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Helmy M, Liao Y, Luo S, Xu B. How I do it: direct pressure measurement in moyamoya bypass. Acta Neurochir (Wien) 2023; 165:3631-3635. [PMID: 37870662 DOI: 10.1007/s00701-023-05842-w] [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] [Received: 06/26/2023] [Accepted: 10/08/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND The direct quantitative measurement of donor and recipient pressures in patients with moyamoya vasculopathy (MMV) during superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery has yet to be reported in academic literature. METHOD Using a wireless pressure wire, we describe our approach to measuring seven pressure parameters in MMV patients step-by-step. CONCLUSION Direct intraluminal pressure measurement of donor and recipient arteries provides a practical and accurate means to quantify cerebral hemodynamic parameters in MMV patients, enhancing understanding of individualized hemodynamic changes pre- and post-surgery.
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Affiliation(s)
- Mohamed Helmy
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai, 200040, China
- China National Center of Neurological Diseases, Shanghai, 200040, China
| | - Yujun Liao
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai, 200040, China
- China National Center of Neurological Diseases, Shanghai, 200040, China
| | - Siliang Luo
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou, 510510, Guangdong, China
| | - Bin Xu
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai, 200040, China.
- China National Center of Neurological Diseases, Shanghai, 200040, China.
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2
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Yao T, Wang C, Wang X, Li X, Jiang Z, Qi P. Enhancing percutaneous coronary intervention with heuristic path planning and deep-learning-based vascular segmentation. Comput Biol Med 2023; 166:107540. [PMID: 37806060 DOI: 10.1016/j.compbiomed.2023.107540] [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] [Received: 07/22/2023] [Revised: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 10/10/2023]
Abstract
Percutaneous coronary intervention (PCI) is a minimally invasive technique for treating vascular diseases. PCI requires precise and real-time visualization and guidance to ensure surgical safety and efficiency. Existing mainstream guiding methods rely on hemodynamic parameters. However, these methods are less intuitive than images and pose some challenges to the decision-making of cardiologists. This paper proposes a novel PCI guiding assistance system by combining a novel vascular segmentation network and a heuristic intervention path planning algorithm, providing cardiologists with clear and visualized information. A dataset of 1077 DSA images from 288 patients is also collected in clinical practice. A Likert Scale is also designed to evaluate system performance in user experiments. Results of user experiments demonstrate that the system can generate satisfactory and reasonable paths for PCI. Our proposed method outperformed the state-of-the-art baselines based on three metrics (Jaccard: 0.4091, F1: 0.5626, Accuracy: 0.9583). The proposed system can effectively assist cardiologists in PCI by providing a clear segmentation of vascular structures and optimal real-time intervention paths, thus demonstrating great potential for robotic PCI autonomy.
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Affiliation(s)
- Tianliang Yao
- College of Electronics and Information Engineering, Tongji University, Shanghai, 200092, China.
| | - Chengjia Wang
- School of Mathematical and Computer Sciences, Heriot-Watt University, Edinburgh, EH14 4AP, United Kingdom; BHF Centre for Cardiovascular Science,University of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom.
| | - Xinyi Wang
- School of Medicine, Tongji University, Shanghai, 200092, China.
| | - Xiang Li
- Departments of Cardiology and Nursing, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200072, China.
| | - Zhaolei Jiang
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China.
| | - Peng Qi
- College of Electronics and Information Engineering, Tongji University, Shanghai, 200092, China.
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3
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Faurie B, Acheampong A, Abdellaoui M, Dessus I, Monsegu J, Wintzer-Wehekind J. Direct wire pacing during measurement of fractional flow reserve: A randomized proof-of-concept noninferiority crossover trial. Front Cardiovasc Med 2023; 10:1137309. [PMID: 37937287 PMCID: PMC10625906 DOI: 10.3389/fcvm.2023.1137309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/30/2023] [Indexed: 11/09/2023] Open
Abstract
Background Adenosine administration for fractional flow reserve (FFR) measurement may induce heart pauses. Aims To assess the accuracy and tolerability of direct wire pacing (DWP) during measurement of FFR. Methods Adults with at least one intermediate coronary artery stenosis (40%-80%) were consecutively enrolled between June 2021 and February 2022 in this randomized, noninferiority, crossover trial (NCT04970082) carried out in France. DWP was applied (DWP) or not (standard method) through the pressure guidewire used for FFR measurement during adenosine-induced maximal hyperaemia. Subjects were randomly assigned to the allocation sequence (DWP first or standard first). A 2-minute washout period was observed between the two FFR measurements performed for each stenosis. The primary endpoint was the reproducibility of FFR measurements between methods. Results A total of 150 focal lesions, presented by 94 subjects, were randomized (ratio: 1:1). The FFR values obtained with each method were nearly identical (R = 0.98, p = 0.005). The mean FFR difference of 0.00054 (95% confidence interval: 0.004 to 0.003) showed the noninferiority of FFR measurement with DWP vs. that with the standard method. Higher levels of chest discomfort were reported with DWP than with the standard method (0.61 ± 0.84 vs. 1.05 ± 0.89, p < 0.001), and a correlation was observed between the electrical sensations reported with DWP and chest discomfort (p < 0.001). Pauses (n = 20/148 lesions) were observed with the standard method, but did not correlate with chest discomfort (p = 0.21). No pauses were observed with DWP. Conclusions DWP during FFR measurement resulted in accurate and reproducible FFR values, and eliminated the pauses induced by adenosine.
