N Tovar Forero
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Alise Vermaire
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Janusz Kochman
- First Department of CardiologyMedical University of WarsawPoland
| | - Isabella Kardys
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Wijnand den Dekker
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Jeroen Wilschut
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Roberto Diletti
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Peter de Jaegere
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Nicolas M Van Mieghem
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Felix Zijlstra
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
| | - Joost Daemen
- Department of CardiologyErasmus Medical Center, University Medical Center Rotterdam, Thorax CentreRotterdamThe Netherlands
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19
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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20
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Kayaert P, Coeman M, Gevaert S, De Pauw M, Haine S. Physiology-Based Revascularization of Left Main Coronary Artery Disease. J Interv Cardiol 2021; 2021:4218769. [PMID: 33628144 PMCID: PMC7892248 DOI: 10.1155/2021/4218769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/12/2021] [Accepted: 01/22/2021] [Indexed: 01/10/2023] Open
Abstract
It is of critical importance to correctly assess the significance of a left main lesion. Underestimation of significance beholds the risk of inappropriate deferral of revascularization, whereas overestimation may trigger major but unnecessary interventions. This article addresses the invasive physiological assessment of left main disease and its role in deciding upon revascularization. It mainly focuses on the available evidence for fractional flow reserve and instantaneous wave-free ratio, their interpretation, and limitations. We also discuss alternative invasive physiological indices and imaging, as well as the link between physiology, ischemia, and prognosis.
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Affiliation(s)
- Peter Kayaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Mathieu Coeman
- Department of Cardiology, Jan Yperman Ziekenhuis, Ypres, Belgium
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Steven Haine
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
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21
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Modi B, Perera D. How to select patients requiring coronary revascularisation using coronary physiology. JRSM Cardiovasc Dis 2021; 10:2048004020979476. [PMID: 33614020 PMCID: PMC7868490 DOI: 10.1177/2048004020979476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/29/2020] [Accepted: 11/18/2020] [Indexed: 01/10/2023] Open
Abstract
The coronary angiogram is an indicator of flow limiting coronary artery disease but coronary physiology at the time of angiography is vital in assessing the true functional significance of coronary artery disease. With advances in guidewire technology and the greater use of physiology within the catheter laboratory, there is now a slow evolution of physiological indices in being able to reliably assess the functional significance of individual lesions and also the adequacy of revascularization in a growing range of clinical scenarios. As co-registration of physiology with the angiogram and intravascular imaging will become easier, we will find ourselves increasingly in an era of 'Precision PCI'.
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Affiliation(s)
- Bhavik Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, UK
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, UK
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Long-Term Clinical Outcomes of Unprotected Left Main Percutaneous Coronary Intervention: A Large Single-Centre Experience. J Interv Cardiol 2021; 2021:8829686. [PMID: 33519307 PMCID: PMC7815387 DOI: 10.1155/2021/8829686] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/16/2020] [Accepted: 12/30/2020] [Indexed: 11/30/2022] Open
Abstract
Aims This study sought to report the 10-year clinical outcomes of patients who underwent unprotected left main (LM) percutaneous coronary intervention (PCI) in a large centre. Methods and Results A total of 913 consecutive patients who underwent unprotected LM PCI from January 2004 to December 2008 at Fu Wai Hospital were retrospectively analysed; the mean age was 60.0 ± 10.9 years, females accounted for 22% of patients, diabetes was present in 27.7% of patients, and an LM bifurcation lesion occurred in 82.9% of patients. During the median follow-up of 9.7 years, major adverse cardiac or cerebrovascular events (MACCEs) occurred in 25.6% (234) of patients, and the rates of all-cause death, myocardial infarction, and stroke were 14.9%, 11.0%, and 7.1%, respectively. Cardiac death occurred in only 7.9% of patients. The estimated event rate was 41.9% for death/myocardial infarction/any revascularization and 45.9% for death/MI/stroke/any revascularization. Definite/probable stent thrombosis occurred in 4.3% (39) of patients. According to the subgroup analysis, IVUS-guided PCI was associated with less long-term MACCEs. Further multivariate analysis identified that age and LVEF<40% were the only independent predictors for 10-year death. Age, LVEF<40%, creatinine clearance, and incomplete revascularization were independent predictors for death/MI, while a two-stent strategy, diabetes, a transradial approach, and the use of bare metal stents (BMSs) or first-generation drug-eluting stents (DESs) were not. Conclusions Unprotected LM PCI in a large cohort of consecutive patients in a single large centre demonstrated favourable long-term outcomes up to 10 years even with the use of BMSs and first-generation of DESs.
