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Drieghe B, De Buyzere M, Bové T, De Backer T. Interventions for renal artery stenosis: Appraisal of novel physiological insights and procedural techniques to improve clinical outcome. Catheter Cardiovasc Interv 2024; 104:285-299. [PMID: 38837309 DOI: 10.1002/ccd.31117] [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: 11/29/2023] [Revised: 05/07/2024] [Accepted: 05/25/2024] [Indexed: 06/07/2024]
Abstract
Randomized clinical trials failed to show additional benefit of renal artery stenting on top of medical therapy. Instead of writing an obituary on renal artery stenting, we try to explain these disappointing results. A transstenotic pressure gradient is needed to reduce renal perfusion and to activate the renin-angiotensin-aldosterone system. In only a minority of patients included in trials, a transstenotic pressure gradient is measured and reported. Like the coronary circulation, integration of physiological lesion assessment will allow to avoid stenting of non-significant lesions and select those patients that are most likely to benefit from renal artery stenting. Renal artery interventions are associated with peri-procedural complications. Contemporary techniques, including radial artery access, no-touch technique to engage the renal ostium and the use of embolic protection devices, will minimize procedural risk. Combining optimal patient selection and meticulous technique might lead to a netto clinical benefit when renal artery stenting is added to optimal medical therapy.
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Affiliation(s)
- Benny Drieghe
- Heart Center, University Hospital Gent, Gent, Belgium
| | | | - Thierry Bové
- Heart Center, University Hospital Gent, Gent, Belgium
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Li F, Li X, Zhou J, Lin Q, Zhou Y, Zhu J, Wu K, Zhao D, Li Q, Wang H, Liu Q. Triglyceride to high-density lipoprotein cholesterol ratio associated with long-term adverse clinical outcomes in patients deferred revascularization following fractional flow reserve. Lipids Health Dis 2024; 23:96. [PMID: 38566225 PMCID: PMC10985980 DOI: 10.1186/s12944-024-02093-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/26/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Guidelines on coronary intermediate lesions strongly recommend deferred revascularization after detecting a normal fractional flow reserve (FFR). Researches about triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) on cardiovascular diseases has also been well conducted. However, the association of TG/HDL-C and long-term adverse clinical outcomes remains unknown for patients deferred revascularization following FFR. METHODS This study retrospectively included 374 coronary artery disease (CAD) patients with non-significant coronary lesions diagnosed by coronary angiography (CAG) and FFR. The main outcome measure was the combination of major adverse cardiovascular and cerebrovascular events (MACCEs). All patients were categorized into three subgroups in terms of TG/HDL-C tertiles (T1 < 0.96, 0.96 ≤ T2 < 1.58, T3 ≥ 1.58). Three different Cox regression models were utilized to reveal the association between TG/HDL-C and prevalence of MACCEs. RESULTS 47 MACCEs were recorded throughout a median monitoring period of 6.6 years. The Kaplan-Meier survival curves showed a higher MACCEs rate occurred in the higher TG/HDL-C group (5.6% vs. 12.9% vs. 19.4%, log-rank P < 0.01). After adjustment, patients in T3 suffered a 2.6-fold risk compared to the T1 group (T3 vs. T1: HR 2.55, 95% CI 1.05-6.21, P = 0.038; T2 vs. T1: HR 1.71, 95% CI 0.65-4.49, P = 0.075; P for trend = 0.001). The restricted cubic spline (RCS) analysis demonstrated that the HR for MACCEs rose as TG/HDL-C increased. Both the receiver operating characteristic (ROC) and time-dependent ROC proved the excellent predictive ability of TG/HDL-C. CONCLUSION The study illustrates that TG/HDL-C correlates with the risk of MACCEs in CAD patients deferred revascularization following FFR. TG/HDL-C could serve as a dependable predictor of cardiovascular events over the long term in this population.
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Affiliation(s)
- Fanqi Li
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, 410000, China
| | - Xiaofang Li
- Department of Digestive Oncology, Tongji Shanxi Hospital, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030032, China
| | - Jiabao Zhou
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, 410000, China
| | - Qiuzhen Lin
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, 410000, China
| | - Yong Zhou
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, 410000, China
| | - Jiayi Zhu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, 410000, China
| | - Keke Wu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, 410000, China
| | - Donghui Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Qiuyu Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Haixiong Wang
- Department of Cardiology, Shanxi Cardiovascular Hospital, Taiyuan, Shanxi, 030001, China.
| | - Qiming Liu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, 410000, China.
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Liu J, Jin J, Yu B, Zhang S, Lu X, Chen G, Yang Y, Dong H. Determinants and Prognoses of Visual-Functional Mismatches After Mechanical Reperfusion in ST-Elevation Myocardial Infarction. Int J Gen Med 2024; 17:693-704. [PMID: 38435112 PMCID: PMC10908277 DOI: 10.2147/ijgm.s444933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/09/2024] [Indexed: 03/05/2024] Open
Abstract
Background Discordance between the anatomy and physiology of the coronary has important implications for managing patients with stable coronary disease, but its significance in ST-elevation myocardial infarction has not been fully elucidated. Methods The retrospective study involved patients diagnosed with ST-elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI), along with quantitative coronary angiography (QCA) and quantitative flow ratio (QFR) assessments. Patients were stratified into four groups regarding the severity of the culprit vessel, both visually and functionally: concordantly negative (QCA-diameter stenosis [DS] ≤ 50% and QFR > 0.80), mismatch (QCA-DS > 50% and QFR > 0.80), reverse mismatch (QCA-DS ≤ 50% and QFR ≤ 0.80), and concordantly positive (QCA-DS > 50% and QFR ≤ 0.80). Multivariable logistic regression analyses were conducted to identify the clinical factors linked to visual-functional mismatches. Kaplan‒Meier analysis was conducted to estimate the 18-month adverse cardiovascular events (MACE)-free survival between the four groups. Results The study involved 310 patients, with 68 presenting visual-functional mismatch, and 51 exhibiting reverse mismatch. The mismatch was associated with higher angiography-derived microcirculatory resistance (AMR) (adjusted odds ratio [aOR]=1.016, 95% CI: 1.010-1.022, P<0.001). Reverse mismatch was associated with larger area stenosis (aOR=1.044, 95% CI: 1.004-1.086, P=0.032), lower coronary flow velocity (aOR=0.690, 95% CI: 0.567-0.970, P<0.001) and lower AMR (aOR=0.947, 95% CI: 0.924-0.970, P<0.001). Additionally, the mismatch group showed the worst 18-month MACE-free survival among the four groups (Log rank test p = 0.013). Conclusion AMR plays a significant role in the occurrence of visual-functional mismatches between QCA-DS and QFR, and the mismatch group showed the worst prognosis.
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Affiliation(s)
- Jieliang Liu
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Junguo Jin
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Bingyan Yu
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Shanghong Zhang
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Xiaoqi Lu
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Guoqiang Chen
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Yi Yang
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Haojian Dong
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
- Nyingchi People’s Hospital, Nyingchi, Tibet, 860000, People’s Republic of China
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Kanaji Y, Ahmad A, Sara JDS, Ozcan I, Akhiyat N, Prasad A, Raphael CE, Kakuta T, Lerman LO, Lerman A. Coronary Vasomotor Dysfunction Is Associated With Cardiovascular Events in Patients With Nonobstructive Coronary Artery Disease. JACC Cardiovasc Interv 2024; 17:474-487. [PMID: 38418053 DOI: 10.1016/j.jcin.2023.11.039] [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: 06/21/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Coronary vasomotor dysfunction (CVDys) can be comprehensively classified on the basis of anatomy and functional mechanisms. OBJECTIVES The aim of this study was to evaluate the association between different CVDys phenotypes and outcomes in patients with angina and nonobstructive coronary artery disease (ANOCA). METHODS Patients with ANOCA who underwent coronary reactivity testing using an intracoronary Doppler guidewire to assess microvascular and epicardial coronary endothelium-dependent and endothelium-independent function were enrolled. Endothelium-dependent microvascular and epicardial coronary dysfunction were defined as a <50% change in coronary blood flow in response to intracoronary acetylcholine (Ach) infusion and a <-20% change in coronary artery diameter in response to Ach. Endothelium-independent microvascular and epicardial coronary dysfunction were defined as coronary flow reserve < 2.5 during adenosine-induced hyperemia and change in cross-sectional area in response to intracoronary nitroglycerin administration < 20%. Major adverse cardiac and cerebrovascular events (cardiovascular death, nonfatal MI, heart failure, stroke, and late revascularization) served as clinical outcomes. RESULTS Among the 1,196 patients with ANOCA, the prevalence of CVDys was 24.5% and 51.8% among those with endothelium-independent and endothelium-dependent microvascular dysfunction, respectively, and 47.4% and 25.4% among those with endothelium-independent and endothelium-dependent epicardial coronary dysfunction, respectively. During 6.3 years (Q1-Q3: 2.5-12.9 years) of follow-up, patients with endothelium-dependent microvascular dysfunction, endothelium-dependent epicardial coronary dysfunction, or endothelium-independent microvascular dysfunction showed significantly higher event rates compared with those without (19.5% vs 12.0% [P < 0.001], 19.7% vs 14.6% [P = 0.038] and 22.2% vs 13.8% [P = 0.001], respectively). Coronary flow reserve (HR: 0.757; 95% CI: 0.604-0.957) and percentage change in coronary blood flow in response to Ach infusion (HR: 0.998; 95% CI: 0.996-0.999) remained significant predictors of major adverse cardiac and cerebrovascular event after adjustment for conventional risk factors. CONCLUSIONS CVDys phenotype is differentially associated with worse outcomes, and endothelium-dependent and endothelium-independent microvascular function provide independent prognostic information in patients with ANOCA.
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Affiliation(s)
- Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ilke Ozcan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nadia Akhiyat
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Lu W, Zhang X, Yan G, Ma G. The Differences of Quantitative Flow Ratio in Coronary Artery Stenosis with or without Atrial Fibrillation. J Interv Cardiol 2023; 2023:7278343. [PMID: 37868769 PMCID: PMC10589068 DOI: 10.1155/2023/7278343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 09/21/2023] [Accepted: 10/04/2023] [Indexed: 10/24/2023] Open
Abstract
Quantitative flow ratio (QFR) is a new method for the assessment of the extent of coronary artery stenosis. But it may be obscured by the cardiac remodeling and abnormal blood flow of the coronary artery when encountering atrial fibrillation (AF). The present study aimed to examine the impact of these changed structures and blood flow of coronary arteries on QFR results in AF patients. Methods and Results. We evaluated QFR in 223 patients (112 patients with AF; 111 non-AF patients served as controls) who had undergone percutaneous coronary intervention (PCI) due to severe stenoses in coronary arteries. QFR of the target coronary was determined according to the flow rate of the contrast agent. Results showed that AF patients had significantly higher QFR values than control (0.792 ± 0.118 vs. 0.685 ± 0.167, p < 0.001). We further analyzed local QFR around the stenoses (0.858 ± 0.304 vs. 0.756 ± 0.146, p=0.002), residual QFR (0.958 ± 0.055 vs. 0.929 ± 0.093, p=0.005), and index QFR (0.807 ± 0.108 vs. 0.713 ± 0.152, p < 0.001) in these two groups of patients with and without AF. Further analysis revealed that QFR in AF patients was negatively correlated with coronary flow velocity (R = -0.22, p=0.02) and area of stenosis (R = -0.70, p < 0.001) but positively correlated with the minimum lumen area (MLA) (R = 0.47, p < 0.001). Conclusion. AF patients with coronary artery stenosis have higher QFR values, which are associated with decreased blood flow velocity, smaller stenosis, and larger MLA in AF patients upon cardiac remodeling.
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Affiliation(s)
- Wenbin Lu
- Department of Cardiology, ZhongDa Hospital Affiliated with Southeast University, China
| | - Xiaoguo Zhang
- Department of Cardiology, ZhongDa Hospital Affiliated with Southeast University, China
| | - Gaoliang Yan
- Department of Cardiology, ZhongDa Hospital Affiliated with Southeast University, China
| | - Genshan Ma
- Department of Cardiology, ZhongDa Hospital Affiliated with Southeast University, China
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Truong CD, Ton TT. The relation between coronary artery disease and newly diagnosed dysglycemia. Perfusion 2023; 38:1428-1435. [PMID: 35817752 DOI: 10.1177/02676591221113970] [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: 11/16/2022]
Abstract
INTRODUCTION There is a known association between hyperglycemia and the presence of coronary syndrome. The purpose of this work is to study risk factors and clinical manifestations of hyperglycemia in patients diagnosed with coronary artery disease. METHODS The study was conducted in 2018-2020 among 505 patients in Ho Chi Minh city, Vietnam. Based on the results of the glucose test at 0 and 120 min, the patients were divided into the groups: with normal glucose metabolism (control, 204), patients with impaired fasting glucose levels (175 patients, group 2), and patients with impaired glucose tolerance, including diabetes mellitus (126, group 3). Anthropometric measurements were performed, and the levels of hemoglobin HbA, glucose, lipids were measured. RESULTS In the group of patients with fasting hyperinsulinemia, all variables (body weight, body mass index, waist circumference, LAP, creatinine clearance) differed considerably as compared to the control group (p ≤ 0.0001). Decrease in tissue sensitivity to insulin is already present at normal levels of glucose metabolism. CONCLUSIONS The study found that diabetes mellitus and prediabetes are more typical for patients with metabolic syndrome and acute coronary syndrome. The results obtained will allow predicting the risk of developing coronary syndrome depending on the presence of diabetes mellitus or prediabetes.