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Affiliation(s)
| | - Angela Acheampong
- Institut Cardiovasculaire de Grenoble, Grenoble, France
- Université Libre de Bruxelles, Bruxelles, Belgium
| | | | - Ilona Dessus
- Institut Cardiovasculaire de Grenoble, Grenoble, France
- Université Grenoble-Alpes, CHU Grenoble-Alpes, Grenoble, France
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Berntorp K, Persson J, Koul SM, Patel MR, Christiansen EH, Gudmundsdottir I, Yndigegn T, Omerovic E, Erlinge D, Fröbert O, Götberg M. Instantaneous wave-free ratio compared with fractional flow reserve in PCI: A cost-minimization analysis. Int J Cardiol 2021; 344:54-59. [PMID: 34600977 DOI: 10.1016/j.ijcard.2021.09.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Coronary physiology is a routine diagnostic tool when assessing whether coronary revascularization is indicated. The iFR-SWEDEHEART trial demonstrated similar clinical outcomes when using instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) to guide revascularization. The objective of this analysis was to assess a cost-minimization analysis of iFR-guided compared with FFR-guided revascularization. METHODS In this cost-minimization analysis we used a decision-tree model from a healthcare perspective with a time-horizon of one year to estimate the cost difference between iFR and FFR in a Nordic setting and a United States (US) setting. Treatment pathways and health care utilizations were constructed from the iFR-SWEDEHEART trial. Unit cost for revascularization and myocardial infarction in the Nordic setting and US setting were derived from the Nordic diagnosis-related group versus Medicare cost data. Unit cost of intravenous adenosine administration and cost per stent placed were based on the average costs from the enrolled centers in the iFR-SWEDEHEART trial. Deterministic and probabilistic sensitivity analyses were carried out to test the robustness of the result. RESULTS The cost-minimization analysis demonstrated a cost saving per patient of $681 (95% CI: $641 - $723) in the Nordic setting and $1024 (95% CI: $934 - $1114) in the US setting, when using iFR-guided compared with FFR-guided revascularization. The results were not sensitive to changes in uncertain parameters or assumptions. CONCLUSIONS IFR-guided revascularization is associated with significant savings in cost compared with FFR-guided revascularization.
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Affiliation(s)
- Karolina Berntorp
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Josefine Persson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
| | - Sasha M Koul
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | | | | | - Ingibjörg Gudmundsdottir
- Department of Cardiology, Reykjavik University Hospital and University of Iceland, Reykjavik, Iceland.
| | - Troels Yndigegn
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - David Erlinge
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Ole Fröbert
- Örebro University, Faculty of Health, Department of Cardiology, Örebro, Sweden.
| | - Matthias Götberg
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
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5
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Gewirtz H. CMR quantitative measurements of myocardial blood flow: Not ready for routine clinical application. J Nucl Cardiol 2021; 28:1267-1270. [PMID: 31317327 DOI: 10.1007/s12350-019-01812-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Henry Gewirtz
- Cardiac Unit, Department of Medicine (Cardiology Division), Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA.
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6
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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7
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FENG YUE, MAO BOYAN, LI BAO, LIU JIAN, LIU JINCHENG, LIU YOUJUN. EFFECT OF HEMODYNAMIC PARAMETERS ON FRACTIONAL FLOW RESERVE. J MECH MED BIOL 2020. [DOI: 10.1142/s0219519420500177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The fractional flow reserve (FFR) is the gold standard used to diagnose whether coronary stenosis triggers myocardial ischemia. Myocardial ischemia is not only related to the degree of coronary artery disease but also to hemodynamic parameters such as mean arterial pressure, flow, and so on. This paper will explore the effects of hemodynamic parameters on FFR. Methods: Construct an ideal vascular model of moderately stenosis lesions (40–70%) with different hemodynamic environments. A pressure waveform was set as the inlet boundary, a microcirculation resistance in the hyperemia state was set as the outlet boundary, and different hemodynamic environments were constructed by changing the mean arterial pressure and flow at rest. The microcirculation resistance in the resting state was determined by the mean arterial pressure and flow, and the microcirculation resistance in the hyperemia state was 0.24 times than in the resting state. Results:Flow at rest was found to have the greatest impact on FFR, followed by arterial pressure. Both a decrease in flow and an increase in mean arterial pressure caused an increase in the FFR value. Conclusion:Based on the degree of stenosis of the diseased blood vessel, systolic pressure, diastolic blood pressure, and blood flow through the diseased blood vessel in the resting state, a preliminary judgment can be directly made as to whether the stenosis causes myocardial ischemia.
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Affiliation(s)
- YUE FENG
- College of Life Science and Bio-engineering, Beijing University of Technology, No.100 Pingleyuan, Chaoyang District, Beijing, P. R. China
| | - BOYAN MAO
- College of Life Science and Bio-engineering, Beijing University of Technology, No.100 Pingleyuan, Chaoyang District, Beijing, P. R. China
| | - BAO LI
- College of Life Science and Bio-engineering, Beijing University of Technology, No.100 Pingleyuan, Chaoyang District, Beijing, P. R. China
| | - JIAN LIU
- Cardiac Surgery Department, PeKing University People’s Hospital, 11th. South Ave. Xizhimen, Beijing, P. R. China
| | - JINCHENG LIU
- College of Life Science and Bio-engineering, Beijing University of Technology, No.100 Pingleyuan, Chaoyang District, Beijing, P. R. China
| | - YOUJUN LIU
- College of Life Science and Bio-engineering, Beijing University of Technology, No.100 Pingleyuan, Chaoyang District, Beijing, P. R. China
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8
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Quantificação do fluxo sanguíneo miocárdico por tomografia por emissão de positrões – Atualização. Rev Port Cardiol 2020; 39:37-46. [DOI: 10.1016/j.repc.2019.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 04/03/2019] [Accepted: 05/05/2019] [Indexed: 10/24/2022] Open
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9
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Fernandes J, Ferreira MJ, Leite L. Update on myocardial blood flow quantification by positron emission tomography. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.03.007] [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] Open
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10
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Design and rationale of ischaemia-driven complete revascularisation versus usual care in patients with non-ST-elevation myocardial infarction and multivessel coronary disease: the South Limburg Myocardial Infarction (SLIM) trial. Neth Heart J 2019; 28:75-80. [PMID: 31531823 PMCID: PMC6977786 DOI: 10.1007/s12471-019-01332-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
AIMS To compare ischaemia-driven complete coronary revascularisation by percutaneous coronary intervention (PCI) with usual care in patients with non-ST-elevation myocardial infarction (non-STEMI) and multivessel disease (MVD). METHODS The South Limburg Myocardial Infarction (SLIM) trial (NCT03562572) is an investigator-initiated, prospective, multicentre, randomised controlled trial that compares fractional flow reserve (FFR)-guided complete revascularisation during the index procedure with usual care in non-STEMI patients with MVD. A total of 414 patients will be randomised in a 1:1 fashion. The primary endpoint is the composite of all-cause mortality, non-fatal myocardial infarction, and any revascularisation and stroke (MACCE) at 12 months. The secondary endpoints are: MACCE at 24 and 36 months, and the composite of cardiac death, myocardial infarction, any revascularisation, stroke, major bleeding and left ventricular ejection fraction below 45% at 12, 24 and 36 months. Furthermore, quality of life will be assessed by the Patient Health Questionnaire (PHQ-9) and the Short Form (36) Health Survey (SF-36) at 1 and 12 months of follow-up. CONCLUSION The SLIM trial aims to provide evidence whether FFR-guided complete revascularisation by PCI is superior to usual care with respect to clinical outcomes (major adverse cardiovascular events) in non-STEMI patients with MVD.