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Nogic J, Prosser H, O’Brien J, Thakur U, Soon K, Proimos G, Brown AJ. The assessment of intermediate coronary lesions using intracoronary imaging. Cardiovasc Diagn Ther 2020; 10:1445-1460. [PMID: 33224767 PMCID: PMC7666953 DOI: 10.21037/cdt-20-226] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 06/23/2020] [Indexed: 02/05/2023]
Abstract
Intermediate coronary artery stenosis, defined as visual angiographic stenosis severity of between 30-70%, is present in up to one quarter of patients undergoing coronary angiography. Patients with this particular lesion subset represent a distinct clinical challenge, with operators often uncertain on the need for revascularization. Although international guidelines appropriately recommend physiological pressure-based assessment of these lesions utilizing either fractional flow reserve (FFR) or quantitative flow ratio (QFR), there are specific clinical scenarios and lesion subsets where the use of such indices may not be reliable. Intravascular imaging, mainly utilizing intravascular ultrasound (IVUS) and optical coherence tomography (OCT) represents an alternate and at times complementary diagnostic modality for the evaluation of intermediate coronary stenoses. Studies have attempted to validate these specific imaging measures with physiological markers of lesion-specific ischaemia with varied results. Intravascular imaging however also provides additional benefits that include portrayal of plaque morphology, guidance on stent implantation and sizing and may portend improved clinical outcomes. Looking forward, research in computational fluid dynamics now seeks to integrate both lesion-based physiology and anatomical assessment using intravascular imaging. This review will discuss the rationale and indications for the use of intravascular imaging assessment of intermediate lesions, while highlighting the current limitations and benefits to this approach.
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Affiliation(s)
- Jason Nogic
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Melbourne, Victoria, Australia
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Hamish Prosser
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Joseph O’Brien
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Udit Thakur
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Melbourne, Victoria, Australia
| | - Kean Soon
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - George Proimos
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Adam J. Brown
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Melbourne, Victoria, Australia
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Modi BN, Rahman H, Ryan M, Ellis H, Pavlidis A, Redwood S, Clapp B, Chowienczyk P, Perera D. Comparison of fractional flow reserve, instantaneous wave-free ratio and a novel technique for assessing coronary arteries with serial lesions. EUROINTERVENTION 2020; 16:577-583. [PMID: 31543499 DOI: 10.4244/eij-d-19-00635] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
AIMS Physiological indices such as fractional flow reserve (FFR), instantaneous wave-free ratio (iFR) and resting distal coronary to aortic pressure (Pd/Pa) are increasingly used to guide revascularisation. However, reliable assessment of individual stenoses in serial coronary disease remains an unmet need. This study aimed to compare conventional pressure-based indices, a reference Doppler-based resistance index (hyperaemic stenosis resistance [hSR]) and a recently described mathematical correction model to predict the contribution of individual stenoses in serial disease. METHODS AND RESULTS Resting and hyperaemic pressure wire pullbacks were performed in 54 patients with serial disease. For each stenosis, FFR, iFR, and Pd/Pa were measured by the translesional gradient in each index and the predicted FFR (FFRpred) derived mathematically from hyperaemic pullback data. "True" stenosis significance by each index was assessed following PCI of the accompanying stenosis or measurements made in a large disease-free branch. In 27 patients, Doppler average peak flow velocity (APV) was also measured to calculate hSR (hSR=∆P/APV, where ∆P=translesional pressure gradient). FFR underestimated individual stenosis severity, inversely proportional to cumulative FFR (r=0.5, p<0.001). Mean errors for FFR, iFR and Pd/Pa were 33%, 20% and 24%, respectively, and 14% for FFRpred (p<0.001). Stenosis misclassification rates based on FFR 0.80, iFR 0.89 and Pd/Pa 0.91 thresholds were not significantly different (17%, 24% and 20%, respectively) but were higher than FFRpred (11%, p<0.001). Apparent and true hSR correlated strongly (r=0.87, p<0.001, mean error 0.19±0.3), with only 7% of stenoses misclassified. CONCLUSIONS Individual stenosis severity is significantly underestimated in the presence of serial disease, using both hyperaemic and resting pressure-based indices. hSR is less prone to error but challenges in optimising Doppler signals limit clinical utility. A mathematical correction model, using data from hyperaemic pressure wire pullback, produces similar accuracy to hSR and is superior to conventional pressure-based indices.
