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Seraphim A, Knott KD, Augusto JB, Menacho K, Tyebally S, Dowsing B, Bhattacharyya S, Menezes LJ, Jones DA, Uppal R, Moon JC, Manisty C. Non-invasive Ischaemia Testing in Patients With Prior Coronary Artery Bypass Graft Surgery: Technical Challenges, Limitations, and Future Directions. Front Cardiovasc Med 2022; 8:795195. [PMID: 35004905 PMCID: PMC8733203 DOI: 10.3389/fcvm.2021.795195] [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: 10/14/2021] [Accepted: 11/25/2021] [Indexed: 01/09/2023] Open
Abstract
Coronary artery bypass graft (CABG) surgery effectively relieves symptoms and improves outcomes. However, patients undergoing CABG surgery typically have advanced coronary atherosclerotic disease and remain at high risk for symptom recurrence and adverse events. Functional non-invasive testing for ischaemia is commonly used as a gatekeeper for invasive coronary and graft angiography, and for guiding subsequent revascularisation decisions. However, performing and interpreting non-invasive ischaemia testing in patients post CABG is challenging, irrespective of the imaging modality used. Multiple factors including advanced multi-vessel native vessel disease, variability in coronary hemodynamics post-surgery, differences in graft lengths and vasomotor properties, and complex myocardial scar morphology are only some of the pathophysiological mechanisms that complicate ischaemia evaluation in this patient population. Systematic assessment of the impact of these challenges in relation to each imaging modality may help optimize diagnostic test selection by incorporating clinical information and individual patient characteristics. At the same time, recent technological advances in cardiac imaging including improvements in image quality, wider availability of quantitative techniques for measuring myocardial blood flow and the introduction of artificial intelligence-based approaches for image analysis offer the opportunity to re-evaluate the value of ischaemia testing, providing new insights into the pathophysiological processes that determine outcomes in this patient population.
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Affiliation(s)
- Andreas Seraphim
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Kristopher D Knott
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Joao B Augusto
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Katia Menacho
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Sara Tyebally
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom
| | - Benjamin Dowsing
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Sanjeev Bhattacharyya
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom
| | - Leon J Menezes
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom
| | - Daniel A Jones
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Rakesh Uppal
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - James C Moon
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Charlotte Manisty
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
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Abstract
Cardiac imaging has a pivotal role in the prevention, diagnosis and treatment of ischaemic heart disease. SPECT is most commonly used for clinical myocardial perfusion imaging, whereas PET is the clinical reference standard for the quantification of myocardial perfusion. MRI does not involve exposure to ionizing radiation, similar to echocardiography, which can be performed at the bedside. CT perfusion imaging is not frequently used but CT offers coronary angiography data, and invasive catheter-based methods can measure coronary flow and pressure. Technical improvements to the quantification of pathophysiological parameters of myocardial ischaemia can be achieved. Clinical consensus recommendations on the appropriateness of each technique were derived following a European quantitative cardiac imaging meeting and using a real-time Delphi process. SPECT using new detectors allows the quantification of myocardial blood flow and is now also suited to patients with a high BMI. PET is well suited to patients with multivessel disease to confirm or exclude balanced ischaemia. MRI allows the evaluation of patients with complex disease who would benefit from imaging of function and fibrosis in addition to perfusion. Echocardiography remains the preferred technique for assessing ischaemia in bedside situations, whereas CT has the greatest value for combined quantification of stenosis and characterization of atherosclerosis in relation to myocardial ischaemia. In patients with a high probability of needing invasive treatment, invasive coronary flow and pressure measurement is well suited to guide treatment decisions. In this Consensus Statement, we summarize the strengths and weaknesses as well as the future technological potential of each imaging modality.