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Pedroni P, Sarmiento RA, Solernó R, Hauqui A, Oscos M, Alvarez F, Lynch AV, Giachello F, Scaglia J, Grinfeld D. Safety and efficacy of intracoronary sodium nitroprusside for the assessment of coronary fractional flow reserve. Indian Heart J 2019; 70 Suppl 3:S245-S249. [PMID: 30595267 PMCID: PMC6309123 DOI: 10.1016/j.ihj.2017.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/07/2017] [Accepted: 12/31/2017] [Indexed: 11/28/2022] Open
Abstract
Background Coronary fractional flow reserve (FFR) determination is a valuable tool for the assessment of stenosis significance in intermediate coronary obstructions. Maximal hyperemia is mandatory for this determination. Although intravenous (IV) Adenosine is the standard agent used, its use carries an elevated incidence of side effects. Intracoronary sodium nitroprusside (IC NTP) is a very well-known coronary vasodilator, but it is not routinely used for FFR determinations. Objectives The purpose of the present study was to compare FFR determinations and side effect profile of IC NTP with IV Adenosine. Methods We prospectively assessed FFR determinations in a total of 20 intermediate coronary artery stenotic lesions in 18 consecutive patients with the administration of IV Adenosine (140 μg/kg/min) and IC NTP (100 μg). The appearance of side effects was registered. Results The mean age was 55.5 ± 7.5 years. Fifteen (83%) of the patients were male. Mean FFR values with IC NTP were similar to those obtained with IV Adenosine (0.82 ± 0.07 vs 0.82 ± 0.06, respectively, r = 0.775, p < 0.0001). Intravenous Adenosine induced side effects in 45% of patients (shortness of breath 30%, flushing 5%, headache 5%, angina pectoris 5%, and transient conduction disturbances 10%). No side effects were reported with IC NTP. Conclusions IC NTP at a dose of 100 μg is as effective as IV Adenosine for FFR assessment. Besides, it is better tolerated and should be consider as a vasodilator agent in the assessment of FFR.
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Affiliation(s)
- Pablo Pedroni
- Department of Interventional Cardiology, Hospital El Cruce, Av. Calchaqui 5401, Florencio Varela, CP 1888, Buenos Aires, Argentina.
| | - Ricardo Aquiles Sarmiento
- Department of Interventional Cardiology, Hospital El Cruce, Av. Calchaqui 5401, Florencio Varela, CP 1888, Buenos Aires, Argentina
| | - Raúl Solernó
- Department of Interventional Cardiology, Hospital El Cruce, Av. Calchaqui 5401, Florencio Varela, CP 1888, Buenos Aires, Argentina
| | - Agustín Hauqui
- Department of Interventional Cardiology, Hospital El Cruce, Av. Calchaqui 5401, Florencio Varela, CP 1888, Buenos Aires, Argentina
| | - Martín Oscos
- Department of Interventional Cardiology, Hospital El Cruce, Av. Calchaqui 5401, Florencio Varela, CP 1888, Buenos Aires, Argentina
| | - Fernando Alvarez
- Department of Interventional Cardiology, Hospital El Cruce, Av. Calchaqui 5401, Florencio Varela, CP 1888, Buenos Aires, Argentina
| | - Angeles Videla Lynch
- Department of Interventional Cardiology, Hospital El Cruce, Av. Calchaqui 5401, Florencio Varela, CP 1888, Buenos Aires, Argentina
| | - Federico Giachello
- Department of Interventional Cardiology, Hospital El Cruce, Av. Calchaqui 5401, Florencio Varela, CP 1888, Buenos Aires, Argentina
| | - Juan Scaglia
- Department of Interventional Cardiology, Hospital El Cruce, Av. Calchaqui 5401, Florencio Varela, CP 1888, Buenos Aires, Argentina
| | - Diego Grinfeld
- Department of Interventional Cardiology, Hospital El Cruce, Av. Calchaqui 5401, Florencio Varela, CP 1888, Buenos Aires, Argentina
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Quintella EF, Ferreira E, Azevedo VMP, Araujo DV, Sant'Anna FM, Amorim B, Albuquerque DCD. Clinical Outcomes and Cost-Effectiveness Analysis of FFR Compared with Angiography in Multivessel Disease Patient. Arq Bras Cardiol 2018; 112:40-47. [PMID: 30570071 PMCID: PMC6317625 DOI: 10.5935/abc.20180262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/23/2018] [Indexed: 11/20/2022] Open
Abstract
Background In multivessel disease patients with moderate stenosis, fractional flow
reserve (FFR) allows the analysis of the lesions and guides treatment, and
could contribute to the cost-effectiveness (CE) of non-pharmacological
stents (NPS). Objectives To evaluate CE and clinical impact of FFR-guided versus angiography-guided
angioplasty (ANGIO) in multivessel patients using NPS. Methods Multivessel disease patients were prospectively randomized to FFR or ANGIO
groups during a 5 year-period and followed for < 12 months. Outcomes
measures were major adverse cardiac events (MACE), restenosis and CE. Results We studied 69 patients, 47 (68.1%) men, aged 62.0 ± 9.0 years, 34
(49.2%) in FFR group and 53 (50.7%) in ANGIO group, with stable angina or
acute coronary syndrome. In FFR, there were 26 patients with biarterial
disease (76.5%) and 8 (23.5%) with triarterial disease, and in ANGIO, 24
(68.6%) with biarterial and 11 (31.4%) with triarterial disease. Twelve
MACEs were observed - 3 deaths: 2 (5.8%) in FFR and 1 (2.8%) in ANGIO, 9
(13.0%) angina: 4(11.7%) in FFR and 5(14.2%) in ANGIO, 6 restenosis: 2(5.8%)
in FFR and 4 (11.4%) in ANGIO. Angiography detected 87(53.0%) lesions in
FFR, 39(23.7%) with PCI and 48(29.3%) with medical treatment; and 77 (47.0%)
lesions in ANGIO, all treated with angioplasty. Thirty-nine (33.3%) stents
were registered in FFR (0.45 ± 0.50 stents/lesion) and 78 (1.05
± 0.22 stents/lesion) in ANGIO (p = 0.0001), 51.4% greater in ANGIO
than FFR. CE analysis revealed a cost of BRL 5,045.97 BRL 5,430.60 in ANGIO
and FFR, respectively. The difference of effectiveness was of 1.82%. Conclusion FFR reduced the number of lesions treated and stents, and the need for
target-lesion revascularization, with a CE comparable with that of
angiography.