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Affiliation(s)
- Bhavik N Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, United Kingdom
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Impact of unprotected left main percutaneous coronary intervention on long-term clinical outcomes: a large single-center study. Coron Artery Dis 2020; 30:249-254. [PMID: 30762624 DOI: 10.1097/mca.0000000000000725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND With the advancements of percutaneous coronary interventions (PCI), it is not clear whether unprotected left main (ULM) coronary artery disease (CAD) remains an independent predictor of adverse outcomes after PCI therapy. We have therefore carried out a large cohort study to investigate the impact of ULM disease on 2-year clinical outcomes in Chinese patients undergoing contemporary PCI treatment. METHODS AND RESULTS From January 2013 to December 2013, 10 724 consecutive patients undergoing PCI were prospectively collected. Two-year clinical outcomes were compared for patients undergoing ULM PCI and non-ULM PCI. Among the 10 724 patients, 272 (2.5%) patients underwent ULM PCI. Overall, these patients had higher baseline clinical risks of CAD and more extensive CAD compared with non-ULM PCI patients. During the 2-year follow-up, patients who underwent ULM PCI experienced higher incidence of cardiac death (2.2 vs. 0.7%; log-rank P=0.002), myocardial infarction (7.0 vs. 1.9%; log-rank P<0.001), stroke (2.9 vs. 1.3%; log-rank P=0.02), and definite and probable stent thrombosis (3.3 vs. 0.5%; log-rank P<0.001), than patients who underwent non-ULM PCI. However, the rates of revascularization (7.4 vs. 8.7%; log-rank P=0.48), target vessel revascularization (5.5 vs. 5.0%; log-rank P=0.66), and major adverse cardiac and cerebrovascular events (15.1 vs. 12.0%; log-rank P=0.11) were not significantly different between the groups. When performing adjusted Cox regression after propensity score matching, ULM PCI was not an independent risk factor of any clinical events (all P>0.05). CONCLUSION In this large cohort of patients who underwent modern PCI, ULM PCI patients had higher baseline clinical risks and poorer prognosis during 2-year follow-up. However, after multivariate analysis, ULM PCI was not an independent risk factor of any clinical adverse events.
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Riley RF, Henry TD, Mahmud E, Kirtane AJ, Brilakis ES, Goyal A, Grines CL, Lombardi WL, Maran A, Rab T, Tremmel JA, Truesdell AG, Yeh RW, Zhao DX, Jaffer FA. SCAI
position statement on optimal percutaneous coronary interventional therapy for complex coronary artery disease. Catheter Cardiovasc Interv 2020; 96:346-362. [DOI: 10.1002/ccd.28994] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/11/2020] [Indexed: 12/14/2022]
Affiliation(s)
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education The Christ Hospital Cincinnati Ohio USA
| | - Ehtisham Mahmud
- Sulpizio Cardiovascular Center University of California San Diego La Jolla California USA
| | - Ajay J. Kirtane
- Center for Interventional Vascular Therapy Columbia University Medical Center New York New York USA
| | | | | | | | | | - Anbukarasi Maran
- Medical University of South Carolina North Charleston South Carolina USA
| | | | | | | | - Robert W. Yeh
- Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - David X. Zhao
- Wake Forest University School of Medicine Winston‐Salem North Carolina USA
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Gogas BD, Fei Y, Song L, Alexopoulos D, Lavarra F, Rab T, King SB, Chen SL. Left Main Coronary Interventions: A Practical Guide. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1596-1605. [PMID: 32546382 DOI: 10.1016/j.carrev.2020.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/12/2020] [Accepted: 05/12/2020] [Indexed: 01/17/2023]
Abstract
Coronary artery bypass surgery has been the accepted treatment for left main coronary artery disease for over 50 years. Balloon angioplasty was later used then abandoned because of deaths likely due to restenosis or thrombotic occlusion. However, rapid innovations in drug-eluting stent designs leading to more biocompatible thin strut platforms with optimal drug elution profiles and further advances in modern pharmacotherapy involving potent P2Y12 inhibitors combined with utilization of intracoronary imaging and physiologic assessment for procedural planning and optimization have transformed percutaneous interventions into successful alternatives to coronary artery bypass graft surgery (CABG) in selected LM anatomic territories. Herein, we provide an evidence-based practical guide on how to approach and perform LM percutaneous interventions (PCI).
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Affiliation(s)
- Bill D Gogas
- The Spencer B. King III Catheterization Laboratory, Nanjing First Hospital, Nanjing Medical University, Nanjing, China. http://twitter.com/@billgogas
| | - Ye Fei
- The Spencer B. King III Catheterization Laboratory, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lin Song
- The Spencer B. King III Catheterization Laboratory, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Dimitrios Alexopoulos
- Division of Cardiology, Interventional Cardiology, ATTIKON Hospital, University of Athens Medical School, Athens, Greece
| | | | - Tanveer Rab
- Emory University School of Medicine, Atlanta, GA, USA
| | | | - Shao-Liang Chen
- The Spencer B. King III Catheterization Laboratory, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Chowdhury M, Osborn EA. Physiological Assessment of Coronary Lesions in 2020. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22:2. [PMID: 31938934 DOI: 10.1007/s11936-020-0803-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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 Physiological assessment of coronary artery disease (CAD) is an essential component of the interventional cardiology toolbox. However, despite long-term data demonstrating improved outcomes, physiology-guided percutaneous coronary intervention (PCI) remains underutilized in current practice. This review outlines the indications and technical aspects involved in evaluating coronary stenosis physiology, focusing on the latest developments in the field. RECENT FINDINGS Beyond fractional flow reserve (FFR), non-hyperemic pressure ratios (NHPR) that assess coronary physiology at rest without hyperemia now abound. Additional advances in other alternative FFR approaches, including non-invasive coronary CT (FFRCT), invasive angiography (FFRangio), and optical coherence tomography (FFROCT), are being realized. Artificial intelligence algorithms and robust tools that enable detailed pre-procedure "virtual" intervention are also emerging. The benefits of coronary physiological assessment to determine lesion functional significance are well established. In addition to stable CAD, coronary physiology can be especially helpful in clinical scenarios such as left main and multivessel CAD, serial lesions, non-infarct-related arteries in acute coronary syndromes, and residual ischemia post-PCI. Today, coronary physiological assessment remains an indispensable tool in the catheterization laboratory, with an exciting technological future that will further refine clinical practice and improve patient care.