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Affiliation(s)
- Cam Dinh Truong
- Cardiovascular Department, Military Hospital 175, Ho Chi Minh, Vietnam
| | - Tung Thanh Ton
- Emergency Department, Military Hospital 175, Ho Chi Minh, Vietnam
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Pintea Bentea G, Berdaoui B, Samyn S, Morissens M, van de Borne P, Castro Rodriguez J. Particularities of coronary physiology in patients with atrial fibrillation: insights from combined pressure and flow indices measurements. Front Cardiovasc Med 2023; 10:1206743. [PMID: 37645524 PMCID: PMC10461314 DOI: 10.3389/fcvm.2023.1206743] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023] Open
Abstract
Background Symptoms suggestive of myocardial ischemia are frequently encountered in patients with atrial fibrillation (AF) even in the absence of obstructive coronary artery disease. Nevertheless, an in-depth characterisation of coronary physiology in patients with AF is currently lacking. Objectives We aim to provide an insight into the characteristics of coronary physiology in AF, by performing simultaneous invasive measurements of coronary flow- and pressure- indices in a real-life population of patients with AF and indication of coronary angiography. Methods This is a prospective open label study including patients with permanent or persistent AF and indication of coronary angiography showing intermediate coronary stenosis requiring routine physiological assessment (n = 18 vessels from 14 patients). We measured FFR (fractional flow reserve), and Doppler-derived coronary flow indices, including CFR (coronary flow reserve) and HMR (hyperaemic microvascular resistance). Results From the analysed vessels, 18/18 vessels (100%) presented a pathological CFR (<2.5), indicative of coronary microvascular dysfunction (CMD), and 3/18 (17%) demonstrated obstructive epicardial coronary disease (FFR ≤ 0.8). A large proportion of vessels (15/18; 83%) showed discordant FFR/CFR with preserved FFR and low CFR. 47% of the coronary arteries in patients with AF and non-obstructive epicardial coronary disease presented structural CMD (HMR ≥ 2.5 mmHg/cm/s), and were associated with high BMR and an impaired response to adenosine. Conversely, vessels from patients with AF and non-obstructive epicardial coronary disease with functional CMD (HMR < 2.5 mmHg/cm/s) showed higher bAPV. The permanent AF subpopulation presented increased values of HMR and BMR compared to persistent AF, while structural CMD was more often associated with persistent symptoms at 3 months, taking into account the limited sample size of our study. Conclusion Our findings highlight a systematically impaired CFR in patients with AF even in the absence of obstructive epicardial coronary disease, indicative of CMD. In addition, patients with AF presented more prevalent structural CMD (HMR ≥ 2.5 mmHg/cm/s), characterized by reduced hyperaemic responses to adenosine, possibly interfering with the FFR assessment.
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Affiliation(s)
| | | | - Sophie Samyn
- Department of Cardiology, CHU Brugmann, Brussels, Belgium
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Prakash RO, Chakrala TS, Feuer DS, Valdes CA, Pepine CJ, Keeley EC. Critical role of the coronary microvasculature in heart disease: From pathologic driving force to "innocent" bystander. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 22:100215. [PMID: 38558907 PMCID: PMC10978433 DOI: 10.1016/j.ahjo.2022.100215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/30/2022] [Indexed: 04/04/2024]
Abstract
The coronary microvasculature is responsible for providing oxygen and nutrients to myocardial tissue. A healthy microvasculature with an intact and properly functioning endothelium accomplishes this by seemless changes in vascular tone to match supply and demand. Perturbations in the normal physiology of the microvasculature, including endothelial and/or vascular smooth muscle dysfunction, result in impaired function (vasoconstriction, antithrombotic, etc.) and structural (hypertrophic, fibrotic) abnormalities that lead to microvascular ischemia and potential organ damage. While coronary microvascular dysfunction (CMD) is the primary pathologic driving force in ischemia with non-obstructive coronary artery disease (INOCA), angina with no obstructive coronary arteries (ANOCA), and myocardial infarction with non-obstructed coronary arteries (MINOCA), it may be a bystander in many cardiac disorders which later become pathologically associated with signs and/or symptoms of myocardial ischemia. Importantly, regardless of the primary or secondary basis of CMD in the heart, it is associated with important increases in morbidity and mortality. In this review we discuss salient features pertaining to known pathophysiologic mechanisms driving CMD, the spectrum of heart diseases where it places a critical role, invasive and non-invasive diagnostic testing, management strategies, and the gaps in knowledge where future research efforts are needed.
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Affiliation(s)
- Roshni O. Prakash
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Teja S. Chakrala
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Daniel S. Feuer
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Carlos A. Valdes
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Carl J. Pepine
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
| | - Ellen C. Keeley
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
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Omar A, Senguttuvan NB, Ueyama H, Kuno T, Beerkens F, Rahim M, Elmariah H, Takagi H, Abdulkader RS, Yallanki HP, Pelliccia F, Mylavarapu DP, Claessen B, Pasceri V, Dangas G. Meta-Analysis Comparing Fractional Flow Reserve and Angiography-Guided Complete Revascularization of Nonculprit Artery for ST-Elevation Myocardial Infarction. Am J Cardiol 2022; 183:8-15. [PMID: 36115726 DOI: 10.1016/j.amjcard.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 07/21/2022] [Accepted: 08/06/2022] [Indexed: 11/28/2022]
Abstract
This study aimed to compare complete revascularization (CR) guided by angiography with a fractional flow reserve (FFR)-guided strategy in patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD). CR is preferred to culprit-only revascularization for patients with STEMI and MVD. However, whether FFR-guided CR is superior to angiography-guided CR is unclear in patients presenting with STEMI who have MVD. Randomized controlled trials comparing CR with an FFR- or angiography-guided strategy to culprit-only revascularization in patients with STEMI and MVD were systematically identified. A random-effects network meta-analysis was performed comparing clinical outcomes in the 3 arms. A total of 13 studies with a total of 8,927 patients were included in our analysis. Compared with culprit-only revascularization, angiography-guided CR was associated with a significantly decreased risk of myocardial infarction (MI) (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.37 to 0.82), all-cause death (HR 0.69, 95% CI 0.49 to 0.97), and cardiovascular death (HR 0.54, 95% CI 0.34 to 0.85) but FFR-guided CR was not (MI: HR 0.77, 95% CI 0.53 to 1.12; cardiovascular death: HR 0.89, 95% CI 0.64 to 1.24; all-cause death: HR 0.93, 95% CI 0.72 to 1.18). The network meta-analysis comparison of angiography- versus FFR-guided CR showed an HR of 0.75 (95% CI 0.50 to 1.11) for all-cause death and an HR of 0.71 (95% CI 0.54 to 1.17) for MI. In conclusion, for patients with MVD presenting with STEMI, angiography-guided CR may provide additional benefits compared with FFR-guided CR.
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Affiliation(s)
- Ali Omar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Hiroki Ueyama
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein Medical College, New York, New York
| | - Frans Beerkens
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mehek Rahim
- Department of Medicine, Hackensack University Medical Center, Hackensack, New Jersey
| | - Hesham Elmariah
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hisato Takagi
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | | | - Hanumath Prasad Yallanki
- Department of Medicine, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | | | - Durga Prasad Mylavarapu
- Department of Medicine, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | - Bimmer Claessen
- Department of Cardiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Vincenzo Pasceri
- Department of Cardiology, University Sapienza of Rome, Rome, Italy
| | - George Dangas
- Department of Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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Wienemann H, Ameskamp C, Mejía-Rentería H, Mauri V, Hohmann C, Baldus S, Adam M, Escaned J, Halbach M. Diagnostic performance of quantitative flow ratio versus fractional flow reserve and resting full-cycle ratio in intermediate coronary lesions. Int J Cardiol 2022; 362:59-67. [PMID: 35662563 DOI: 10.1016/j.ijcard.2022.05.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/23/2022] [Accepted: 05/29/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Quantitative flow ratio (QFR) is a novel angiography-derived index aimed to assess the functional relevance of coronary stenoses without pressure wires and adenosine. Good diagnostic yield with the hyperemic fractional flow reserve (FFR) have been reported, while data on the comparison of QFR to non-hyperemic pressure ratios (NHPR) are scarce. METHODS In this retrospective, observational and single-center study with a large population representative of the real practice, we assessed and compared the diagnostic performance of contrast flow (cQFR) and fixed flow (fQFR) QFR against the NHPR resting full-cyle ratio (RFR) using FFR as reference standard. RESULTS A total of 626 lesions from 544 patients were investigated. Mean diameter stenosis, FFR, cQFR, fQFR and RFR were 44.8%, 0.842, 0.847, 0.857 and 0.912, respectively. The correlation between cQFR and FFR was stronger (r = 0.830, P < 0.001) compared to that between FFR and RFR (r = 0.777, P < 0.001) and between cQFR and RFR (r = 0.687, P < 0.001). Using FFR ≤0.80 as reference, the sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy for cQFR were 82%, 95%, 87%, 92%, and 91%, respectively. cQFR displayed a higher area under the curve (AUC) than fQFR and RFR (0.938 vs. 0.891 vs. 0.869, P < 0.01). The good diagnostic yield of cQFR appeared to be maintained in different clinical subsets including female gender, aortic valve stenosis and atrial fibrillation, and in different anatomical subsets including focal and non-focal lesions. CONCLUSION cQFR has a high and better diagnostic performance than the NHPR RFR in predicting FFR-based functional significance of coronary stenoses.
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Affiliation(s)
- Hendrik Wienemann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Christopher Ameskamp
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Hernán Mejía-Rentería
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Victor Mauri
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Christopher Hohmann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Stephan Baldus
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Matti Adam
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Marcel Halbach
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany.
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11
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Hansen B, Holtzman JN, Juszczynski C, Khan N, Kaur G, Varma B, Gulati M. Ischemia with No Obstructive Arteries (INOCA): A review of the prevalence, diagnosis and management. Curr Probl Cardiol 2022; 48:101420. [DOI: 10.1016/j.cpcardiol.2022.101420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 11/03/2022]
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12
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Joh HS, Shin D, Lee JM, Lee SH, Hong D, Choi KH, Hwang D, Boerhout CKM, de Waard GA, Jung JH, Mejia-Renteria H, Hoshino M, Echavarria-Pinto M, Meuwissen M, Matsuo H, Madera-Cambero M, Eftekhari A, Effat MA, Murai T, Marques K, Doh JH, Christiansen EH, Banerjee R, Kim HK, Nam CW, Niccoli G, Nakayama M, Tanaka N, Shin ES, Chamuleau SAJ, van Royen N, Knaapen P, Koo BK, Kakuta T, Escaned J, Piek JJ, van de Hoef TP. Prognostic Impact of Coronary Flow Reserve in Patients With Reduced Left Ventricular Ejection Fraction. J Am Heart Assoc 2022; 11:e025841. [PMID: 35876408 PMCID: PMC9375477 DOI: 10.1161/jaha.122.025841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Intracoronary physiologic indexes such as coronary flow reserve (CFR) and left ventricular ejection fraction (LVEF) have been regarded as prognostic indicators in patients with coronary artery disease. The current study evaluated the association between intracoronary physiologic indexes and LVEF and their differential prognostic implications in patients with coronary artery disease. Methods and Results A total of 1889 patients with 2492 vessels with available CFR and LVEF were selected from an international multicenter prospective registry. Baseline physiologic indexes were measured by thermodilution or Doppler methods and LVEF was recorded at the index procedure. The primary outcome was target vessel failure, which was a composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization over 5 years of follow‐up. Patients with reduced LVEF <50% (162 patients [8.6%], 202 vessels [8.1%]) showed a similar degree of epicardial coronary artery disease but lower CFR values than those with preserved LVEF (2.4±1.2 versus 2.7±1.2, P<0.001), mainly driven by the increased resting coronary flow. Conversely, hyperemic coronary flow, fractional flow reserve, and the degree of microvascular dysfunction were similar between the 2 groups. Reduced CFR (≤2.0) was seen in 613 patients (32.5%) with 771 vessels (30.9%). Reduced CFR was an independent predictor for target vessel failure (hazard ratio, 2.081 [95% CI, 1.385–3.126], P<0.001), regardless of LVEF. Conclusions CFR was lower in patients with reduced LVEF because of increased resting coronary flow. Patients with reduced CFR showed a significantly higher risk of target vessel failure than did those with preserved CFR, regardless of LVEF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04485234.