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Affiliation(s)
- Edgard Freitas Quintella
- Hospital Universitário Pedro Ernesto - Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brazil.,Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ - Brazil
| | - Esmeralci Ferreira
- Hospital Universitário Pedro Ernesto - Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brazil
| | - Vitor Manuel Pereira Azevedo
- Cardiology Department. Hospital Clínico Universitario, INCLIVA. Universitat de València, Valencia - Spain.,Instituto Nacional de Cardiologia Laranjeiras (INCL), Rio de Janeiro, RJ - Brazil
| | - Denizar V Araujo
- Hospital Universitário Pedro Ernesto - Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brazil
| | - Fernando Mendes Sant'Anna
- Hospital Universitário Pedro Ernesto - Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brazil
| | - Bernardo Amorim
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ - Brazil
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13
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Wang BJ, Geng J, Li QJ, Hu TT, Xu B, Ma SR. Clinical effect of selective interventional therapy on sub-acute ST-segment elevation myocardial infarction under the guidance of fractional flow reserve and coronary arteriography. Eur J Med Res 2018; 23:27. [PMID: 29793533 PMCID: PMC5968604 DOI: 10.1186/s40001-018-0319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/23/2018] [Indexed: 11/23/2022] Open
Abstract
Objective This study aims to compare the clinical effects of selective interventional therapy (PCI) under the guidance of fractional flow reserve (FFR) and coronary arteriography. Methods Patients with sub-acute ST-segment elevation myocardial infarction (sub-acute STEMI), who were under selective PCI treatment between April 2012 and June 2014, were included into this study. These patients were divided into two groups, based on FFR measurements: FFR-PCI group and radiography-PCI group. Then, differences in clinical symptoms, coronary angiography, intervention, and endpoint events were compared between these two groups. Results A total of 592 patients with sub-acute STEMI were included in this study (207 patients in the FFR-PCI group and 385 patients in the radiography-PCI group). No statistical differences were observed in baseline clinical data and coronary angiography results between these two groups. Mean stent number was greater in the radiography-PCI group (1.22 ± 0.32) than in the FFR-PCI group (1.10 ± 0.29), and the difference was statistically significant (P = 0.019). During the follow-up period, 78 adverse events occurred (21 adverse events in the FFR-PCI group and 57 adverse events in the radiography-PCI group); and no statistical significance was observed between these two groups (log-rank P = 0.112). Conclusion Selective PCI treatment in patients with sub-acute STEMI under FFR acquired similar effects, compared to PCI treatment under the guidance of radiography, which can reduce the mean stent number.
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Affiliation(s)
- Bing-Jian Wang
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, No. 6 West Beijing Road, Huaiyin District, Huai'an, 223300, China
| | - Jin Geng
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, No. 6 West Beijing Road, Huaiyin District, Huai'an, 223300, China
| | - Qian-Jun Li
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, No. 6 West Beijing Road, Huaiyin District, Huai'an, 223300, China
| | - Ting-Ting Hu
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, No. 6 West Beijing Road, Huaiyin District, Huai'an, 223300, China
| | - Biao Xu
- Department of Cardiology, Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, China
| | - Shu-Ren Ma
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, No. 6 West Beijing Road, Huaiyin District, Huai'an, 223300, China.
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14
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Götberg M, Cook CM, Sen S, Nijjer S, Escaned J, Davies JE. The Evolving Future of Instantaneous Wave-Free Ratio and Fractional Flow Reserve. J Am Coll Cardiol 2017; 70:1379-1402. [PMID: 28882237 DOI: 10.1016/j.jacc.2017.07.770] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/12/2017] [Accepted: 07/25/2017] [Indexed: 01/10/2023]
Abstract
In this review, the authors reflect upon the role of coronary physiology in the modern management of coronary artery disease. They critically appraise the scientific background of the instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR), from early experimental studies to validation studies against indexes of ischemia, to clinical trials assessing outcome. At this important juncture for the field, the authors make predictions for the future of physiological stenosis assessment, outlining developments for both iFR and FFR in new clinical domains beyond the confines of stable angina. With a focus on the evolving future of iFR and FFR, the authors describe how physiological assessment with iFR may advance its application from simply justifying to guiding revascularization.
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Affiliation(s)
- Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden.
| | | | - Sayan Sen
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Sukhjinder Nijjer
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | | | - Justin E Davies
- Hammersmith Hospital, Imperial College London, London, United Kingdom
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15
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Costantini CRF, Ramires JA, Costantini CO, Denk MA, Tarbine SG, Santos MDF, Zanuttini DA, Silveira CW, de Souza AM, de Macedo RM. Comparative Study between Perfusion Changes and Positive Findings on Coronary Flow Reserve. Arq Bras Cardiol 2017; 108:38-46. [PMID: 27982159 PMCID: PMC5245846 DOI: 10.5935/abc.20160184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 08/08/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Functional assessment of coronary artery obstruction is used in cardiology practice to correlate anatomic obstructions with flow decrease. Among such assessments, the study of the coronary fractional flow reserve (FFR) has become the most widely used. OBJECTIVE To evaluate the correlation between FFR and findings of ischemia obtained by noninvasive methods including stress echocardiography and nuclear medicine and the presence of critical coronary artery obstruction. METHODS Retrospective study of cases treated with systematized and standardized procedures for coronary disease between March 2011 and August 2014. We included 96 patients with 107 critical coronary obstructions (> 50% in the coronary trunk and/or ≥ 70% in other segments) estimated by quantitative coronary angiography (QCA) and intracoronary ultrasound (ICUS). All cases presented ischemia in one of the noninvasive studies. RESULTS All 96 patients presented ischemia (100%) in one of the functional tests. On FFR study with adenosine 140 g/kg/min, 52% of the cases had values ≤ 0.80. On correlation analysis for FFR ≤ 0.80, the evaluation of sensitivity, specificity, positive and negative predictive values, accuracy, and ROC curve in relation to the stenosis degree and length, and presence of ischemia, no significant values or strong correlation were observed. CONCLUSION Coronary FFR using a cut-off value of 0.80 showed no correlation with noninvasive ischemia tests in patients with severe coronary artery obstructions on QCA and ICUS.