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Affiliation(s)
- Mohsin Chowdhury
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Baker 4, Boston, MA, 02215, USA
| | - Eric A Osborn
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Baker 4, Boston, MA, 02215, USA.
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Baydoun H, Jabbar A, Nakhle A, Irimpen A, Patel T, Ward C. Revascularization of Left Main Coronary Artery. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:1014-1019. [DOI: 10.1016/j.carrev.2018.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/05/2018] [Accepted: 11/05/2018] [Indexed: 10/27/2022]
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Measurement of Hyperemic Pullback Pressure Gradients to Characterize Patterns of Coronary Atherosclerosis. J Am Coll Cardiol 2019; 74:1772-1784. [DOI: 10.1016/j.jacc.2019.07.072] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/05/2019] [Accepted: 07/21/2019] [Indexed: 11/22/2022]
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Collet C, Capodanno D, Onuma Y, Banning A, Stone GW, Taggart DP, Sabik J, Serruys PW. Left main coronary artery disease: pathophysiology, diagnosis, and treatment. Nat Rev Cardiol 2019; 15:321-331. [PMID: 29599504 DOI: 10.1038/s41569-018-0001-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The advent of coronary angiography in the 1960s allowed for the risk stratification of patients with stable angina. Patients with unprotected left main coronary artery disease have an increased risk of death related to the large amount of myocardium supplied by this vessel. Although coronary angiography remains the preferred imaging modality for the evaluation of left main coronary artery stenosis, this technique has important limitations. Angiograms of the left main coronary artery segment can be difficult to interpret, and almost one-third of patients can be misclassified when fractional flow reserve is used as the reference. In patients with clinically significant unprotected left main coronary artery disease, surgical revascularization was shown to improve survival compared with medical therapy and has been regarded as the treatment of choice for unprotected left main coronary artery disease. Two large-scale clinical trials published in 2016 support the usefulness of catheter-based revascularization in selected patients with unprotected left main coronary artery disease. In this Review, we describe the pathophysiology of unprotected left main coronary artery disease, discuss diagnostic approaches in light of new noninvasive and invasive imaging techniques, and detail risk stratification models to aid the Heart Team in the decision-making process for determining the best revascularization strategy for these patients.
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Affiliation(s)
- Carlos Collet
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", Catania, Italy.,Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Yoshinobu Onuma
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University, Rotterdam, Netherlands
| | - Adrian Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford, UK
| | - Gregg W Stone
- New York Presbyterian Hospital and Columbia University Medical Center, New York, NY, USA
| | - David P Taggart
- Department of Cardiology, John Radcliffe Hospital, Oxford, UK
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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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Coppel R, Lagache M, Finet G, Rioufol G, Gómez A, Dérimay F, Malvé M, Yazdani SK, Pettigrew RI, Ohayon J. Influence of Collaterals on True FFR Prediction for a Left Main Stenosis with Concomitant Lesions: An In Vitro Study. Ann Biomed Eng 2019; 47:1409-1421. [DOI: 10.1007/s10439-019-02235-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 02/20/2019] [Indexed: 12/20/2022]
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Modi BN, Sankaran S, Kim HJ, Ellis H, Rogers C, Taylor CA, Rajani R, Perera D. Predicting the Physiological Effect of Revascularization in Serially Diseased Coronary Arteries. Circ Cardiovasc Interv 2019; 12:e007577. [PMID: 30722688 PMCID: PMC6794156 DOI: 10.1161/circinterventions.118.007577] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/19/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR) is commonly used to assess the functional significance of coronary artery disease but is theoretically limited in evaluating individual stenoses in serially diseased vessels. We sought to characterize the accuracy of assessing individual stenoses in serial disease using invasive FFR pullback and the noninvasive equivalent, fractional flow reserve by computed tomography (FFRCT). We subsequently describe and test the accuracy of a novel noninvasive FFRCT-derived percutaneous coronary intervention (PCI) planning tool (FFRCT-P) in predicting the true significance of individual stenoses. METHODS AND RESULTS Patients with angiographic serial coronary artery disease scheduled for PCI were enrolled and underwent prospective coronary CT angiography with conventional FFRCT-derived post hoc for each vessel and stenosis (FFRCT). Before PCI, the invasive hyperemic pressure-wire pullback was performed to derive the apparent FFR contribution of each stenosis (FFRpullback). The true FFR attributable to individual lesions (FFRtrue) was then measured following PCI of one of the lesions. The predictive accuracy of FFRpullback, FFRCT, and the novel technique (FFRCT-P) was then assessed against FFRtrue. From the 24 patients undergoing the protocol, 19 vessels had post hoc FFRCT and FFRCT-P calculation. When assessing the distal effect of all lesions, FFRCT correlated moderately well with invasive FFR ( R=0.71; P<0.001). For lesion-specific assessment, there was significant underestimation of FFRtrue using FFRpullback (mean discrepancy, 0.06±0.05; P<0.001, representing a 42% error) and conventional trans-lesional FFRCT (0.05±0.06; P<0.001, 37% error). Using FFRCT-P, stenosis underestimation was significantly reduced to a 7% error (0.01±0.05; P<0.001). CONCLUSIONS FFR pullback and conventional FFRCT significantly underestimate true stenosis contribution in serial coronary artery disease. A novel noninvasive FFRCT-based PCI planner tool more accurately predicts the true FFR contribution of each stenosis in serial coronary artery disease.