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Affiliation(s)
- Hyun Sung Joh
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Doosup Shin
- Division of Cardiology, Department of Internal Medicine Duke University Medical Center Durham NC
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine Chonnam National University Hospital Gwangju Korea
| | - David Hong
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Doyeon Hwang
- Seoul National University Hospital Department of Internal Medicine, Cardiovascular Center Seoul Korea
| | - Coen K M Boerhout
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam the Netherlands
| | - Guus A de Waard
- Department of Cardiology NoordWest Ziekenhuisgroep Alkmaar the Netherlands
| | - Ji-Hyun Jung
- Sejong General Hospital Sejong Heart Institute Bucheon Korea
| | - Hernan Mejia-Renteria
- Hospital Clínico San Carlos IDISSC, and Universidad Complutense de Madrid Madrid Spain
| | - Masahiro Hoshino
- Department of Cardiology Tsuchiura Kyodo General Hospital Tsuchiura city Japan
| | - Mauro Echavarria-Pinto
- Hospital General ISSSTE Querétaro - Facultad de Medicina Universidad Autónoma de Querétaro Querétaro Mexico
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine Gifu Heart Center Gifu Japan
| | | | - Ashkan Eftekhari
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Mohamed A Effat
- Division of Cardiovascular Health and Disease University of Cincinnati Cincinnati OH
| | - Tadashi Murai
- Cardiovascular Center Yokosuka Kyosai Hospital Yokosuka Japan
| | - Koen Marques
- Department of Cardiology Amsterdam UMC - location VUmc Amsterdam the Netherlands
| | - Joon-Hyung Doh
- Department of Medicine Inje University Ilsan Paik Hospital Goyang Korea
| | | | - Rupak Banerjee
- Department of Mechanical and Materials Engineering University of Cincinnati, Veterans Affairs Medical Center Cincinnati OH
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center Chosun University Hospital, University of Chosun College of Medicine Gwangju Korea
| | - Chang-Wook Nam
- Department of Medicine Keimyung University Dongsan Medical Center Daegu Korea
| | - Giampaolo Niccoli
- Department of Cardiovascular Medicine, Institute of Cardiology Catholic University of the Sacred Heart Milano Italy
| | - Masafumi Nakayama
- Department of Cardiovascular Medicine Gifu Heart Center Gifu Japan.,Toda Central General Hospital Cardiovascular Center Toda Japan
| | - Nobuhiro Tanaka
- Tokyo Medical University Hachioji Medical Center Department of Cardiology Tokyo Japan
| | - Eun-Seok Shin
- Department of Cardiology Ulsan University Hospital, University of Ulsan College of Medicine Ulsan Korea
| | | | - Niels van Royen
- Department of Cardiology Radboud University Medical Center Nijmegen the Netherlands
| | - Paul Knaapen
- Department of Cardiology Amsterdam UMC - location VUmc Amsterdam the Netherlands
| | - Bon Kwon Koo
- Seoul National University Hospital Department of Internal Medicine, Cardiovascular Center Seoul Korea
| | - Tsunekazu Kakuta
- Department of Cardiology Tsuchiura Kyodo General Hospital Tsuchiura city Japan
| | - Javier Escaned
- Hospital Clínico San Carlos IDISSC, and Universidad Complutense de Madrid Madrid Spain
| | - Jan J Piek
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam the Netherlands
| | - Tim P van de Hoef
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam the Netherlands
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13
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de Winter RW, Schumacher SP, van Diemen PA, Jukema RA, Somsen YB, Stuijfzand WJ, Driessen RS, Bom MJ, Everaars H, van Rossum AC, van de Ven PM, Opolski MP, Verouden NJ, Danad I, Raijmakers PG, Nap A, Knaapen P. Impact of percutaneous coronary intervention of chronic total occlusions on absolute perfusion in remote myocardium. EUROINTERVENTION 2022; 18:e314-e323. [PMID: 34866043 PMCID: PMC9912974 DOI: 10.4244/eij-d-21-00702] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Revascularisation of a chronic total coronary occlusion (CTO) impacts the coronary physiology of the remote myocardial territory. AIMS This study aimed to evaluate the intrinsic effect of CTO percutaneous coronary intervention (PCI) on changes in absolute perfusion in remote myocardium. METHODS A total of 164 patients who underwent serial [15O]H2O positron emission tomography (PET) perfusion imaging at baseline and three months after successful single-vessel CTO PCI were included to evaluate changes in hyperaemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) in the remote myocardium supplied by both non-target coronary arteries. RESULTS Perfusion indices in CTO and remote myocardium showed a positive correlation before (resting MBF: r=0.84, hMBF: r=0.75, and CFR: r=0.77, p<0.01 for all) and after (resting MBF: r=0.87, hMBF: r=0.87, and CFR: r=0.81, p<0.01 for all) CTO PCI. Absolute increases in hMBF and CFR were observed in remote myocardium following CTO revascularisation (from 2.29±0.67 to 2.48±0.75 mL·min-1·g-1 and from 2.48±0.76 to 2.74±0.85, respectively, p<0.01 for both). Improvements in remote myocardial perfusion were largest in patients with a higher increase in hMBF (β 0.58, 95% CI: 0.48-0.67, p<0.01) and CFR (β 0.54, 95% CI: 0.44-0.64, p<0.01) in the CTO territory, independent of clinical, angiographic and procedural characteristics. CONCLUSIONS CTO revascularisation resulted in an increase in remote myocardial perfusion. Furthermore, the quantitative improvement in hMBF and CFR in the CTO territory was independently associated with the absolute perfusion increase in remote myocardial regions. As such, CTO PCI may have a favourable physiologic impact beyond the intended treated myocardium.
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Affiliation(s)
- Ruben W. de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Stefan P. Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pepijn A. van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruurt A. Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Yvemarie B.O. Somsen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Wynand J. Stuijfzand
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Roel S. Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michiel J. Bom
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Henk Everaars
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Albert C. van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Peter M. van de Ven
- Department of Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Maksymilian P. Opolski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Niels J. Verouden
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pieter G. Raijmakers
- Radiology, Nuclear Medicine & PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Alex Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology Heart Center, Amsterdam UMC, location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
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14
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Geng Y, Liu H, Wang X, Zhang J, Gong Y, Zheng D, Jiang J, Xia L. Effect of microcirculatory dysfunction on coronary hemodynamics: A pilot study based on computational fluid dynamics simulation. Comput Biol Med 2022; 146:105583. [DOI: 10.1016/j.compbiomed.2022.105583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/21/2022] [Accepted: 04/30/2022] [Indexed: 01/09/2023]
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Lancellotti P, Go YY, Nchimi A. Stress imaging versus fractional flow reserve: what comes first-the chicken or the egg? Eur Heart J 2022; 43:3129-3131. [PMID: 35713675 DOI: 10.1093/eurheartj/ehac287] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Domaine Universitaire du Sart Tilman B.35, 4000 Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Yun Yun Go
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore
| | - Alain Nchimi
- University of Liège Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Domaine Universitaire du Sart Tilman B.35, 4000 Liège, Belgium
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16
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de Winter RW, Jukema RA, van Diemen PA, Schumacher SP, Driessen RS, Stuijfzand WJ, Everaars H, Bom MJ, van Rossum AC, van de Ven PM, Verouden NJ, Nap A, Raijmakers PG, Danad I, Knaapen P. The impact of coronary revascularization on vessel-specific coronary flow capacity and long-term outcomes: a serial [15O]H2O positron emission tomography perfusion imaging study. Eur Heart J Cardiovasc Imaging 2022; 23:743-752. [PMID: 34878102 PMCID: PMC9159743 DOI: 10.1093/ehjci/jeab263] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/25/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Coronary flow capacity (CFC) integrates quantitative hyperaemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) to comprehensively assess physiological severity of coronary artery disease (CAD). This study evaluated the effects of revascularization on CFC as assessed by serial [15O]H2O positron emission tomography (PET) perfusion imaging. METHODS AND RESULTS A total of 314 patients with stable CAD underwent [15O]H2O PET imaging at baseline and after myocardial revascularization to assess changes in hMBF, CFR, and CFC in 415 revascularized vessels. Using thresholds for ischaemia and normal perfusion, vessels were stratified in five CFC categories: myocardial steal, severely reduced CFC, moderately reduced CFC, minimally reduced CFC, and normal flow. Additionally, the association between CFC increase and the composite endpoint of death and non-fatal myocardial infarction (MI) was studied. Vessel-specific CFC improved after revascularization (P < 0.01). Furthermore, baseline CFC was an independent predictor of CFC increase (P < 0.01). The largest changes in ΔhMBF (0.90 ± 0.74, 0.93 ± 0.65, 0.79 ± 0.74, 0.48 ± 0.61, and 0.29 ± 0.66 mL/min/g) and ΔCFR (1.01 ± 0.88, 0.99 ± 0.69, 0.87 ± 0.88, 0.66 ± 0.91, and -0.01 ± 1.06) were observed in vessels with lower baseline CFC (P < 0.01 for both). During a median follow-up of 3.5 (95% CI 3.1-3.9) years, an increase in CFC was independently associated with lower rates of death and non-fatal MI (HR 0.43, 95% CI 0.19-0.98, P = 0.04). CONCLUSION Successful revascularization results in an increase in CFC. Furthermore, baseline CFC was an independent predictor of change in hMBF, CFR, and subsequently CFC. In addition, an increase in CFC was associated with a favourable outcome in terms of death and non-fatal MI.
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Affiliation(s)
- Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Wynand J Stuijfzand
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Henk Everaars
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Michiel J Bom
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Niels J Verouden
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology, Nuclear Medicine & PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Kim J, Shin D, Lee JM, Lee SH, Hong D, Choi KH, Hwang D, Boerhout CKM, de Waard GA, Jung JH, Mejia-Renteria H, Hoshino M, Echavarria-Pinto M, Meuwissen M, Matsuo H, Madera-Cambero M, Eftekhari A, Effat MA, Murai T, Marques K, Doh JH, Christiansen EH, Banerjee R, Kim HK, Nam CW, Niccoli G, Nakayama M, Tanaka N, Shin ES, Chamuleau SAJ, van Royen N, Knaapen P, Koo BK, Kakuta T, Escaned J, Piek JJ, van de Hoef TP. Differential Prognostic Value of Revascularization for Coronary Stenosis With Intermediate FFR by Coronary Flow Reserve. JACC Cardiovasc Interv 2022; 15:1033-1043. [PMID: 35490124 DOI: 10.1016/j.jcin.2022.01.297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The authors sought to evaluate comparative prognosis between deferred versus performed percutaneous coronary intervention (PCI) according to coronary flow reserve (CFR) values of patients with intermediate fractional flow reserve (FFR). BACKGROUND For coronary stenosis with intermediate FFR, the prognostic value of PCI remains controversial. The prognostic impact of PCI may be different according to CFR in patients with intermediate FFR. METHODS From the ILIAS Registry (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry, N = 2,322), 400 patients (412 vessels) with intermediate FFR (0.75-0.80) were selected. Patients were stratified into preserved CFR (>2.0, n = 253) and depressed CFR (≤2.0, n = 147) cohorts. Per-vessel clinical outcomes during 5 years of follow-up were compared between deferred versus performed PCI groups in both cohorts. The primary outcome was target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization. RESULTS Among the study population, PCI was deferred for 210 patients (219 vessels, 53.2%) (deferred group) and performed for 190 patients (193 vessels, 46.8%) (performed group). The risk of TVF was comparable between the deferred and performed groups (12.8% vs 14.2%; adjusted HR: 1.403; 95% CI: 0.584-3.369; P = 0.448). When stratified by CFR, PCI was performed in 39.1% (100/261 vessels) of the preserved CFR cohort and 61.9% (93/151 vessels) of the depressed CFR cohort. Within the preserved CFR cohort, the risk of TVF did not differ significantly between the deferred and performed groups (11.0% vs 13.9%; adjusted HR: 0.770; 95% CI: 0.262-2.266; P = 0.635). However, in the depressed CFR cohort, the deferred group had a significantly higher risk of TVF than the performed group (17.2% vs 14.2%; adjusted HR: 4.932; 95% CI: 1.312-18.53; P = 0.018). A significant interaction was observed between CFR and the treatment decision (interaction P = 0.049). Results were consistent after inverse probability weighting adjustment. CONCLUSIONS In patients with intermediate FFR of 0.75 to 0.80, the prognostic value of PCI differed according to CFR, with a significant interaction. PCI was associated with a lower risk of TVF compared with the deferral strategy when CFR was depressed (≤2.0), but there was no difference when CFR was preserved (>2.0). CFR could be used as an additional risk stratification tool to determine treatment strategies in patients with intermediate FFR. (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry [ILIAS Registry]; NCT04485234).