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Affiliation(s)
| | - Jose Antonio Ramires
- Instituto do Coração (InCor) - Faculdade de Medicina
da Universidade de São Paulo, São Paulo, SP - Brazil
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16
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Finet G, Rioufol G. FFR in daily clinical practice: from “Prêt-à-Porter” to “Haute Couture”. EUROINTERVENTION 2016; 12:e1322-e1324. [DOI: 10.4244/eijv12i11a219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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17
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Ando H, Takashima H, Suzuki A, Sakurai S, Kumagai S, Kurita A, Waseda K, Amano T. Impact of lesion characteristics on the prediction of optimal poststent fractional flow reserve. Am Heart J 2016; 182:119-124. [PMID: 27914491 DOI: 10.1016/j.ahj.2016.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/25/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Poststent fractional flow reserve (FFR) is a useful indicator of optimal percutaneous coronary intervention, and higher poststent FFR is associated with favorable long-term clinical outcome. However, little is known about the factors influencing poststent FFR. The purpose of this study was to determine the impact of lesion characteristics on poststent FFR. METHODS For patients who had scheduled stent implantation for stable angina, FFR measurements at maximum hyperemia were performed before and after coronary stent implantation. As one of lesion characteristics, the FFR pressure drop pattern was evaluated and classified as either an abrupt or a gradual pattern according to the pullback curve of FFR. RESULTS A total of 205 lesions with physiological significant stenosis were evaluated. Fractional flow reserve value increased from 0.67±0.10 to 0.87±0.07 after stent implantation. Optimal poststent FFR was achieved in 75 lesions (36.6%). Logistic regression analysis demonstrated that optimal poststent FFR was positively correlated with an abrupt pressure drop pattern (hazard ratio [HR] 2.11, 95% CI 1.06-4.15, P=.03) and prestent FFR (HR 1.04, 95% CI 1.03-2.04, P=.03; per 0.1 increase), and negatively correlated with lesion localization to the left anterior descending artery (HR 0.18, 95% CI 0.09-0.36, P<.0001). The c statistic for predicting optimal poststent FFR was 0.763 (95% CI 0.702-0.819). CONCLUSION Abrupt pressure drop patterns, prestent FFR, and lesion localization to the left anterior descending artery were independent predictors of optimal poststent FFR.
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18
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Resting multilayer 2D speckle-tracking transthoracic echocardiography for the detection of clinically stable myocardial ischemic segments confirmed by invasive fractional flow reserve. Part 1: Vessel-by-vessel analysis. Int J Cardiol 2016; 218:324-332. [DOI: 10.1016/j.ijcard.2016.05.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/12/2016] [Accepted: 05/12/2016] [Indexed: 11/23/2022]
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19
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Matsuo H, Kawase Y. FFR and iFR guided percutaneous coronary intervention. Cardiovasc Interv Ther 2016; 31:183-95. [DOI: 10.1007/s12928-016-0404-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/14/2016] [Indexed: 01/15/2023]
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20
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Adiputra Y, Chen SL. Clinical Relevance of Coronary Fractional Flow Reserve: Art-of-state. Chin Med J (Engl) 2016; 128:1399-406. [PMID: 25963364 PMCID: PMC4830323 DOI: 10.4103/0366-6999.156805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: The objective was to delineate the current knowledge of fractional flow reserve (FFR) in terms of definition, features, clinical applications, and pitfalls of measurement of FFR. Data Sources: We searched database for primary studies published in English. The database of National Library of Medicine (NLM), MEDLINE, and PubMed up to July 2014 was used to conduct a search using the keyword term “FFR”. Study Selection: The articles about the definition, features, clinical application, and pitfalls of measurement of FFR were identified, retrieved, and reviewed. Results: Coronary pressure-derived FFR rapidly assesses the hemodynamic significance of individual coronary artery lesions and can readily be performed in the catheterization laboratory. The use of FFR has been shown to effectively guide coronary revascularization procedures leading to improved patient outcomes. Conclusions: FFR is a valuable tool to determine the functional significance of coronary stenosis. It combines physiological and anatomical information, and can be followed immediately by percutaneous coronary intervention (PCI) if necessary. The technique of FFR measurement can be performed easily, rapidly, and safely in the catheterization laboratory. By systematic use of FFR in dubious stenosis and multi-vessel disease, PCI can be made an even more effective and better treatment than it is currently. The current clinical evidence for FFR should encourage cardiologists to use this tool in the catheterization laboratory.