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Affiliation(s)
- Bhavik N. Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
| | | | - Hyun Jin Kim
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Howard Ellis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
| | - Campbell Rogers
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Charles A. Taylor
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Ronak Rajani
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
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Almomani A, Abdel-Karim AR, Uretsky BF. Evaluating Equivocal Left Main Stenosis with Fractional Flow Reserve – Not all Daughter Vessels are Created Equally. Heart Int 2019; 13:38-40. [DOI: 10.17925/hi.2019.13.2.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 11/05/2019] [Indexed: 11/24/2022] Open
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Djordjevic Dikic A, Tesic M, Boskovic N, Giga V, Stepanovic J, Petrovic M, Dobric M, Aleksandric S, Juricic S, Dikic M, Nedeljkovic I, Nedeljkovic M, Ostojic M, Beleslin B. Prognostic Value of Preserved Coronary Flow Velocity Reserve by Noninvasive Transthoracic Doppler Echocardiography in Patients With Angiographically Intermediate Left Main Stenosis. J Am Soc Echocardiogr 2018; 32:74-80. [PMID: 30459120 DOI: 10.1016/j.echo.2018.09.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND The potential of angiography to evaluate the hemodynamic severity of a left main coronary artery (LM) stenosis is limited. Noninvasive transthoracic Doppler echocardiographic coronary flow velocity reserve (CFVR) evaluation of intermediate coronary stenosis has demonstrated remarkably high negative prognostic value. The aim of this study was to assess clinical outcomes in patients with angiographically intermediate LM stenosis and preserved CFVR (>2.0) as evaluated by transthoracic Doppler echocardiographic CFVR. METHODS The initial study population included 102 patients with intermediate coronary stenosis of the LM referred for transthoracic Doppler echocardiographic CFVR assessment. Peak diastolic CFVR measurements were performed in the distal segment of the left anterior descending coronary artery after intravenous adenosine (140 μg/kg/min), and CFVR was calculated as the ratio between maximal hyperemic and baseline coronary flow velocity. Nineteen patients had impaired CFVR (≤2.0) and were excluded from further analysis, as well as two patients with poor acoustic windows. The final group consisted of 81 patients (mean age, 60 ± 9 years; 76 men) evaluated for adverse cardiac events including death, myocardial infarction, and revascularization. RESULTS Mean follow-up duration was 62 ± 26 months. Mean CFVR was 2.4 ± 0.4. Total event-free survival was 75 of 81 (92.6%), as six patients were referred for revascularization (five patients with coronary artery bypass grafting, one patient with percutaneous coronary intervention). There were no documented myocardial infarctions or cardiovascular deaths in the follow-up period. CONCLUSIONS In patients with angiographically intermediate and equivocal LM stenosis and preserved CFVR values of >2.0, revascularization can be safely deferred.
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Affiliation(s)
- Ana Djordjevic Dikic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Milorad Tesic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia
| | | | - Vojislav Giga
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Jelena Stepanovic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Marija Petrovic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Milan Dobric
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia
| | | | - Stefan Juricic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Miodrag Dikic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Ivana Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Milan Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Miodrag Ostojic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia.