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Affiliation(s)
- Juwon Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doosup Shin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - David Hong
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doyeon Hwang
- Seoul National University Hospital, Department of Internal Medicine, Cardiovascular Center, Seoul, Korea
| | - Coen K M Boerhout
- Department of Cardiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands
| | - Guus A de Waard
- Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Ji-Hyun Jung
- Sejong General Hospital, Sejong Heart Institute, Bucheon, Korea
| | - Hernan Mejia-Renteria
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Masahiro Hoshino
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Mauro Echavarria-Pinto
- Hospital General Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estad Querétaro, Facultad de Medicina, Universidad Autónoma de Querétaro, Querétaro, Mexico
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | | | - Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mohamed A Effat
- Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, Ohio, USA
| | - Tadashi Murai
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Koen Marques
- Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | | | - Rupak Banerjee
- Department of Mechanical and Materials Engineering, University of Cincinnati, Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | | | - Masafumi Nakayama
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan; Toda Central General Hospital, Cardiovascular Center, Toda, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Steven A J Chamuleau
- Department of Cardiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Bon Kwon Koo
- Seoul National University Hospital, Department of Internal Medicine, Cardiovascular Center, Seoul, Korea
| | - Tsunekazu Kakuta
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Javier Escaned
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Jan J Piek
- Department of Cardiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands; Department of Cardiology, NoordWest Ziekenhuisgroep, the Netherlands
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18
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Eftekhari A, Westra J, Stegehuis V, Holm NR, van de Hoef TP, Kirkeeide RL, Piek JJ, Lance Gould K, Johnson NP, Christiansen EH. Prognostic value of microvascular resistance and its association to fractional flow reserve: a DEFINE-FLOW substudy. Open Heart 2022; 9:e001981. [PMID: 35410913 PMCID: PMC9003618 DOI: 10.1136/openhrt-2022-001981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the prognostic value of hyperemic microvascular resistance (HMR) and its relationship with hyperemic stenosis resistance (HSR) index and fractional flow reserve (FFR) in stable coronary artery disease. METHODS This is a substudy of the DEFINE-FLOW cohort (NCT02328820), which evaluated the prognosis of lesions (n=456) after combined FFR and coronary flow reserve (CFR) assessment in a prospective, non-blinded, non-randomised, multicentre study in 12 centres in Europe and Japan. Participants (n=430) were evaluated by wire-based measurement of coronary pressure, flow and vascular resistance (ComboWire XT, Phillips Volcano, San Diego, California, USA). RESULTS Mean FFR and CFR were 0.82±0.10 and 2.2±0.6, respectively. When divided according to FFR and CFR thresholds (above and below 0.80 and 2.0, respectively), HMR was highest in lesions with FFR>0.80 and CFR<2.0 (n=99) compared with lesions with FFR≤0.80 and CFR≥2.0 (n=68) (2.92±1.2 vs 1.91±0.64 mm Hg/cm/s, p<0.001). The FFR value was proportional to the ratio between HMR and the HMR+HSR (total resistance), 95% limits of agreement (-0.032; 0.019), bias (-0.003±0.02) and correlation (r2=0.98, p<0.0001). Cox regression model using HMR as continuous parameter for target vessel failure showed an HR of 1.51, 95% CI (0.9 to 2.4), p=0.10. CONCLUSIONS Increased HMR was not associated with a higher rate of adverse clinical events, in this population of mainly stable patients. FFR can be equally well expressed as HMR/HMR+HSR, thereby providing an alternative conceptual formulation linking epicardial severity with microvascular resistance. TRIAL REGISTRATION NUMBER NCT02328820.
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Affiliation(s)
- Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
- Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Valérie Stegehuis
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Niels Ramsing Holm
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Tim P van de Hoef
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Richard L Kirkeeide
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | - Jan J Piek
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - K Lance Gould
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | - Nils P Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
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19
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Li C, Xu R, Yao K, Zhang J, Chen S, Pang L, Lu H, Dai Y, Qian J, Shi H, Ge J. Functional significance of intermediate coronary stenosis in patients with single-vessel coronary artery disease: A comparison of dynamic SPECT coronary flow reserve with intracoronary pressure-derived fractional flow reserve (FFR). J Nucl Cardiol 2022; 29:622-629. [PMID: 32770319 DOI: 10.1007/s12350-020-02293-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 07/09/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to investigate the correlation of coronary flow reserve (CFR) assessed by rest/stress myocardial perfusion imaging with dynamic single-photon emission computed tomography (SPECT) with intracoronary pressure-derived fractional flow reserve (FFR) in patients with single-vessel coronary artery disease (CAD). METHODS Patients with suspected or known stable CAD who were referred for invasive coronary angiography were prospectively enrolled. Both invasive FFR and SPECT were performed in subjects with single-vessel intermediate coronary stenosis. A cutoff value of < 0.8 was used to define abnormal FFR. RESULTS A total of 34 patients were enrolled. The mean age of the subjects was 62.1 ± 6.7 years, and 79.4% were male. SPECT-derived CFR showed a significantly moderate correlation with FFR (r = 0.505, P = .003). The diagnostic performance for the identification of abnormal FFR in terms of sensitivity, specificity, and accuracy was 88.9%, 83.3%, and 87.9%, respectively, for CFR, with an optimized cutoff value of 1.73. CONCLUSION In patients with single-vessel CAD, SPECT CFR was useful for the detection of functionally significant stenosis. Our data support the use of this technique as an optional method for hemodynamic assessment, especially when FFR results are in normal range.
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Affiliation(s)
- Chenguang Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Rende Xu
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Kang Yao
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Jie Zhang
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Shuguang Chen
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Lifang Pang
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Hao Lu
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yuxiang Dai
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Juying Qian
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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20
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Fu B, Wei X, Lin Y, Chen J, Yu D. Pathophysiologic Basis and Diagnostic Approaches for Ischemia With Non-obstructive Coronary Arteries: A Literature Review. Front Cardiovasc Med 2022; 9:731059. [PMID: 35369287 PMCID: PMC8968033 DOI: 10.3389/fcvm.2022.731059] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 01/31/2022] [Indexed: 02/05/2023] Open
Abstract
Ischemia with non-obstructive coronary arteries (INOCA) has gained increasing attention due to its high prevalence, atypical clinical presentations, difficult diagnostic procedures, and poor prognosis. There are two endotypes of INOCA-one is coronary microvascular dysfunction and the other is vasospastic angina. Diagnosis of INOCA lies in evaluating coronary flow reserve, microcirculatory resistance, and vasoreactivity, which is usually obtained via invasive coronary interventional techniques. Non-invasive diagnostic approaches such as echocardiography, single-photon emission computed tomography, cardiac positron emission tomography, and cardiac magnetic resonance imaging are also valuable for assessing coronary blood flow. Some new techniques (e.g., continuous thermodilution and angiography-derived quantitative flow reserve) have been investigated to assist the diagnosis of INOCA. In this review, we aimed to discuss the pathophysiologic basis and contemporary and novel diagnostic approaches for INOCA, to construct a better understanding of INOCA evaluation.
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Affiliation(s)
- Bingqi Fu
- Shantou University Medical College, Shantou, China
- Division of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xuebiao Wei
- Division of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Division of Geriatric Intensive Medicine, Guangdong Provincial Geriatrics Institute, Guangdong Provincial People Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yingwen Lin
- Shantou University Medical College, Shantou, China
- Division of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiyan Chen
- Division of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Danqing Yu
- Division of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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21
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Razavi A, Sachdeva S, Frommelt PC, LaDisa JF. Computational Assessment of Hemodynamic Significance in Patients With Intramural Anomalous Aortic Origin of the Coronary Artery Using Virtually Derived Fractional Flow Reserve and Downstream Microvascular Resistance. J Biomech Eng 2022; 144:1119460. [PMID: 34505124 DOI: 10.1115/1.4052368] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Indexed: 11/08/2022]
Abstract
Anomalous aortic origin of a coronary artery (AAOCA) is the second most common cause of sudden cardiac death in young athletes. One of the hypothesized mechanisms of ischemia in these patients is the lateral compression of the anomalous artery with an intramural or interarterial course. The presence of a narrowing in the anomalous artery will cause physiologic changes in downstream resistance that should be included for computational assessment of possible clinical ramifications. In this study, we created different compression levels, i.e., proximal narrowing, in the intramural course of a representative patient model and calculated hyperemic stenosis resistance (HSR) as well as virtual fractional flow reserve (vFFR). Models also included the effect of the distal hyperemic microvascular resistance (HMR) on vFFR. Our results agreed with similar FFR studies indicating that FFR is increased with increasing HMR and that different compression levels could have similar FFR depending on the HMR. For example, vFFR at HSR: 1.0-1.3 and HMR: 2.30 mmHg/cm/s is 0.68 and close to vFFR at HSR: 0.6-0.7 and HMR: 1.6 mmHg/cm/s, which is 0.7. The current findings suggest that functional assessment of anomalous coronary arteries through FFR should consider the vascular resistance distal to the narrowing in addition to the impact of a proximal narrowing and provides computational approaches for implementation of these important considerations.
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Affiliation(s)
- Atefeh Razavi
- Department of Biomedical Engineering, Marquette University, Milwaukee, WI 53233; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332
| | - Shagun Sachdeva
- Pediatric Cardiology, Baylor College of Medicine, Houston, TX 77030
| | - Peter C Frommelt
- Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin Children's Wisconsin, Milwaukee, WI 53226
| | - John F LaDisa
- Department of Biomedical Engineering, Marquette University, Milwaukee, WI 53233; Departments of Pediatrics, Cardiovascular Medicine and Physiology, Medical College of Wisconsin, Wauwatosa, WI 53226
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22
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Sugiyama T, Kanno Y, Hamaya R, Kanaji Y, Hoshino M, Murai T, Lee T, Yonetsu T, Sasano T, Kakuta T. Determinants of visual-functional mismatches as assessed by coronary angiography and quantitative flow ratio. Catheter Cardiovasc Interv 2021; 98:1047-1056. [PMID: 33197120 DOI: 10.1002/ccd.29388] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/04/2020] [Accepted: 10/26/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We aimed to evaluate the determinants of visual-functional mismatches between quantitative coronary angiography (QCA) and the quantitative flow ratio (QFR). BACKGROUND The fractional flow reserve (FFR) has been established as a method to estimate the functional stenosis severity of coronary artery disease and to optimize decision-making for revascularization. The QFR is a novel angiography-derived computational index that can estimate the FFR without pharmacologically induced hyperemia or the use of pressure wire. METHODS A total of 504 de novo intermediate-to-severe stable lesions that underwent angiographic and physiological assessments were analyzed. All lesions were divided into four groups based on the significance of visual (QCA-diameter stenosis [DS] > 50% and ≤ 50%) and functional (QFR ≤ 0.80 and > 0.80) stenosis severity. Patient characteristics, angiographic findings, and physiological indices were compared. RESULTS One-hundred seventy-eight lesions (35.3%) showed discordant visual-functional assessments; mismatch (QCA-DS > 50% and QFR > 0.80) in 75 lesions (14.9%) and reverse mismatch (QCA-DS ≤ 50% and QFR ≤ 0.80) in 103 lesions (20.4%), respectively. Reverse mismatch was associated with non-diabetes, lower ejection fraction, higher Duke jeopardy score, and lower coronary flow reserve (CFR). Mismatch was associated with smaller QCA-DS, larger reference diameter, shorter lesion length, lower Duke jeopardy score, and higher CFR. Lesion location and microcirculatory resistance was not associated with the prevalence of mismatches. Reverse mismatch group had the higher prevalence of discordant decision-makings between QFR and FFR than the other three groups. CONCLUSIONS The CFR and subtended myocardial mass were predictors of visual-functional mismatches between QCA-DS and the QFR. Caution should be exercised in lesions showing QCA-DS/QFR reverse mismatch.
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Affiliation(s)
- Tomoyo Sugiyama
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Yoshinori Kanno
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Rikuta Hamaya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Masahiro Hoshino
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tadashi Murai
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tetsumin Lee
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Taishi Yonetsu
- Department of Interventional Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
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23
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Vallurupalli S, Salehi N, Agarwal S, Hasan R, Hassan A, Siraj A, Madmani ME, Rafeedheen R, Ayan M, Al-Hawwas M, Hakeem A, Uretsky BF. Exhaustion of coronary vasodilatory reserve in the resting state: Clinical characteristics and long-term outcomes after intervention. Catheter Cardiovasc Interv 2021; 98:1021-1026. [PMID: 34499399 DOI: 10.1002/ccd.29945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/29/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/BACKGROUND Resting coronary blood flow approximates flow with maximal vasodilation in very severe coronary stenosis. We studied the incidence of exhausted vasodilatory reserve by FFR, its clinical characteristics and long-term prognosis after FFR guided percutaneous coronary intervention (PCI). METHODS Consecutive patients undergoing FFR-guided PCI for coronary stenosis with reduced resting blood flow (baseline Pd/Pa < 0.8) were included. Basal maximal vasodilation (BMV) was defined as less than 5% difference between resting Pd/Pa and FFR, that is, FFR-baseline Pd/Pa < 0.05. RESULTS Of 658 vessels that underwent FFR-guided PCI in 602 patients, 151 vessels had resting blood flow in the ischemic range (baseline Pd/Pa ≤ 0.8) and were included in the analysis. Of these, 28 lesions in 28 patients met criteria for BMV (4.25% of the entire registry and 18.5% of those with the reduced basal coronary flow). Stenosis severity was a significant predictor of the presence of BMV. In long term follow-up (median 106 ± 3.6 months), BMV was not associated with increased target vessel revascularization (TVR) or major adverse cardiac event compared to non-BMV(OR 1.9, 95% CI 0.7-4.8, p-value 0.2 and OR 1.3, 95% CI 0.75-2.5, p = 0.3, respectively). CONCLUSION Low baseline Pd/Pa that approximates fractional flow reserve (exhausted vasodilatory reserve) defines a subgroup of patients with severe coronary artery stenosis. Prognosis, when treated with PCI along with medical therapy, appears similar to those with intact vasodilatory reserve.