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Affiliation(s)
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital of Nanjing Medical University, Nanjing, Jiangsu 210006, China
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21
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Nishi T, Kitahara H, Iwata Y, Fujimoto Y, Nakayama T, Takahara M, Sugimoto K, Kobayashi Y. Efficacy of combined administration of intracoronary papaverine plus intravenous adenosine 5'-triphosphate in assessment of fractional flow reserve. J Cardiol 2016; 68:512-516. [PMID: 26811149 DOI: 10.1016/j.jjcc.2015.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 11/17/2015] [Accepted: 12/16/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Inducing maximal coronary hyperemia is important to measure fractional flow reserve (FFR) accurately. Intravenous adenosine and adenosine 5'-triphosphate (ATP) have been used to achieve maximal hyperemia. However, they may not induce maximal hyperemia in all patients. The present study evaluated the combined effect of intracoronary papaverine and intravenous ATP on FFR measurements. METHODS FFR measurements with administration of intracoronary papaverine (12mg in the left coronary artery and 8mg in the right coronary artery), intravenous ATP (140μg/kg/min), and combined administration of intracoronary papaverine and intravenous ATP were performed in 51 patients with 57 intermediate lesions. RESULTS The mean FFR after intravenous ATP was higher compared to intracoronary papaverine and intravenous ATP plus intracoronary papaverine (0.76±0.13 vs. 0.75±0.13 vs. 0.75±0.13, p=0.01). FFR-positive lesions (FFR ≤0.80) were observed more frequently with intravenous ATP plus intracoronary papaverine compared to intravenous ATP (64.9% vs. 47.4%, p=0.02). Of 32 and 25 FFR-negative lesions with intravenous ATP and intracoronary papaverine, 11 (34%) and 7 (28%) had positive FFR after administration of intravenous ATP plus intracoronary papaverine. No ventricular tachycardia or ventricular fibrillation was observed after administration of intracoronary papaverine. CONCLUSIONS Maximal hyperemia may not be induced with intravenous ATP in all lesions. When sufficient hyperemia is doubtful during intravenous infusion of ATP, additional intracoronary administration of papaverine may be a possible option.
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Affiliation(s)
- Takeshi Nishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yo Iwata
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshihide Fujimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takashi Nakayama
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masayuki Takahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kazumasa Sugimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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22
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Qi X, Fan G, Zhu D, Ma W, Yang C. Comprehensive assessment of coronary fractional flow reserve. Arch Med Sci 2015; 11:483-93. [PMID: 26170840 PMCID: PMC4495145 DOI: 10.5114/aoms.2015.52351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 07/30/2013] [Accepted: 08/01/2013] [Indexed: 02/06/2023] Open
Abstract
Fractional flow reserve (FFR) is considered nowadays as the gold standard for invasive assessment of physiologic stenosis significance and an indispensable tool for decision-making in coronary revascularization. Robust studies have shown that FFR is more effective in accurately identifying which lesions should be stented, and revascularization guided by FFR improves the outcome of coronary artery disease in patients. Therefore, FFR has been upgraded to a class A recommendation in current guidelines when the ischemic potential for specific target lesions is controversial. This article reviews the laboratory practice, functional evaluation of FFR as a gold standard and its emerging clinical application. In addition, novel noninvasive technologies of FFR measurement are discussed in depth.
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Affiliation(s)
- Xiaolong Qi
- Division of Gastroenterology, Institute of Digestive Disease, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guoxin Fan
- Division of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Deqiu Zhu
- Division of Pharmacy, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wanrong Ma
- Division of Gastroenterology, Institute of Digestive Disease, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Changqing Yang
- Division of Gastroenterology, Institute of Digestive Disease, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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Leesar MA, Hakeem A, Azarnoush K, Thuesen L. Coronary bifurcation lesions: Present status and future perspectives. Int J Cardiol 2015; 187:48-57. [PMID: 25828312 DOI: 10.1016/j.ijcard.2015.03.183] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
Abstract
Coronary bifurcation lesions (CBLs) are challenging and associated with a higher rate of adverse events than non-bifurcation lesions. In the era of drug-eluting stents, 2 primary interventional strategies for treating CBL include the complex strategy the main vessel (MV) and side-branch (SB) stenting, and the simple strategy MV stenting combined with provisional SB stenting. The meta-analysis of the simple vs. complex strategies demonstrated an increased incidence of myocardial infarction in the complex strategy. Likewise, the Tryton dedicated bifurcation stents, as compared with the simple strategy, increased the rate of myocardial infarction. In contrast, the Nordic-Baltic Bifurcation Study IV demonstrated that event rates were not significantly different comparing the simple vs. complex strategies in true bifurcation lesions involving a large SB. Fractional flow reserve (FFR) has emerged as a powerful catheter based tool for the functional assessment of a stenosis, but the role of FFR on the long-term outcomes of patients with CBL has not been studied. Given the recent evidence that Tryton stents (a dedicated bifurcation stent) increased event rates, and the lack of benefit from using 2-stent techniques (the Nordic Baltic Bifurcation Study IV) in true CBL, assessing the FFR of the SB seems now of outmost importance, but randomized data are lacking. An intravascular study showed that kissing balloon inflation (KBI) significantly reduced SB stenosis, restored stent lumen at the carina, and expanded stent in the proximal segment. However, a recent randomized study showed no significant benefit of routine KBI. This review highlights current concepts and future perspectives in patients with CBL.
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Affiliation(s)
| | - Abdul Hakeem
- University of Arkansas Health Sciences Center, United States
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Iwasaki K. Myocardial ischemia is a key factor in the management of stable coronary artery disease. World J Cardiol 2014; 6:130-9. [PMID: 24772253 PMCID: PMC3999333 DOI: 10.4330/wjc.v6.i4.130] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/16/2013] [Accepted: 03/03/2014] [Indexed: 02/07/2023] Open
Abstract
Previous studies demonstrated that coronary revascularization, especially percutaneous coronary intervention (PCI), does not significantly decrease the incidence of cardiac death or myocardial infarction in patients with stable coronary artery disease. Many studies using myocardial perfusion imaging (MPI) showed that, for patients with moderate to severe ischemia, revascularization is the preferred therapy for survival benefit, whereas for patients with no to mild ischemia, medical therapy is the main choice, and revascularization is associated with increased mortality. There is some evidence that revascularization in patients with no or mild ischemia is likely to result in worsened ischemia, which is associated with increased mortality. Studies using fractional flow reserve (FFR) demonstrate that ischemia-guided PCI is superior to angiography-guided PCI, and the presence of ischemia is the key to decision-making for PCI. Complementary use of noninvasive MPI and invasive FFR would be important to compensate for each method's limitations. Recent studies of appropriateness criteria showed that, although PCI in the acute setting and coronary bypass surgery are properly performed in most patients, PCI in the non-acute setting is often inappropriate, and stress testing to identify myocardial ischemia is performed in less than half of patients. Also, some studies suggested that revascularization in an inappropriate setting is not associated with improved prognosis. Taken together, the presence and the extent of myocardial ischemia is a key factor in the management of patients with stable coronary artery disease, and coronary revascularization in the absence of myocardial ischemia is associated with worsened prognosis.