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39
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Modi BN, Ryan M, Chattersingh A, Eruslanova K, Ellis H, Gaddum N, Lee J, Clapp B, Chowienczyk P, Perera D. Optimal Application of Fractional Flow Reserve to Assess Serial Coronary Artery Disease: A 3D-Printed Experimental Study With Clinical Validation. J Am Heart Assoc 2018; 7:e010279. [PMID: 30371265 PMCID: PMC6474982 DOI: 10.1161/jaha.118.010279] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/20/2018] [Indexed: 01/10/2023]
Abstract
Background Assessing the physiological significance of stenoses with coexistent serial disease is prone to error. We aimed to use 3-dimensional-printing to characterize serial stenosis interplay and to derive and validate a mathematical solution to predict true stenosis significance in serial disease. Methods and Results Fifty-two 3-dimensional-printed serial disease phantoms were physiologically assessed by pressure-wire pullback (Δ FFR app) and compared with phantoms with the stenosis in isolation (Δ FFR true). Mathematical models to minimize error in predicting FFR true, the FFR in the vessel where the stenosis is present in isolation, were subsequently developed using 32 phantoms and validated in another 20 and also a clinical cohort of 30 patients with serial disease. Δ FFR app underestimated Δ FFR true in 88% of phantoms, with underestimation proportional to total FFR . Discrepancy as a proportion of Δ FFR true was 17.1% (absolute difference 0.036±0.048), which improved to 2.9% (0.006±0.023) using our model. In the clinical cohort, discrepancy was 38.5% (0.05±0.04) with 13.3% of stenoses misclassified (using FFR <0.8 threshold). Using mathematical correction, this improved to 15.4% (0.02±0.03), with the proportion of misclassified stenoses falling to 6.7%. Conclusions Individual stenoses are considerably underestimated in serial disease, proportional to total FFR . We have shown within in vitro and clinical cohorts that this error is significantly improved using a mathematical correction model, incorporating routinely available pressure-wire pullback data.
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Affiliation(s)
- Bhavik N. Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Matthew Ryan
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Anjalee Chattersingh
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Kseniia Eruslanova
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Howard Ellis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Nicholas Gaddum
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUnited Kingdom
| | - Jack Lee
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUnited Kingdom
| | - Brian Clapp
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Phil Chowienczyk
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
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40
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Sezer M. New Mathematical Correction Model in Pursuit of Optimal Hemodynamic Assessment of Serial Coronary Artery Disease: Overcoming Hyperemic Cross Talk Between Coronary Stenoses in Series? J Am Heart Assoc 2018; 7:e010754. [PMID: 30371268 PMCID: PMC6474979 DOI: 10.1161/jaha.118.010754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Murat Sezer
- Department of CardiologyIstanbul UniversityIstanbulTurkey
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41
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Smits PC. To screen and treat silent ischemia: A tough dilemma. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:738-739. [DOI: 10.1016/j.carrev.2018.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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42
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Lotfi A, Davies JE, Fearon WF, Grines CL, Kern MJ, Klein LW. Focused update of expert consensus statement: Use of invasive assessments of coronary physiology and structure: A position statement of the society of cardiac angiography and interventions. Catheter Cardiovasc Interv 2018; 92:336-347. [DOI: 10.1002/ccd.27672] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 04/23/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Amir Lotfi
- Baystate Medical Center; Tufts University School of Medicine; Springfield Massachusetts
| | | | | | - Cindy L. Grines
- Northwell Health, North Shore University Hospital; Manhasset New York
| | - Morton J. Kern
- Long Beach Veterans Administration Hospital; University of California, Irvine; Irvine California
| | - Lloyd W. Klein
- Advocate Illinois Masonic Medical Center, Rush Medical College; Chicago Illinois
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43
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Pellicano M, De Bruyne B, Toth GG, Casselman F, Wijns W, Barbato E. Fractional flow reserve to guide and to assess coronary artery bypass grafting. Eur Heart J 2018; 38:1959-1968. [PMID: 28025191 DOI: 10.1093/eurheartj/ehw505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 09/30/2016] [Indexed: 11/14/2022] Open
Abstract
The aim of this review is to highlight the role of invasive functional evaluation in patients in whom coronary artery bypass graft (CABG) is indicated, and to examine the clinical evidence available in favour of fractional flow reserve (FFR) adoption in these patients, outline appropriate use, as well as point out potential pitfalls. FFR after CABG will also be reviewed, highlighting its correct interpretation and adoption when applied to both native coronary arteries and bypass grafts. Practice European guidelines support the use of FFR to complement coronary angiography with the highest degree of recommendation (Class IA) for the assessment of coronary stenosis before undertaking myocardial revascularization when previous non-invasive functional evaluation is unavailable or not conclusive. As a result, FFR has been adopted in routine clinical practice to guide clinicians decision as to whether or not perform a revascularization. Of note, due to the increasing confidence of the interventional cardiologists, FFR guidance is also being implemented to indicate or guide CABG. This is in anticipation of supportive clear-cut evidence, since recommendations for FFR adoption were based on randomized clinical trials investigating percutaneous coronary intervention (PCI) strategies in which patients with typical indications for CABG were excluded (e.g. left main disease, valvular disease, and coronary anatomy unsuitable for PCI). Based on the critical appraisal of the literature, FFR can play an important role in risk stratification and determining management strategy of patients either before or after CABG.