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Affiliation(s)
- Srikanth Vallurupalli
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Cardiology Section, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA
| | - Negar Salehi
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Shiv Agarwal
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Cardiology Section, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA
| | - Rimsha Hasan
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Atif Hassan
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Aisha Siraj
- Cardiology, MetroHealth Medical Center, Cleveland, Ohio, USA
| | | | - Rahil Rafeedheen
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mohamed Ayan
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Malek Al-Hawwas
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Cardiology Section, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA
| | - Abdul Hakeem
- Division of Cardiology, Rutgers University, New Brunswick, New Jersey, USA
| | - Barry F Uretsky
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Cardiology Section, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA
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24
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Ge X, Liu Y, Tu S, Simakov S, Vassilevski Y, Liang F. Model-based analysis of the sensitivities and diagnostic implications of FFR and CFR under various pathological conditions. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2021; 37:e3257. [PMID: 31487426 DOI: 10.1002/cnm.3257] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 07/28/2019] [Accepted: 09/01/2019] [Indexed: 06/10/2023]
Abstract
Although fractional flow reserve (FFR) and coronary flow reserve (CFR) are both frequently used to assess the functional severity of coronary artery stenosis, discordant results of diagnosis between FFR and CFR in some patient cohorts have been reported. In the present study, a computational model was employed to quantify the impacts of various pathophysiological factors on FFR and CFR. In addition, a hyperemic myocardial ischemic index (HMIx) was proposed as a reference for comparing the diagnostic performances of FFR and CFR. Obtained results showed that CFR was more susceptible than FFR to the influence of many pathophysiological factors unrelated to coronary artery stenosis. In particular, the numerical study proved that increasing hyperemic coronary microvascular resistance significantly elevated FFR while reducing CFR despite fixed severity of coronary artery stenosis, whereas introducing aortic valve disease only caused a significant decrease in CFR with little influence on FFR. These results provided theoretical evidence for explaining some clinical observations, such as the increased risk of discordant diagnostic results between FFR and CFR in patients with increased hyperemic microvascular resistance, and significant increase in CFR after surgical relief of severe aortic valve disease. When evaluated with respect to the predictive value for hyperemic myocardial ischemia, the performance of FFR was found to be considerably compromised in the presence of severe coronary vasodilation dysfunction or aortic valve disease, whereas the relationship between CFR and HMIx remained relatively stable, suggesting that CFR may be a more reliable indicator of myocardial ischemia under complex pathophysiological conditions.
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Affiliation(s)
- Xinyang Ge
- School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China
- Collaborative Innovation Center for Advanced Ship and Deep-Sea Exploration (CISSE), Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Youjun Liu
- College of Life Science and Bioengineering, Beijing University of Technology, Beijing, 100124, China
| | - Shengxian Tu
- Med-X Research Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Sergey Simakov
- Moscow Institute of Physics and Technology, Dolgoprudny, 141700, Russia
- Institute for Personalized Medicine, Sechenov University, Moscow, 119991, Russia
| | - Yuri Vassilevski
- Moscow Institute of Physics and Technology, Dolgoprudny, 141700, Russia
- Institute for Personalized Medicine, Sechenov University, Moscow, 119991, Russia
- Institute of Numerical Mathematics, Russian Academy of Sciences, Moscow, 119333, Russia
| | - Fuyou Liang
- School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China
- Collaborative Innovation Center for Advanced Ship and Deep-Sea Exploration (CISSE), Shanghai Jiao Tong University, Shanghai, 200240, China
- Institute for Personalized Medicine, Sechenov University, Moscow, 119991, Russia
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25
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Abstract
PURPOSE OF REVIEW Percutaneous coronary intervention (PCI) is a commonly used treatment option in coronary artery disease (CAD). Reduced major adverse cardiovascular events (MACE) in those randomized to PCI compared to optimal medical therapy have been demonstrated only if it is performed for physiologically significant coronary lesions. Despite data demonstrating improved outcomes primarily in stable CAD and then acute settings, physiology-guided PCI remains underutilized. This review summarizes the evidence and commonly used methods for physiologic assessment of coronary stenosis. RECENT FINDINGS Fractional flow reserve (FFR) is the gold standard for the analysis of lesion severity. Its use is limited by the need for adenosine, which adds time, complexity, and potential adverse effects. Non-hyperemic instantaneous wave-free ratio-guided revascularization and quantitative flow reserve ratio assessment both have shown safety and effectiveness with improved patient outcomes. Coronary physiological assessment solves the ambiguity of coronary angiography. Detecting physiologically significant stenoses is crucial to decide which lesion needs to be treated. Technological advances have led to the development of new assessment indices in addition to FFR.
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26
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Geng L, Yuan Y, Du P, Gao L, Wang Y, Li J, Guo W, Huang Y, Zhang Q. Association of quantitative flow ratio-derived microcirculatory indices with anatomical-functional discordance in intermediate coronary lesions. Int J Cardiovasc Imaging 2021; 37:2803-2813. [PMID: 34059977 DOI: 10.1007/s10554-021-02292-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/16/2021] [Indexed: 12/18/2022]
Abstract
Discrepancy between coronary lesion severity and functional significance has always been a relevant issue in the management of patients undergoing coronary angiography and/or revascularization. We sought to investigate the relationship between quantitative flow ratio (QFR)-derived microcirculatory indices and anatomical-functional mismatch/reverse mismatch in intermediate coronary lesions. Intravascular ultrasound (IVUS) imaging and QFR were analyzed in 117 de novo intermediate coronary lesions. Lesions with QFR ≤ 0.8 were considered hemodynamically significant. Anatomical significance of the lesions was defined according to the best cutoff value of combined IVUS parameters for predicting QFR ≤ 0.8. QFR-derived microcirculatory indices including contrast-flow QFR minus fixed-flow QFR (cQFR-fQFR), hyperemic flow velocity and angiography-derived index of microcirculatory resistance (IMRangio) were calculated. The best cutoff values of IVUS parameters for predicting QFR ≤ 0.8 were minimum lumen area (MLA) 3.1mm2 and plaque burden (PB) 70%, with area under the curve of 0.635 and 0.703, respectively. The total discordance rate of lesion functional significance between IVUS and QFR assessments was 26.5%, with 21 lesions (17.9%) being classified as mismatch (MLA ≤ 3.1mm2 and PB ≥ 70% and QFR > 0.8) and 10 lesions (8.5%) as reverse-mismatch (MLA > 3.1 mm2 or PB < 70% and QFR ≤ 0.8). At multivariate analysis, IMRangio was identified as an independent predictor of mismatch (OR1.675, 95%CI:1.176-2.386, P = 0.004), whereas hyperemic flow velocity was identified as an independent predictor of reverse-mismatch (OR 1.233, 95%CI:1.073-1.416, P = 0.003). In intermediate coronary lesions, although MLA 3.1mm2 and PB 70% determined by IVUS are predictive of QFR-defined functional significance, the discordance rate remains substantial. QFR-derived microcirculatory indices are independently associated with anatomical-functional discordance between IVUS and QFR assessments.
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Affiliation(s)
- Liang Geng
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.,Department of Cardiology, JI'AN Hospital, Shanghai East Hospital, Ji An, 343006, China
| | - Yuan Yuan
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Peizhao Du
- Department of Cardiology, Baoshan Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, 201900, China
| | - Liming Gao
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yunkai Wang
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Jiming Li
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Wei Guo
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Ying Huang
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Qi Zhang
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
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27
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Noirclerc N, Marliere S, Bakhti A, Mangin L, Cassar E, Vautrin E, Piliero N, Ormezzano O, Bouvaist H, Riou L, Vanzetto G, Belle L, Barone-Rochette G. Impact of a micro-net mesh technology covering stent on coronary microvascular dysfunction in patients with high thrombus burden. Catheter Cardiovasc Interv 2021; 99:397-404. [PMID: 34057279 DOI: 10.1002/ccd.29782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/26/2021] [Accepted: 05/10/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Highly thrombotic coronary lesions continue to be a serious and clinically significant problem that is not effectively and completely addressed by current technology. OBJECTIVES We aimed to investigate whether a micro-net mesh (MNM) technology covering stent could preserve the index of microcirculatory resistance (IMR) after percutaneous coronary intervention (PCI) in patients with high thrombus burden. METHODS AND RESULTS Fifty-two patients with non-ST elevation myocardial infarction or ST Elevation Myocardial Infarction and high thrombus burden (TIMI thrombus grade ≥ 3) were randomized into two groups, PCI with a MNM covering stent (MNM group, n = 25) and PCI with any commercially available stent (DES group, n = 27). As the primary endpoint, IMR was measured immediately after PCI using a pressure-temperature sensor-tipped coronary wire. The secondary endpoint was left ventricular ejection fraction (LVEF) at 6 months of follow-up. The IMR in the MNM group was significantly lower in comparison to the DES group (33.2 [21.3, 48.9] vs. 57.2 [39.9, 98.0], p = 0.005). No significant differences were observed in baseline LVEF (54.5 ± 10.2% vs. 53.1 ± 6.87%, p = .57), while LVEF was significantly improved at follow-up in the MNM group (61.1 ± 7.1% vs. 53.9 ± 6.35%, p = .0001). CONCLUSION MNM technology significantly improved coronary microvascular dysfunction after PCI in patient with acute coronary syndrome and appears as a useful technological option for thrombus management.
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Affiliation(s)
| | | | - Akader Bakhti
- Department of Cardiology, Hospital Center, Annecy-Genevois, France
| | - Lionel Mangin
- Department of Cardiology, Hospital Center, Annecy-Genevois, France
| | - Emmanuel Cassar
- Department of Cardiology, Hospital Center, Annecy-Genevois, France
| | - Estelle Vautrin
- Department of Cardiology, University Hospital, Grenoble-Alpes, France
| | - Nicolas Piliero
- Department of Cardiology, University Hospital, Grenoble-Alpes, France
| | - Olivier Ormezzano
- Department of Cardiology, University Hospital, Grenoble-Alpes, France.,University Grenoble alpes, INSERM U1039, Bioclinic Radiopharmaceutics Laboratory, Grenoble, France
| | - Helene Bouvaist
- Department of Cardiology, University Hospital, Grenoble-Alpes, France
| | - Laurent Riou
- University Grenoble alpes, INSERM U1039, Bioclinic Radiopharmaceutics Laboratory, Grenoble, France
| | - Gerald Vanzetto
- Department of Cardiology, University Hospital, Grenoble-Alpes, France.,University Grenoble alpes, INSERM U1039, Bioclinic Radiopharmaceutics Laboratory, Grenoble, France.,French Alliance Clinical Trial, French Clinical Research Infrastructure Network, Paris, France
| | - Loic Belle
- Department of Cardiology, Hospital Center, Annecy-Genevois, France
| | - Gilles Barone-Rochette
- Department of Cardiology, University Hospital, Grenoble-Alpes, France.,University Grenoble alpes, INSERM U1039, Bioclinic Radiopharmaceutics Laboratory, Grenoble, France.,French Alliance Clinical Trial, French Clinical Research Infrastructure Network, Paris, France
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Patel KK, Spertus JA, Chan PS, Sperry BW, Al Badarin F, Kennedy KF, Thompson RC, Case JA, McGhie AI, Bateman TM. Myocardial blood flow reserve assessed by positron emission tomography myocardial perfusion imaging identifies patients with a survival benefit from early revascularization. Eur Heart J 2021; 41:759-768. [PMID: 31228200 DOI: 10.1093/eurheartj/ehz389] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 04/13/2019] [Accepted: 05/20/2019] [Indexed: 01/08/2023] Open
Abstract
AIMS Positron emission tomography (PET) myocardial perfusion imaging (MPI) can non-invasively measure myocardial blood flow reserve (MBFR). We aimed to examine whether MBFR identifies patients with a survival benefit after revascularization, helping to guide post-test management. METHODS AND RESULTS We examined all-cause mortality in 12 594 consecutive patients undergoing Rb82 rest/stress PET MPI from January 2010 to December 2016, after excluding those with cardiomyopathy, prior coronary artery bypass surgery (CABG), and missing MBFR. Myocardial blood flow reserve was calculated as the ratio of stress to rest absolute myocardial blood flow. A Cox model adjusted for patient and test characteristics, early revascularization (percutaneous coronary intervention or CABG ≤90 days of MPI), and the interaction between MBFR and early revascularization was developed to identify predictors of all-cause mortality. After a median follow-up of 3.2 years, 897 patients (7.1%) underwent early revascularization and 1699 patients (13.5%) died. Ischaemia was present in 4051 (32.3%) patients, with 1413 (11.2%) having ≥10% ischaemia. Mean MBFR was 2.0 ± 1.3, with MBFR <1.8 in 4836 (38.5%). After multivariable adjustment, every 0.1 unit decrease in MBFR was associated with 9% greater hazard of all-cause death (hazard ratio 1.09, 95% confidence interval 1.08-1.10; P < 0.001). There was a significant interaction between MBFR and early revascularization (P < 0.001); such that patients with MBFR ≤1.8 had a survival benefit with early revascularization, regardless of type of revascularization or level of ischaemia. CONCLUSION Myocardial blood flow reserve on PET MPI is associated with all-cause mortality and can identify patients who receive a survival benefit with early revascularization compared to medical therapy. This may be used to guide revascularization, and prospective validation is needed.