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Affiliation(s)
- Kohichiro Iwasaki
- Kohichiro Iwasaki, Department of Cardiology, Okayama Kyokuto Hospital, Okayama 703-8265, Japan
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25
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Jain RK, Chitnis NS, Hygriv Rao B. ST elevation after intracoronary administration of Papaverine for fractional flow reserve estimation. Indian Heart J 2014; 66:289-93. [PMID: 24973833 DOI: 10.1016/j.ihj.2014.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 11/07/2013] [Accepted: 03/23/2014] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Intracoronary (IC) papaverine which is one of the commonly used agents for Fractional Flow Reserve (FFR) estimation has been reported to cause transient ST elevation in some patients. This phenomenon has not been systematically studied. MATERIAL AND METHODS This is a prospective, observational study. Consecutive patients, who underwent FFR at our institute using IC papaverine from May 2012 to April 2013, were included. FFR was done when clinically indicated. The procedure involved administration of 20 mg papaverine (Paparin)--Troikaa, Ahmedabad) as a fast bolus by intracoronary route followed by a 10 cc contrast flush, following which pressure measurements were made. Continuous ECG recording by Philips Hemodynamic Laboratory was obtained for all patients throughout the procedure. Post procedure, they were observed for any delayed effects and eventual outcome was documented. Fischer's mid-p test was used for statistical analysis. RESULT Twenty-five patients (18 males, 7 females, mean age 57.9 ± 20 years) underwent FFR using Papaverine. The mean LVEF was (51 ± 15%). Fourteen patients (56%) developed transient ST elevation ≥0.5 mm in one or more leads which resolved spontaneously in all cases without any sequelae. The presence of a significant lesion either in the coronary artery being evaluated or in a remote coronary artery did not predict the ST elevation. 70.5% of diabetics (p = 0.02), 75% of hypertensives (p = 0.008) and 75% of patients with LVH (p = 0.008) had ST elevation. None of the 5 patients without any one of these comorbidities showed ST elevation. CONCLUSION Transient ST elevation occurs in a significant proportion of cases receiving IC papaverine which is not associated with any adverse clinical outcomes. Micro vascular dysfunction is the most likely mechanism of this phenomenon.
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Affiliation(s)
- R K Jain
- Director, Department of Cardiology, Krishna Institute of Medical Sciences, Hyderabad 500003, India
| | - Nishad S Chitnis
- Consultant, Department of Cardiology, Krishna Institute of Medical Sciences, Hyderabad 500003, India.
| | - B Hygriv Rao
- Senior Consultant Cardiologist and Electrophysiologist, Department of Cardiology, Krishna Institute of Medical Sciences, Hyderabad 500003, India
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Wada T, Hirata K, Shiono Y, Orii M, Shimamura K, Ishibashi K, Tanimoto T, Yamano T, Ino Y, Kitabata H, Yamaguchi T, Kubo T, Imanishi T, Akasaka T. Coronary flow velocity reserve in three major coronary arteries by transthoracic echocardiography for the functional assessment of coronary artery disease: a comparison with fractional flow reserve. Eur Heart J Cardiovasc Imaging 2013; 15:399-408. [DOI: 10.1093/ehjci/jet168] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Schaap J, Kauling RM, Boekholdt SM, Nieman K, Meijboom WB, Post MC, Van der Heyden JA, de Kroon TL, van Es HW, Rensing BJ, Verzijlbergen JF. Incremental diagnostic accuracy of hybrid SPECT/CT coronary angiography in a population with an intermediate to high pre-test likelihood of coronary artery disease. Eur Heart J Cardiovasc Imaging 2013; 14:642-9. [DOI: 10.1093/ehjci/jes303] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Abstract
When selecting coronary stenoses for interventional treatment, assessment of reversible ischaemia is paramount from a symptomatic as well as prognostic point of view. Fractional flow reserve (FFR) is now considered the gold standard for invasive assessment of ischaemia. By measuring FFR in the catheterization laboratory, one can accurately identify which lesions should be stented resulting in improved patient outcome in most elective clinical and angiographic conditions. Recently, in the European Society of Cardiology guidelines on coronary revascularization, FFR was upgraded to an IA classification in multivessel percutaneous coronary intervention. In this review paper, the rationale for routine measurement of FFR will be reviewed and studies supporting its integration into everyday practice will be highlighted.
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Rudzinski W, Waller AH, Rusovici A, Dehnee A, Nasur A, Benz M, Sanchez S, Klapholz M, Kaluski E. Comparison of efficacy and safety of intracoronary sodium nitroprusside and intravenous adenosine for assessing fractional flow reserve. Catheter Cardiovasc Interv 2012; 81:540-4. [PMID: 22961876 DOI: 10.1002/ccd.24652] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 09/01/2012] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The purpose of this study was to compare the efficacy and safety of intracoronary (IC) nitroprusside and intravenous adenosine (IVA) for assessing fractional flow reserve (FFR). BACKGROUND IV infusion of adenosine is a standard method to achieve a coronary hyperemia for FFR measurement. However, adenosine is expensive, causes multiple side effects, and is contraindicated in patients with reactive airway disease. Sodium nitroprusside (NTP) is a strong coronary vasodilator but its efficacy and safety for assessing FFR is not well established. METHODS We compared FFR response and side effects profile of IC NTP and IVA. Bolus of NTP at a dose of 100 μg and IVA (140 μg/kg/min) were used to achieve coronary hyperemia. RESULTS We evaluated 75 lesions in 53 patients (60% male) mean age 61.6 ± 13.9 years. Mean FFR after NTP was similar to FFR after adenosine (0.836 ± 0.107 vs. 0.856 ± 0.106; P = 0.26; r = 0.91, P < 0.001). NTP induced maximal stable hyperemia within 10 sec (mean: 6.4 ± 1) which lasted consistently between 38 and 60 sec (mean 51 ± 7.5). NTP caused significant (14%), but asymptomatic decrease in mean blood pressure which returned to baseline within 60 sec. Adenosine caused shortness of breath in 26%, headache and flushing in 19%, and transient second degree heart block in 6% of patients. No adverse symptoms were reported after NTP. CONCLUSIONS IC NTP is as effective as IVA for measuring FFR. NTP is better tolerated by patients. Since NTP is inexpensive, readily available, well tolerated, and safe, it may be a better choice for FFR assessment.