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Affiliation(s)
- Mariano Pellicano
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium.,Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bernard De Bruyne
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium
| | - Gabor G Toth
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium.,University Heart Center Graz, Medical University Graz, Graz, Austria
| | - Filip Casselman
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium
| | - William Wijns
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium.,The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway and Saolta University Healthcare Group, Galway, Ireland
| | - Emanuele Barbato
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan n 164, B 9300 Aalst, Belgium.,Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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44
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Fajadet J, Capodanno D, Stone GW. Management of left main disease: an update. Eur Heart J 2018; 40:1454-1466. [DOI: 10.1093/eurheartj/ehy238] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 02/24/2018] [Accepted: 04/06/2018] [Indexed: 01/10/2023] Open
Affiliation(s)
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Gregg W Stone
- Columbia University Medical Center, New York-Presbyterian Hospital, Cardiovascular Research Foundation, New York, NY, USA
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45
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Balouch M, Ballard-Hernandez J, Kim M, Seto A, Kern M. The occult hemodynamically significant left main stenosis in the asymptomatic patient: Reconciling the visual-functional mismatch - A case report and review of screening appropriateness and assessment of left main in patient with multi-vessel CAD. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:805-809. [PMID: 29627360 DOI: 10.1016/j.carrev.2018.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/06/2018] [Accepted: 02/15/2018] [Indexed: 11/16/2022]
Abstract
We present a 40 year old asymptomatic man with mild left main artery narrowing who demonstrated extreme discordance between symptom presentation and ischemic burden i.e. visual (angiographic) and ischemic (functional) mismatch. The use of an appropriately selected screening stress test can lead to an appropriate decision for revascularization, supported by landmark risk assessment documents and revascularization trials.
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Affiliation(s)
| | - Jennifer Ballard-Hernandez
- Veterans Administration Long Beach Health Care System, United States; University of California, Irvine, United States
| | - Min Kim
- Veterans Administration Long Beach Health Care System, United States; University of California, Irvine, United States.
| | - Arnold Seto
- Veterans Administration Long Beach Health Care System, United States; University of California, Irvine, United States
| | - Morton Kern
- Veterans Administration Long Beach Health Care System, United States; University of California, Irvine, United States
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46
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Affiliation(s)
- Ronnie Ramadan
- VA Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Woman's Hospital, Boston, MA
| | - William E Boden
- VA Boston Healthcare System, Boston, MA
- Boston University School of Medicine, Boston, MA
| | - Scott Kinlay
- VA Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Woman's Hospital, Boston, MA
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47
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De Maria GL, Banning AP. Use of Intravascular Ultrasound Imaging in Percutaneous Coronary Intervention to Treat Left Main Coronary Artery Disease. Interv Cardiol 2018; 12:8-12. [PMID: 29588723 DOI: 10.15420/icr.2017:1:3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Due to its potential prognostic implications and technical complexity, revascularisation of left main coronary artery (LMCA) disease requires careful consideration. Since publication of the results of the SYNTAX study, and more recently the EXCEL and NOBLE trials, there has been particular interest in percutaneous revascularisation of the LMCA. It is becoming clear that percutaneous revascularisation of LMCA disease requires appropriate lesion preparation and carefully optimised stenting in order to offer patients a treatment option as effective as coronary artery bypass grafting. For this reason intravascular imaging, and especially intravascular ultrasound, is becoming a key procedural step in LMCA percutaneous coronary intervention. In the current review paper we analyse the role of intravascular imaging with intravascular ultrasound in LMCA percutaneous coronary intervention, focusing on the main applications in this context from lesion assessment to stent sizing and optimisation.
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Affiliation(s)
| | - Adrian P Banning
- Heart Centre, Oxford University Hospitals NHS Trust Foundation, Oxford, UK
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48
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Liu X, Peng C, Xia Y, Gao Z, Xu P, Wang X, Xian Z, Yin Y, Jiao L, Wang D, Shi L, Huang W, Liu X, Zhang H. Hemodynamics analysis of the serial stenotic coronary arteries. Biomed Eng Online 2017; 16:127. [PMID: 29121932 PMCID: PMC5679505 DOI: 10.1186/s12938-017-0413-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 10/11/2017] [Indexed: 11/25/2022] Open
Abstract
Coronary arterial stenoses, particularly serial stenoses in a single branch, are responsible for complex hemodynamic properties of the coronary arterial trees, and the uncertain prognosis of invasive intervention. Critical information of the blood flow redistribution in the stenotic arterial segments is required for the adequate treatment planning. Therefore, in this study, an image based non-invasive functional assessment is performed to investigate the hemodynamic significances of serial stenoses. Twenty patient-specific coronary arterial trees with different combinations of stenoses were reconstructed from the computer tomography angiography for the evaluation of the hemodynamics. Our results showed that the computed FFR based on CTA images (FFRCT) pullback curves with wall shear stress (WSS) distribution could provide more effectively examine the physiological significance of the locations of the segmental narrowing and the curvature of the coronary arterial segments. The paper thus provides the diagnostic efficacy of FFRCT pullback curve for noninvasive quantification of the hemodynamics of stenotic coronary arteries with serial lesions, compared to the gold standard invasive FFR, to provide a reliable physiological assessment of significant amount of coronary artery stenosis. Further, we were also able to demonstrate the potential of carrying out virtual revascularization, to enable more precise PCI procedures and improve their outcomes.