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Affiliation(s)
- Krishna K Patel
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - John A Spertus
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Paul S Chan
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Brett W Sperry
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Firas Al Badarin
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Randall C Thompson
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - James A Case
- Cardiovascular Imaging Technologies, Kansas City, MO, USA
| | - A Iain McGhie
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Timothy M Bateman
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
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Beck S, Pereyra VM, Seitz A, McChord J, Hubert A, Bekeredjian R, Sechtem U, Ong P. Invasive Diagnosis of Coronary Functional Disorders Causing Angina Pectoris. Eur Cardiol 2021; 16:e27. [PMID: 34276812 PMCID: PMC8280748 DOI: 10.15420/ecr.2021.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/26/2021] [Indexed: 01/16/2023] Open
Abstract
Coronary vasomotion disorders represent a frequent cause of angina and/or dyspnoea in patients with non-obstructed coronary arteries. The highly sophisticated interplay of vasodilatation and vasoconstriction can be assessed in an interventional diagnostic procedure. Established parameters characterising adequate vasodilatation are coronary blood flow at rest, and, after drug-induced vasodilation, coronary flow reserve, and microvascular resistance (hyperaemic microvascular resistance, index of microcirculatory resistance). An increased vasoconstrictive potential is diagnosed by provocation testing with acetylcholine or ergonovine. This enables a diagnosis of coronary epicardial and/or microvascular spasm. Ischaemia associated with microvascular spasm can be confirmed by ischaemic ECG changes and the measurement of lactate concentrations in the coronary sinus. Although interventional diagnostic procedures are helpful for determining the mechanism of the angina, which may be the key to successful medical treatment, they are still neither widely accepted nor applied in many medical centres. This article summarises currently well-established invasive methods for the diagnosis of coronary functional disorders causing angina pectoris.
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Affiliation(s)
- Sascha Beck
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | | | - Andreas Seitz
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Johanna McChord
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Astrid Hubert
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Raffi Bekeredjian
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Peter Ong
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
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30
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Liu H, Ou S, Liu P, Xu Y, Gong Y, Xia L, Leng X, Leung TWH, Shi L, Zheng D. Effect of microcirculatory resistance on coronary blood flow and instantaneous wave-free ratio: A computational study. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 196:105632. [PMID: 32615491 DOI: 10.1016/j.cmpb.2020.105632] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/21/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND AND OBJECTIVE The instantaneous wave-free ratio (iFR) has been proposed to estimate the hemodynamic severity of atherosclerotic stenosis in coronary arteries. The atherosclerotic stenosis in a proximal coronary artery could change its distal microcirculatory resistance (MR). However, there is a lack of investigation about the effect of MR variation on the blood flow and iFR of stenotic coronary arteries. We aim to investigate the changes of blood flow and iFR caused by distal MR variation. METHODS Four three-dimensional models of coronary arteries were reconstructed from the computed tomography images of two normal cases and two cases with 74.9% and 96.4% (in area) stenoses in a large branch of left anterior descending artery (LAD). Computational fluid dynamics simulation was performed on each model under 6 MR situations: hyperemia as the reference situation, resting when MR was multiplied by 8/3 in all outlet branches, h-one-1.5 and h-one-2 when MR was multiplied by 1.5 and 2.0 in one branch (the stenotic, or the corresponding branch in normal case) of LAD, h-branches-1.5 and h-branches-2 when MR was multiplied by 1.5 and 2.0 in the stenotic/corresponding and its cognate branches. Flow rate and iFR of each outlet branch were then calculated and compared between different MR situations to investigate the effect of MR variation on flow rate and iFR. RESULTS In the 74.9% stenosed and normal cases, referring to the hyperemia situation, the increase of MR in any branch significantly decreased its flow rate and increased its iFR, with limited effect on the flow rate (<3%) and iFR (<0.01) of other branches. However, in the 96.4% stenosed case, the doubled MR in the stenosed branch (h-one-2) significantly increased the flow rate (>10%) and iFR (>0.05) of its cognate branches. CONCLUSION The increase of MR in a normal or mildly stenosed branch of coronary artery decreases its blood flow and increases its iFR, with limited effect on other branches. Whereas, the increase of MR in a severely stenotic large branch could significantly increase the flow velocity and iFR of its cognate branches.
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Affiliation(s)
- Haipeng Liu
- Research Centre for Intelligent Healthcare, Faculty of Health and Life Sciences, Coventry University, Coventry CV1 5FB, UK
| | - Shanxing Ou
- Department of Radiology, General Hospital of Southern Theater Command, PLA, Guangzhou, China
| | - Panli Liu
- Department of Radiology, Guangzhou First People's Hospital, Nansha Hospital, Guangzhou, China
| | - Yuhang Xu
- Research Centre for Intelligent Healthcare, Faculty of Health and Life Sciences, Coventry University, Coventry CV1 5FB, UK
| | - Yinglan Gong
- Department of Biomedical Engineering, Zhejiang University, Hangzhou, China
| | - Ling Xia
- Department of Biomedical Engineering, Zhejiang University, Hangzhou, China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Thomas Wai Hong Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Lin Shi
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.
| | - Dingchang Zheng
- Research Centre for Intelligent Healthcare, Faculty of Health and Life Sciences, Coventry University, Coventry CV1 5FB, UK.
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31
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Sechtem U, Brown D, Godo S, Lanza GA, Shimokawa H, Sidik N. Coronary microvascular dysfunction in stable ischaemic heart disease (non-obstructive coronary artery disease and obstructive coronary artery disease). Cardiovasc Res 2020; 116:771-786. [PMID: 31958128 DOI: 10.1093/cvr/cvaa005] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/09/2019] [Accepted: 01/15/2020] [Indexed: 01/12/2023] Open
Abstract
Diffuse and focal epicardial coronary disease and coronary microvascular abnormalities may exist side-by-side. Identifying the contributions of each of these three players in the coronary circulation is a difficult task. Yet identifying coronary microvascular dysfunction (CMD) as an additional player in patients with coronary artery disease (CAD) may provide explanations of why symptoms may persist frequently following and why global coronary flow reserve may be more prognostically important than fractional flow reserve measured in a single vessel before percutaneous coronary intervention. This review focuses on the challenges of identifying the presence of CMD in the context of diffuse non-obstructive CAD and obstructive CAD. Furthermore, it is going to discuss the pathophysiology in this complex situation, examine the clinical context in which the interaction of the three components of disease takes place and finally look at non-invasive diagnostic methods relevant for addressing this question.
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Affiliation(s)
- Udo Sechtem
- Department of Cardiology, Robert Bosch Krankenhaus, Auerbachstr. 110, D-70376 Stuttgart, Germany
| | - David Brown
- Cardiovascular Division, Washington University School of Medicine, St Louis, MO, USA
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Gaetano Antonio Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Cardiology Institute, Roma, Italy
| | - Hiro Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Novalia Sidik
- University of Glasgow, Golden Jubilee National Hospital, Glasgow, UK
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32
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Clinical implication of QFR in patients with ST-segment elevation myocardial infarction after drug-eluting stent implantation. Int J Cardiovasc Imaging 2020; 37:755-766. [PMID: 33044717 DOI: 10.1007/s10554-020-02068-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022]
Abstract
The feasibility and prognostic value of quantitative flow ratio (QFR) after percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients have not been assessed. The aim of this study was to investigate the prognostic utility of post-PCI QFR to predict outcomes in STEMI and determine the influence of functional results, in both culprit and nonculprit lesions, after PCI. Patients undergoing PCI of culprit lesions and receiving staged procedures of nonculprit lesions after 7 days were enrolled from 2 centers and underwent post-PCI QFR. The primary outcome was the vessel-oriented composite endpoints (VOCEs), defined as vessel-related cardiovascular death, vessel-related myocardial infarction, and target vessel revascularization. Four hundred fifteen vessels (186 culprit lesions and 219 nonculprit lesions) in 186 patients were analyzed. Measured at staged PCI, the post-PCI QFR of culprit lesions was significantly lower than that of nonculprit lesions (0.92 ± 0.10 versus 0.95 ± 0.08, p < 0.001). The multivariable model demonstrated that low post-PCI QFR was an independent predictor of 2-year VOCE (20.8% versus 5.7%; hazard ratio 2.718; 95% CI 1.347-5.486; p = 0.005). In STEMI patients with a low angiography-derived index of microcirculatory resistance (≤ 40U), a good correlation and agreement between post-PCI QFR value of culprit lesions at primary and staged procedures (r = 0.942; mean difference: - 0.0017 [- 0.074 to 0.070]) was identified. In conclusion, culprit lesions suffered from suboptimal functional results more frequently compared to nonculprit lesions after PCI in STEMI patients. Low post-PCI QFR was associated with subsequent adverse clinical outcomes. After stenting, culprit lesions may feasibly be assessed through QFR without significant microvascular dysfunction.
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van de Hoef TP, Echavarria-Pinto M, Meuwissen M, Stegehuis VE, Escaned J, Piek JJ. Contribution of Age-Related Microvascular Dysfunction to Abnormal Coronary: Hemodynamics in Patients With Ischemic Heart Disease. JACC Cardiovasc Interv 2020; 13:20-29. [PMID: 31918939 DOI: 10.1016/j.jcin.2019.08.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study sought to investigate the contribution of age-related microcirculatory dysfunction to abnormal coronary hemodynamics in patients with coronary atherosclerosis. BACKGROUND Impairment in myocardial blood supply in patients with coronary atherosclerosis can be accentuated due to age-related changes in microcirculatory function. METHODS Intracoronary pressure and flow were measured with the Doppler technique in 299 vessels (228 patients), and the thermodilution technique in 120 vessels (99 patients). In 172 patients, Doppler measurements were also performed in unobstructed vessels. Associations of coronary hemodynamics with aging were studied in both the stenosed and unobstructed arteries. RESULTS Aging was associated with a progressive increase in minimal microvascular resistance and a progressive decrease in hyperemic flow in both obstructed and nonobstructed coronary arteries. As such, coronary flow reserve decreased with advancing age. Epicardial stenosis severity assessed by resting Pd/Pa, basal stenosis resistance index, and hyperemic stenosis resistance index was equivalent across age groups. By contrast, fractional flow reserve increased with advancing age. Consequently, the adjusted risk of a fractional flow reserve/coronary flow reserve pattern reflective of concomitant focal epicardial and diffuse or microvascular disease (relative risk: 1.6; 95% confidence interval: 1.1 to 2.3; p = 0.017) increased with advancing age, whilst the adjusted risk of a fractional flow reserve/coronary flow reserve pattern reflective of non-flow-limiting stenosis with a healthy microcirculation decreased (relative risk: 0.7; 95% CI: 0.5 to 1.0; p = 0.022). CONCLUSIONS Aging is associated with progressive pan-myocardial impairment of coronary vasodilatory capacity due to an increase in minimal microvascular resistance. Concomitant aging-related impairment in microvascular function impacts the pathophysiology of ischemic heart disease in the individual patient and is not adequately identified by hyperemic coronary pressure measurements alone.