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Martens J, Panzer S, den Wijngaard J, Siebes M, Schreiber LM. Influence of contrast agent dispersion on bolus‐based MRI myocardial perfusion measurements: A computational fluid dynamics study. Magn Reson Med 2019; 84:467-483. [DOI: 10.1002/mrm.28125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Johannes Martens
- Chair of Molecular and Cellular Imaging, Comprehensive Heart Failure CenterUniversity Hospitals Würzburg Germany
- Department of Cardiovascular Imaging Comprehensive Heart Failure Center University Hospitals Würzburg Germany
| | - Sabine Panzer
- Chair of Molecular and Cellular Imaging, Comprehensive Heart Failure CenterUniversity Hospitals Würzburg Germany
- Department of Cardiovascular Imaging Comprehensive Heart Failure Center University Hospitals Würzburg Germany
| | - Jeroen den Wijngaard
- Department of Biomedical Engineering & Physics Amsterdam University Medical Center University of Amsterdam Amsterdam Cardiovascular Sciences Amsterdam Netherlands
- Department of Clinical Chemistry and Hematology Diakonessenhuis Utrecht Netherlands
| | - Maria Siebes
- Department of Biomedical Engineering & Physics Amsterdam University Medical Center University of Amsterdam Amsterdam Cardiovascular Sciences Amsterdam Netherlands
| | - Laura M. Schreiber
- Chair of Molecular and Cellular Imaging, Comprehensive Heart Failure CenterUniversity Hospitals Würzburg Germany
- Department of Cardiovascular Imaging Comprehensive Heart Failure Center University Hospitals Würzburg Germany
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Agujetas R, González-Fernández MR, Nogales-Asensio JM, Montanero JM. Numerical analysis of the pressure drop across highly-eccentric coronary stenoses: application to the calculation of the fractional flow reserve. Biomed Eng Online 2018; 17:67. [PMID: 29848333 PMCID: PMC5977766 DOI: 10.1186/s12938-018-0503-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/23/2018] [Indexed: 11/29/2022] Open
Abstract
Background Fractional flow reverse (FFR) is the gold standard assessment of the hemodynamic significance of coronary stenoses. However, it requires the catheterization of the coronary artery to determine the pressure waveforms proximal and distal to the stenosis. On the contrary, computational fluid dynamics enables the calculation of the FFR value from relatively non-invasive computed tomography angiography (CTA). Methods We analyze the flow across idealized highly-eccentric coronary stenoses by solving the Navier–Stokes equations. We examine the influence of several aspects (approximations) of the simulation method on the calculation of the FFR value. We study the effects on the FFR value of errors made in the segmentation of clinical images. For this purpose, we compare the FFR value for the nominal geometry with that calculated for other shapes that slightly deviate from that geometry. This analysis is conducted for a range of stenosis severities and different inlet velocity and pressure waveforms. Results and conclusions The errors made in assuming a uniform velocity profile in front of the stenosis, as well as those due to the Newtonian and laminar approximations, are negligible for stenosis severities leading to FFR values around the threshold 0.8. The limited resolution of the stenosis geometry reconstruction is the major source of error when predicting the FFR value. Both systematic errors in the contour detection of just 1-pixel size in the CTA images and a low-quality representation of the stenosis surface (coarse faceted geometry) may yield wrong outcomes of the FFR assessment for an important set of eccentric stenoses. On the contrary, the spatial resolution of images acquired with optical coherence tomography may be sufficient to ensure accurate predictions for the FFR value.
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Affiliation(s)
- R Agujetas
- Depto. de Ingeniería Mecánica, Energética y de los Materiales and Instituto de Computación Científica Avanzada (ICCAEx), Universidad de Extremadura, Avda. de Elvas s/n, 06006, Badajoz, Spain
| | - M R González-Fernández
- Servicio de Cardiología, Hospital Infanta Cristina, Avda. de Elvas s/n, 06006, Badajoz, Spain
| | - J M Nogales-Asensio
- Servicio de Cardiología, Hospital Infanta Cristina, Avda. de Elvas s/n, 06006, Badajoz, Spain
| | - J M Montanero
- Depto. de Ingeniería Mecánica, Energética y de los Materiales and Instituto de Computación Científica Avanzada (ICCAEx), Universidad de Extremadura, Avda. de Elvas s/n, 06006, Badajoz, Spain.
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Agujetas R, Ferrera C, Marcos AC, Alejo JP, Montanero JM. Numerical and experimental analysis of the transitional flow across a real stenosis. Biomech Model Mechanobiol 2017; 16:1447-1458. [PMID: 28343259 DOI: 10.1007/s10237-017-0898-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 03/15/2017] [Indexed: 11/25/2022]
Abstract
In this paper, we present a numerical study of the pulsatile transitional flow crossing a severe real stenosis located right in front of the bifurcation between the right subclavian and right common carotid arteries. The simulation allows one to determine relevant features of this subject-specific flow, such as the pressure waves in the right subclavian and right common carotid arteries. We explain the subclavian steal syndrome suffered by the patient in terms of the drastic pressure drop in the right subclavian artery. This pressure drop is caused by both the diverging part of the analyzed stenosis and the reverse flow in the bifurcation induced by another stenosis in the right internal carotid artery.
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Affiliation(s)
- R Agujetas
- Depto. de Ingeniería Mecánica, Energética y de los Materiales and Instituto de Computación Científica Avanzada (ICCAEx), Universidad de Extremadura, 06006, Badajoz, Spain
| | - C Ferrera
- Depto. de Ingeniería Mecánica, Energética y de los Materiales and Instituto de Computación Científica Avanzada (ICCAEx), Universidad de Extremadura, 06006, Badajoz, Spain
| | - A C Marcos
- Depto. de Expresión Gráfica, Universidad de Extremadura, 06006, Badajoz, Spain
| | - J P Alejo
- Servicio de Radiología, Hospital Infanta Cristina, 06006, Badajoz, Spain
| | - J M Montanero
- Depto. de Ingeniería Mecánica, Energética y de los Materiales and Instituto de Computación Científica Avanzada (ICCAEx), Universidad de Extremadura, 06006, Badajoz, Spain.
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