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Affiliation(s)
- Xin Liu
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Science, Southern Medical University, 1023-1063 Shatai South Road, Baiyun, Guangzhou, 510515 Guangdong China
| | - Changnong Peng
- Department of Cardiology, Shenzhen Sun Yat-Sen Cardiovascular Hospital, Shenzhen, 518055 China
| | - Yufa Xia
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
| | - Zhifan Gao
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
- Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences, Shenzhen, 518055 China
| | - Pengcheng Xu
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Science, Southern Medical University, 1023-1063 Shatai South Road, Baiyun, Guangzhou, 510515 Guangdong China
| | - Xiaoqing Wang
- Department of Cardiology, Shenzhen Sun Yat-Sen Cardiovascular Hospital, Shenzhen, 518055 China
| | - Zhanchao Xian
- Department of Cardiology, Shenzhen Sun Yat-Sen Cardiovascular Hospital, Shenzhen, 518055 China
| | - Youbing Yin
- Shenzhen Keya Medical Technology, Shenzhen, China
| | - Liqun Jiao
- Xuanwu Hospital, Capital University of Medical Sciences, Beijing, China
| | - Defeng Wang
- Department of Imaging and Interventional Radiology, Prince Of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Lin Shi
- Department of Imaging and Interventional Radiology, Prince Of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Wenhua Huang
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Science, Southern Medical University, 1023-1063 Shatai South Road, Baiyun, Guangzhou, 510515 Guangdong China
| | - Xin Liu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
| | - Heye Zhang
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Ave., Xili University Town, Nanshan, Shenzhen, 518055 Guangdong China
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49
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Ihdayhid AR, Yong A, Harper R, Rankin J, Wong C, Brown AJ, Leung M, Ko B. A Practical Guide for Fractional Flow Reserve Guided Revascularisation. Heart Lung Circ 2017; 27:406-419. [PMID: 29191506 DOI: 10.1016/j.hlc.2017.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 09/04/2017] [Accepted: 09/13/2017] [Indexed: 11/15/2022]
Abstract
The presence and extent of myocardial ischaemia is a major determinant of prognosis and benefit from revascularisation in patients with stable coronary artery disease. Fractional Flow Reserve (FFR) is accepted as the reference standard for invasive assessment of ischaemia. Its ability to detect lesion specific ischaemia makes it a useful test in a wide range of patient and lesion subsets, with FFR guided intervention improving clinical outcomes and reducing health care costs compared to assessment with coronary angiography alone. This article will review the basic principles in FFR, practical tips in FFR guided revascularisation and the role of emerging non-hyperaemic indices of ischaemia.
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Affiliation(s)
- Abdul Rahman Ihdayhid
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Melbourne, Vic, Australia
| | - Andy Yong
- Department of Cardiology, Concord Hospital, Sydney, NSW, Australia
| | - Richard Harper
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Melbourne, Vic, Australia
| | | | - Christopher Wong
- Department of Cardiology, Concord Hospital, Sydney, NSW, Australia
| | - Adam J Brown
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Melbourne, Vic, Australia
| | - Michael Leung
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Melbourne, Vic, Australia
| | - Brian Ko
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Melbourne, Vic, Australia.
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50
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Picard F, Pighi M, Ly HQ. Fractional flow reserve and resting indices for coronary physiologic assessment: Practical guide, tips, and tricks. Catheter Cardiovasc Interv 2017; 90:598-611. [PMID: 28160376 DOI: 10.1002/ccd.26933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 11/19/2016] [Accepted: 12/22/2016] [Indexed: 01/10/2023]
Abstract
Physiologic assessment using fractional flow reserve (FFR) to guide percutaneous coronary interventions (PCI) has been demonstrated to improve clinical outcomes, compared to angiography-guided PCI. Recently, resting indices such as resting Pd/Pa, "instantaneous wave-free ratio", and contrast medium induced FFR have been evaluated for the assessment of the functional consequences of coronary lesions. Herein, we review and discuss the use of FFR and other indices for the functional assessment of coronary lesions. This review will cover theoretical aspects, as well as practical points and common pitfalls related to coronary physiological assessment. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Fabien Picard
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Qubec, Canada
| | - Michele Pighi
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Qubec, Canada
| | - Hung Q Ly
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Qubec, Canada
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