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Affiliation(s)
- Tim P van de Hoef
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Cardiovascular Institute, Hospital Clínico San Carlos, and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.
| | - Mauro Echavarria-Pinto
- Cardiovascular Institute, Hospital Clínico San Carlos, and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Hospital General ISSSTE - Facultad de Medicina, Universidad Autónoma de Querétaro, Querétaro, México
| | | | - Valerie E Stegehuis
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Faculty of Medicine, Complutense University, Madrid, Spain
| | - Jan J Piek
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Sezer M, Aslanger E, Cakir O, Atici A, Sezer I, Ozcan A, Umman B, Bugra Z, Umman S. The Interplay between Features of Plaque Vulnerability and Hemodynamic Relevance of Coronary Artery Stenoses. Cardiology 2020; 146:1-10. [PMID: 32846410 DOI: 10.1159/000508885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/23/2020] [Indexed: 11/19/2022]
Abstract
Fractional flow reserve (FFR) may not be immune from hemodynamic perturbations caused by both vessel and lesion related factors. The aim of this study was to investigate the impact of plaque- and vessel wall-related features of vulnerability on the hemodynamic effect of intermediate coronary stenoses. Methods and Results: In this cross-sectional study, patients referred to catheterization laboratory for clinically indicated coronary angiography were prospectively screened for angiographically intermediate stenosis (50-80%). Seventy lesions from 60 patients were evaluated. Mean angiographic stenosis was 62.1 ± 16.3%. After having performed FFR assessment, intravascular ultrasound (IVUS) was performed over the FFR wire. Virtual histology IVUS was used to identify the plaque components and thin cap fibroatheroma (TCFA). TCFA was significantly more frequent (65 vs. 38%, p = 0.026), and necrotic core volume (26.15 ± 14.22 vs. 16.21 ± 8.93 mm3, p = 0.04) was significantly larger in the positively remodeled than non-remodeled vessels. Remodeling index correlated with necrotic core volume (r = 0.396, p = 0.001) and with FFR (r = -0. 419, p = 0.001). With respect to plaque components, only necrotic core area (r = -0.262, p = 0.038) and necrotic core volume (r = -0.272, p = 0.024) were independently associated with FFR. In the multivariable model, presence of TCFA was independently associated with significantly lower mean FFR value as compared to absence of TCFA (adjusted, 0.71 vs. 0.78, p = 0.034). Conclusion: The current study demonstrated that for a given stenosis geometry, features of plaque vulnerability such as necrotic core volume, TCFA, and positive remodeling may influence the hemodynamic relevance of intermediate coronary stenoses.
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Affiliation(s)
- Murat Sezer
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey,
| | - Emre Aslanger
- Department of Cardiology, Yeditepe University, Istanbul, Turkey
| | - Ozan Cakir
- Department of Cardiology, Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| | - Adem Atici
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Irem Sezer
- Department of Cardiology, School of Medicine, Acibadem University, Istanbul, Turkey
| | - Alp Ozcan
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Berrin Umman
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zehra Bugra
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sabahattin Umman
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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35
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Non-hyperaemic coronary pressure measurements to guide coronary interventions. Nat Rev Cardiol 2020; 17:629-640. [DOI: 10.1038/s41569-020-0374-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2020] [Indexed: 01/11/2023]
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36
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Xu H, Liu J, Zhou D, Jin Y. Influence of microcirculation load on FFR in coronary artery stenosis model. BMC Cardiovasc Disord 2020; 20:144. [PMID: 32199456 PMCID: PMC7085198 DOI: 10.1186/s12872-020-01437-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 03/13/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The coronary artery hemodynamics are impacted by both the macrocirculation and microcirculation. Whether microcirculation load impact the functional assessment of a coronary artery stenosis is unknown. The purpose of this study is to investigate the effect of porous media of the microcirculation on fractional flow reserve (FFR) in stenotic coronary artery model. METHODS A three dimensional computational simulation of blood flow in coronary artery symmetric stenotic model was constructed. The computational fluid dynamics (CFD) model was developed with Fluent 16.0. Blood was modeled as a shear thinning, non-Newtonian fluid with the Carreau model. A seepage outlet boundary condition and transient inlet conditions were imposed on the model. Coronary physiologica diagnostic parameter such as pressure, velocity and fractional flow reserve (FFR) were investigated in the model and compared with the microcirculation load (ML) and constant pressure load (PL) condition. RESULTS The present study showed the different hemodynamics in the ML and PL condition. The pre-stenotic pressure is almost the same in the two model. However the pressure in the post-stenotic artery domain is much lower in the PL model. The fluctuation range of the pressures is much higher in ML model than those in PL model. The velocity flow was more steady and lower in the ML model. For the PL model with 75% artery stenosis the FFR was 0.776, while for the ML model with the same stenosis, the FFR was 0.813. CONCLUSIONS This study provides evidence that FFR increased in the presentation of ML condition. There is a strong hemodynamic effect of microcirculation on coronary artery stenosis.
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Affiliation(s)
- Hongzeng Xu
- Department of Cardiology, The fourth Affiliated Hospital of China Medical University, No. 4, Chongshan Road, Huanggu District, Shenyang, 110032, China
| | - Jing Liu
- Department of Cardiology, The fourth Affiliated Hospital of China Medical University, No. 4, Chongshan Road, Huanggu District, Shenyang, 110032, China
| | - Donghui Zhou
- Department of Cardiology, The fourth Affiliated Hospital of China Medical University, No. 4, Chongshan Road, Huanggu District, Shenyang, 110032, China
| | - Yuanzhe Jin
- Department of Cardiology, The fourth Affiliated Hospital of China Medical University, No. 4, Chongshan Road, Huanggu District, Shenyang, 110032, China.
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Soares A, Brown DL. The fallacies of fractional flow reserve. Int J Cardiol 2020; 302:34-35. [PMID: 31889563 DOI: 10.1016/j.ijcard.2019.12.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 12/19/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Andrea Soares
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, United States of America
| | - David L Brown
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, United States of America.
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van Lavieren MA, Bax M, Stegehuis VE, van de Hoef TP, Wijntjens GWM, de Winter RJ, Koch KT, Henriques JPS, Meuwissen M, Sjauw KD, Piek JJ. Acute alterations in glucose homeostasis impact coronary microvascular function in patients presenting with ST-segment elevation myocardial infarction. Neth Heart J 2020; 28:161-170. [PMID: 31953778 PMCID: PMC7052118 DOI: 10.1007/s12471-020-01366-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Microvascular dysfunction in the setting of ST-segment myocardial infarction (STEMI) is thought to be related to stress-related metabolic changes, including acute glucose intolerance. The aim of this study was to assess the relationship between admission glucose levels and microvascular function in non-diabetic STEMI patients. Methods 92 consecutive patients with a first anterior-wall STEMI treated with primary percutaneous coronary intervention (PPCI) were enrolled. Blood glucose levels were determined immediately prior to PPCI. After successful PPCI, at 1‑week and 6‑month follow-up, Doppler flow was measured in culprit and reference coronary arteries to calculate coronary flow velocity reserve (CFVR), baseline (BMR) and hyperaemic (HMR) microvascular resistance. Results The median admission glucose was 8.3 (7.2–9.6) mmol/l respectively 149.4 mg/dl [129.6–172.8] and was significantly associated with peak troponin T (standardised beta coefficient [std beta] = 0.281; p = 0.043). Multivariate analysis revealed that increasing glucose levels were significantly associated with a decrease in reference vessel CFVR (std beta = −0.313; p = 0.002), dictated by an increase in rest average peak velocity (APV) (std beta = 0.216; p = 0.033), due to a decreasing BMR (std beta = −0.225; p = 0.038) in the acute setting after PPCI. These associations disappeared at follow-up. These associations were not found for the infarct-related artery. Conclusion Elevated admission glucose levels are associated with impaired microvascular function assessed directly after PPCI in first anterior-wall STEMI. This influence of glucose levels is an acute phenomenon and contributes to microvascular dysfunction through alterations in resting flow and baseline microvascular resistance.
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Affiliation(s)
- M A van Lavieren
- Amsterdam UMC, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - M Bax
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - V E Stegehuis
- Amsterdam UMC, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - T P van de Hoef
- Amsterdam UMC, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - G W M Wijntjens
- Amsterdam UMC, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - R J de Winter
- Amsterdam UMC, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - K T Koch
- Amsterdam UMC, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - J P S Henriques
- Amsterdam UMC, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - M Meuwissen
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - K D Sjauw
- Amsterdam UMC, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands.,Heart Center, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - J J Piek
- Amsterdam UMC, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands.
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Hennigan B, Berry C, Collison D, Corcoran D, Eteiba H, Good R, McEntegart M, Watkins S, McClure JD, Mangion K, Ford TJ, Petrie MC, Hood S, Rocchiccioli P, Shaukat A, Lindsay M, Oldroyd KG. Percutaneous coronary intervention versus medical therapy in patients with angina and grey-zone fractional flow reserve values: a randomised clinical trial. Heart 2020; 106:758-764. [PMID: 32114516 PMCID: PMC7229900 DOI: 10.1136/heartjnl-2019-316075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/27/2019] [Accepted: 01/03/2020] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION There is conflicting evidence regarding the benefits of percutaneous coronary intervention (PCI) in patients with grey zone fractional flow reserve (GZFFR artery) values (0.75-0.80). The prevalence of ischaemia is unknown. We wished to define the prevalence of ischaemia in GZFFR artery and assess whether PCI is superior to optimal medical therapy (OMT) for angina control. METHODS We enrolled 104 patients with angina with 1:1 randomisation to PCI or OMT. The artery was interrogated with a Doppler flow/pressure wire. Patients underwent Magnetic Resonance Imaging (MRI) with follow-up at 3 and 12 months. The primary outcome was angina status at 3 months using the Seattle Angina Questionnaire (SAQ). RESULTS 104 patients (age 60±9 years), 79 (76%) males and 79 (76%) Left Anterior Descending (LAD) stenoses were randomised. Coronary physiology and SAQ were similar. Of 98 patients with stress perfusion MRI data, 17 (17%) had abnormal perfusion (≥2 segments with ≥25% ischaemia or ≥1 segment with ≥50% ischaemia) in the target GZFFR artery. Of 89 patients with invasive physiology data, 26 (28%) had coronary flow velocity reserve <2.0 in the target GZFFR artery. After 3 months of follow-up, compared with patients treated with OMT only, patients treated by PCI and OMT had greater improvements in SAQ angina frequency (21 (28) vs 10 (23); p=0.026) and quality of life (24 (26) vs 11 (24); p=0.008) though these differences were no longer significant at 12 months. CONCLUSIONS Non-invasive evidence of major ischaemia is uncommon in patients with GZFFR artery. Compared with OMT alone, patients randomised to undergo PCI reported improved symptoms after 3 months but these differences were no longer significant after 12 months. TRIAL REGISTRATION NUMBER NCT02425969.
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Affiliation(s)
- Barry Hennigan
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom .,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK.,Cardiology Department, The Mater Private Hospital Cork, Cork, Ireland
| | - Colin Berry
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Damien Collison
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - David Corcoran
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Hany Eteiba
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Richard Good
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Margaret McEntegart
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Stuart Watkins
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - John D McClure
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Kenneth Mangion
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Thomas Joseph Ford
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Stuart Hood
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Paul Rocchiccioli
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Aadil Shaukat
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Mitchell Lindsay
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Keith G Oldroyd
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
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Jones RE, Karamasis GV, Dungu JN, Mohdnazri SR, Al-Janabi F, Hammersley DJ, Prasad SK, Tang KH, Kelly PA, Gedela S, Davies JR, Keeble TR. Stress perfusion cardiovascular magnetic resonance and serial fractional flow reserve assessment of the left anterior descending artery in patients undergoing right coronary artery chronic total occlusion revascularization. Cardiol J 2020; 29:80-87. [PMID: 32037503 PMCID: PMC8890403 DOI: 10.5603/cj.a2020.0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/21/2020] [Accepted: 12/25/2019] [Indexed: 11/25/2022] Open
Abstract
Background Fractional flow reserve (FFR) assessment of remote arteries, in the context of a bystander chronic total occlusion (CTO), can lead to false positive results. Adenosine stress cardiovascular magnetic resonance (CMR) evaluates perfusion defects across the entire myocardium and may therefore be a reliable tool in the work-up of remote lesions in CTO patients. The IMPACT-CTO study investigated donor artery invasive physiology before, immediately post, and at 4 months following right coronary artery (RCA) CTO percutaneous coronary intervention (PCI). The aim of this subanalysis was to assess the concordance between baseline perfusion CMR and serial FFR evaluation of left anterior descending artery (LAD) ischemia in patients from the IMPACT-CTO study. Methods Baseline adenosine stress CMR examinations from 26 patients were analyzed for qualitative evidence of LAD ischemia. The results were correlated with the serial LAD FFR measurements. Results The present findings demonstrated that before RCA CTO PCI, there was 62% agreement between perfusion CMR and FFR (ischemic threshold ≤ 0.8) in the assessment of LAD ischemia (k = 0.29; fair concordance). At 4 months after revascularization, there was 77% agreement (k = 0.52; moderate concordance) between the index CMR assessment of LAD ischemia and the follow-up LAD FFR. Concordance was improved at a LAD FFR ischemic threshold of ≤ 0.75. Conclusions In this hypothesis generating study, baseline CMR assessment of LAD ischemia correlated better with the 4 months LAD FFR data (threshold ≤ 0.8) as compared to the FFR measurements taken prior to RCA CTO revascularization.
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Affiliation(s)
- Richard E Jones
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom.
| | - Grigoris V Karamasis
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom.,School of Medicine, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, United Kingdom
| | - Jason N Dungu
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom
| | - Shah R Mohdnazri
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom.,School of Medicine, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, United Kingdom
| | - Firas Al-Janabi
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom.,School of Medicine, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, United Kingdom
| | | | - Sanjay K Prasad
- National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Kare H Tang
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom
| | - Paul A Kelly
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom
| | - Swamy Gedela
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom
| | - John R Davies
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom.,School of Medicine, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, United Kingdom
| | - Thomas R Keeble
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom.,School of Medicine, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, United Kingdom
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Sheng X, Qiao Z, Ge H, Sun J, He J, Li Z, Ding S, Pu J. Novel application of quantitative flow ratio for predicting microvascular dysfunction after ST-segment-elevation myocardial infarction. Catheter Cardiovasc Interv 2020; 95 Suppl 1:624-632. [PMID: 31912991 DOI: 10.1002/ccd.28718] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 12/31/2019] [Indexed: 11/05/2022]
Abstract
OBJECTIVES This study evaluated quantitative flow ratio (QFR) to predict microvascular dysfunction (MVD) in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND QFR is a novel approach for the rapid computation of fractional flow reserve based on three-dimensional quantitative coronary angiography. We hypothesized that QFR computation could be used to predict MVD after STEMI. METHODS Indexes such as contrast-flow QFR (cQFR), fixed-flow QFR (fQFR), and hyperemic flow velocity (HFV) were calculated in 130 STEMI patients with culprit lesion with ≥50% diameter stenosis and TIMI flow grade 2/3 in the spontaneously recanalized culprit artery on initial angiography. MVD was defined as microvascular obstruction determined by contrast-enhanced cardiac magnetic resonance at a median of 5 days after percutaneous coronary intervention. RESULTS Patients were divided into the MVD group (76/130, 58.5%) and non-MVD group (54/130, 41.5%). Patients with MVD had higher cQFR-fQFR value (0.080 ± 0.058 vs. 0.038 ± 0.039, p < .001) and lower modeled HFV (0.096 ± 0.044 vs. 0.144 ± 0.041 m/s, p < .001). Receiver operator characteristic curve analysis revealed that both the cQFR-fQFR value (area under the curve, AUC = 0.716, p < .001) and modeled HFV (AUC = 0.805, p < .001) had high specificity and positive predictive value to predict MVD. In multivariable logistic analysis, cQFR-fQFR was identified as an independent predictor of MVD (odds ratio = 9.800, p < .001). CONCLUSIONS This proof-of-concept study suggested that QFR computation may be a useful tool to predict MVD after STEMI (Trial Registration:NCT03780335).
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Affiliation(s)
- Xincheng Sheng
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhiqing Qiao
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Heng Ge
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jiateng Sun
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jie He
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zheng Li
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Song Ding
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jun Pu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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43
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Dorobantu M, Calmac L. Coronary Microcirculatory Dysfunction Evaluation in Chronic Angina. Microcirculation 2020. [DOI: 10.1007/978-3-030-28199-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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44
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Fractional Flow Reserve and Instantaneous Wave-Free Ratio for Nonculprit Stenosis in Patients With Acute Myocardial Infarction. JACC Cardiovasc Interv 2019; 11:1848-1858. [PMID: 30236358 DOI: 10.1016/j.jcin.2018.06.045] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The aim of this study was to compare the changes of fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) with severity of epicardial coronary stenosis between nonculprit vessel of acute myocardial infarction (AMI) and stable ischemic heart disease (SIHD). BACKGROUND There has been debate regarding the reliability of FFR or iFR for nonculprit stenosis in the acute stage of AMI. METHODS A total of 100 AMI patients underwent comprehensive physiologic assessment including FFR, iFR, coronary flow reserve (CFR), and index of microcirculatory resistance (IMR) for nonculprit vessel stenosis after primary percutaneous coronary intervention (PCI) for culprit vessel. The changes in FFR and iFR for diameter stenosis (%DS) of nonculprit vessel stenosis were compared with FFR and iFR measured in 203 patients with SIHD. RESULTS From 40% to 80% stenosis, FFR and iFR measured in nonculprit vessel of AMI patient showed significant decrease with worsening stenosis severity (all p values < 0.001). Nonculprit vessels of AMI patients showed lower CFR than SIHD; however, IMR was not different between the nonculprit vessel of AMI and SIHD patients. FFR and iFR were not significantly different between the nonculprit vessel of AMI and SIHD patients in all %DS groups from 40% to 80% (all p values > 0.05). In addition, percent difference of FFR and iFR according to the increase in %DS was also not significantly different between nonculprit vessel of AMI or SIHD. There was no significant interaction between clinical presentation and the changes of FFR and iFR for worsening %DS (interaction p value = 0.698 and 0.257, respectively). CONCLUSIONS Changes in FFR and iFR for the nonculprit stenosis of AMI patients were not significantly different from those in SIHD patients. These data support the use of invasive physiological parameters to guide treatment of nonculprit stenoses in the acute stage of successfully revascularized AMI.
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45
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Making the Case for Ischemia: Using Myocardial Contrast Echocardiography to Understand When the (Circumstantial) Evidence Doesn't Add Up. J Am Soc Echocardiogr 2019; 32:1102-1104. [DOI: 10.1016/j.echo.2019.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 11/21/2022]
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46
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The Relationship of Capillary Blood Flow Assessments with Real Time Myocardial Perfusion Echocardiography to Invasively Derived Microvascular and Epicardial Assessments. J Am Soc Echocardiogr 2019; 32:1095-1101. [DOI: 10.1016/j.echo.2019.04.424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/05/2019] [Accepted: 04/27/2019] [Indexed: 01/18/2023]
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47
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Alzahrani T, Tashkandi A, Sarkar A, Smuclovisky C, Earls JP, Choi AD. Practical Clinical Application of Cardiac Computed Tomography‐Derived Fractional Flow Reserve. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2019. [DOI: 10.15212/cvia.2019.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Liou KP, Ooi SYM, Hoole SP, West NEJ. Fractional flow reserve in acute coronary syndrome: a meta-analysis and systematic review. Open Heart 2019; 6:e000934. [PMID: 30774965 PMCID: PMC6350698 DOI: 10.1136/openhrt-2018-000934] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/05/2018] [Accepted: 11/12/2018] [Indexed: 01/02/2023] Open
Abstract
Background The utility of fractional flow reserve (FFR) to guide revascularisation in the management of acute coronary syndrome (ACS) remains unclear. Objective This study aims to compare the clinical outcomes of patients following FFR-guided revascularisation for either ACS or stable angina (SA) and in particular focuses on the outcome of those with deferred revascularisation after FFR. Methods A meta-analysis of existing literature was performed. Outcomes including the rate of major adverse cardiovascular events (MACE), recurrent myocardial infarction (MI), mortality and unplanned revascularisation were analysed. Results A review of 937 records yielded 9 studies comparing 5457 patients, which were included in the analyses. Patients with ACS had a higher rate of recurrent MI (OR 1.81, p=0.02) and a strong trend towards more MACE and all-cause mortality compared with patients with SA when treated by an FFR-guided revascularisation strategy. Deferral of invasive therapy on the basis of FFR led to a higher rate of MACE (17.6% vs 7.3 %; p=0.004), recurrent MI (5.3% vs 1.5%, p=0.001) and target vessel revascularisation (16.4% vs 5.6 %; p=0.02) in patients with ACS, and a strong trend towards a higher cardiovascular mortality at follow-up when compared with patients with SA. Conclusion The event rate in patients with ACS is much higher than SA despite following an FFR-guided revascularisation strategy. Deferring revascularisation does not appear to be as safe for ACS as it is for SA using contemporary FFR cut-offs validated in SA. Refinement of the therapeutic strategy for patients with ACS with multivessel disease is needed to redress the balance.
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Affiliation(s)
- Kevin P Liou
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK.,Eastern Heart Clinic, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Sze-Yuan M Ooi
- Eastern Heart Clinic, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Stephen P Hoole
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Nick E J West
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
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Garcia D, Harbaoui B, van de Hoef TP, Meuwissen M, Nijjer SS, Echavarria-Pinto M, Davies JE, Piek JJ, Lantelme P. Relationship between FFR, CFR and coronary microvascular resistance - Practical implications for FFR-guided percutaneous coronary intervention. PLoS One 2019; 14:e0208612. [PMID: 30616240 PMCID: PMC6322913 DOI: 10.1371/journal.pone.0208612] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 11/20/2018] [Indexed: 01/09/2023] Open
Abstract
Objective The aim was threefold: 1) expound the independent physiological parameters that drive FFR, 2) elucidate contradictory conclusions between fractional flow reserve (FFR) and coronary flow reserve (CFR), and 3) highlight the need of both FFR and CFR in clinical decision making. Simple explicit theoretical models were supported by coronary data analyzed retrospectively. Methodology FFR was expressed as a function of pressure loss coefficient, aortic pressure and hyperemic coronary microvascular resistance. The FFR-CFR relationship was also demonstrated mathematically and was shown to be exclusively dependent upon the coronary microvascular resistances. The equations were validated in a first series of 199 lesions whose pressures and distal velocities were monitored. A second dataset of 75 lesions with pre- and post-PCI measures of FFR and CFR was also analyzed to investigate the clinical impact of our hemodynamic reasoning. Results Hyperemic coronary microvascular resistance and pressure loss coefficient had comparable impacts (45% and 49%) on FFR. There was a good concordance (y = 0.96 x − 0.02, r2 = 0.97) between measured CFR and CFR predicted by FFR and coronary resistances. In patients with CFR < 2 and CFR/FFR ≥ 2, post-PCI CFR was significantly >2 (p < 0.001), whereas it was not (p = 0.94) in patients with CFR < 2 and CFR/FFR < 2. Conclusion The FFR behavior and FFR-CFR relationship are predictable from basic hemodynamics. Conflicting conclusions between FFR and CFR are explained from coronary vascular resistances. As confirmed by our results, FFR and CFR are complementary; they could jointly contribute to better PCI guidance through the CFR-to-FFR ratio in patients with coronary artery disease.
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Affiliation(s)
- Damien Garcia
- CREATIS, INSERM U1206, Université Lyon 1, INSA Lyon, Villeurbanne, France
- * E-mail: ,
| | - Brahim Harbaoui
- CREATIS, INSERM U1206, Université Lyon 1, INSA Lyon, Villeurbanne, France
- Department of Cardiology, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, France
| | - Tim P. van de Hoef
- AMC Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands
| | | | | | - Mauro Echavarria-Pinto
- AMC Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Justin E. Davies
- Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands
| | - Jan J. Piek
- AMC Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Pierre Lantelme
- CREATIS, INSERM U1206, Université Lyon 1, INSA Lyon, Villeurbanne, France
- Department of Cardiology, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, France
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50
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Stegehuis VE, Wijntjens GW, Murai T, Piek JJ, van de Hoef TP. Assessing the Haemodynamic Impact of Coronary Artery Stenoses: Intracoronary Flow Versus Pressure Measurements. Eur Cardiol 2018; 13:46-53. [PMID: 30310471 DOI: 10.15420/ecr.2018:7:2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Fractional flow reserve (FFR)-guided percutaneous coronary intervention results in better long-term clinical outcomes compared with coronary angiography alone in intermediate stenoses in stable coronary artery disease (CAD). Coronary physiology measurements have emerged for clinical decision making in interventional cardiology, but the focus lies mainly on epicardial vessels rather than the impact of these stenoses on the myocardial microcirculation. The latter can be quantified by measuring the coronary flow reserve (CFR), a combined pressure and flow index with a strong ability to predict clinical outcomes in CAD. However, combined pressure-flow measurements show 30-40 % discordance despite similar diagnostic accuracy between FFR and CFR, which is explained by the effect of microvascular resistance on both indices. Both epicardial and microcirculatory involvement has been acknowledged in ischaemic heart disease, but clinical implementation remains difficult as it requires individual proficiency. The recent introduced pressure-only index instantaneous wave-free ratio, a resting adenosine-free stenosis assessment, led to a revival of interest in coronary physiology measurements. This review focuses on elaborating the coronary physiological parameters and potential of combined pressure-flow measurements in daily clinical practice.
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Affiliation(s)
- Valérie E Stegehuis
- AMC Heart Center, Academic Medical Center, University of Amsterdam Amsterdam, the Netherlands
| | - Gilbert Wm Wijntjens
- AMC Heart Center, Academic Medical Center, University of Amsterdam Amsterdam, the Netherlands
| | - Tadashi Murai
- AMC Heart Center, Academic Medical Center, University of Amsterdam Amsterdam, the Netherlands
| | - Jan J Piek
- AMC Heart Center, Academic Medical Center, University of Amsterdam Amsterdam, the Netherlands
| | - Tim P van de Hoef
- AMC Heart Center, Academic Medical Center, University of Amsterdam Amsterdam, the Netherlands
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