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Affiliation(s)
- Wojciech Rudzinski
- Department of Medicine, New Jersey Medical School, University Hospital, Newark, NJ, USA.
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Pijls NHJ, Sels JWEM. Functional measurement of coronary stenosis. J Am Coll Cardiol 2012; 59:1045-57. [PMID: 22421298 DOI: 10.1016/j.jacc.2011.09.077] [Citation(s) in RCA: 184] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 08/05/2011] [Accepted: 09/05/2011] [Indexed: 01/17/2023]
Abstract
Fractional flow reserve (FFR) is considered nowadays as the gold standard for invasive assessment of physiologic stenosis significance and an indispensable tool for decision making in coronary revascularization. Use of FFR in the catheterization laboratory accurately identifies which lesions should be stented and improves the outcome in most elective clinical and angiographic conditions. Recently, FFR has been upgraded to a class IA classification in multivessel percutaneous coronary intervention in the guidelines on coronary revascularization of the European Society of Cardiology. In this state-of-the-art paper, the basic concept of FFR and its application, characteristics, and use in several subsets of patients are discussed from a practical point of view.
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Affiliation(s)
- Nico H J Pijls
- Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands.
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Gewirtz H. PET measurement of adenosine stimulated absolute myocardial blood flow for physiological assessment of the coronary circulation. J Nucl Cardiol 2012; 19:347-54. [PMID: 22231036 DOI: 10.1007/s12350-011-9510-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Considerable awareness has been raised of late of the need to reduce radiation exposure and control costs of x-ray and radionuclide imaging procedures. PET/CT cameras are now widely available and in conjunction with appropriate radionuclides and commercially available software make quantitative measurement of absolute MBF feasible for routine clinical practice. Quantitative measurement of absolute MBF under condition of coronary vasodilation permits independent assessment of the functional status of each of the three major coronary perfusion zones and so obviates the need for rest MBF determination in the great majority of cases. Coronary microvascular function also may be assessed in this same way. Thus, the stress-only protocol with quantitative PET measurement of MBF provides essential information required for clinical decision making related to need for catheterization and intervention for patients with known or suspected ischemic heart disease. Moreover, the single PET determination of maximal MBF in contrast to the usual rest/stress procedure addresses both safety and cost concerns. The present review focuses on: (1) quantitative PET measurements of myocardial blood flow for physiological assessment of the coronary circulation and (2) the value and potential limitations of performing stress only imaging in the clinical context.
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Affiliation(s)
- Henry Gewirtz
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Cardiac Unit/Yawkey 5E, Boston, MA 02114, USA.
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Puymirat E, Peace A, Mangiacapra F, Conte M, Ntarladimas Y, Bartunek J, Vanderheyden M, Wijns W, De Bruyne B, Barbato E. Long-term clinical outcome after fractional flow reserve-guided percutaneous coronary revascularization in patients with small-vessel disease. Circ Cardiovasc Interv 2012; 5:62-8. [PMID: 22319067 DOI: 10.1161/circinterventions.111.966937] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Small coronary vessels supply small myocardial territories. The clinical significance of small-vessel stenoses is therefore questionable. Moreover, percutaneous coronary intervention (PCI) of nonfunctionally significant lesions does not improve clinical outcome and might be associated with potential procedural or stent related risks. The aim of this study was to assess the clinical outcome of fractional flow reserve (FFR)-guided PCI in the treatment of small coronary vessel lesions as compared with an angio-guided PCI. METHODS AND RESULTS From January 2004 to December 2008, all patients treated with PCI for stable or unstable angina in small native coronary vessels (reference vessel diameter and stent size <3 mm) were retrospectively analyzed. Patients were divided into angio-guided and an FFR-guided PCI groups. A total of 717 patients were enrolled (495 angio-guided, 222 FFR-guided). End points were death, nonfatal myocardial infarction (MI), combined death or nonfatal MI, target vessel revascularization (TVR), and procedure costs. Major adverse cardiac events (MACE) were defined as death, nonfatal MI, and TVR. Clinical follow-up was obtained in 97.5% (median follow-up: 3.3 [from 0.01-5] years) of the patients. Seventy-eight patients (35%) had a significant FFR (<0.80) and underwent PCI. Using a propensity score adjusted Cox analysis, patients treated with FFR-guided PCI had significantly lower combined death or nonfatal MI (hazard ratio [HR], 0.413; 95% confidence interval [CI], 0.227-0.750; P=0.004), nonfatal MI (HR, 0.063; 95% CI, 0.009-0.462; P=0.007), TVR (HR, 0.517; 95% CI, 0.323-0.826; P=0.006), and MACE (HR, 0.458; 95% CI, 0.310-0.679; P<0.001). No difference was observed in mortality alone (HR, 0.684; 95% CI, 0.355-1.316; P=0.255). Procedure costs were also reduced in the FFR guided strategy (3253±102 Euros versus 4714±37 Euros, P<0.0001). CONCLUSIONS FFR-guided PCI of small coronary arteries is safe and results in better clinical outcomes when compared with an angio-guided PCI.
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Nam CW, Fearon WF. Role of the functional SYNTAX score in evaluating multivessel coronary artery disease. Interv Cardiol 2011. [DOI: 10.2217/ica.11.77] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Pijls NH, Tonino PA. The Crux of Maximum Hyperemia. JACC Cardiovasc Interv 2011; 4:1093-5. [DOI: 10.1016/j.jcin.2011.08.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 08/25/2011] [Indexed: 10/16/2022]
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Kajander SA, Joutsiniemi E, Saraste M, Pietilä M, Ukkonen H, Saraste A, Sipilä HT, Teräs M, Mäki M, Airaksinen J, Hartiala J, Knuuti J. Clinical value of absolute quantification of myocardial perfusion with (15)O-water in coronary artery disease. Circ Cardiovasc Imaging 2011; 4:678-84. [PMID: 21926262 DOI: 10.1161/circimaging.110.960732] [Citation(s) in RCA: 139] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The standard interpretation of perfusion imaging is based on the assessment of relative perfusion distribution. The limitations of that approach have been recognized in patients with multivessel disease and endothelial dysfunction. To date, however, no large clinical studies have investigated the value of measuring quantitative blood flow and compared that with relative uptake. METHODS AND RESULTS One hundred four patients with moderate (30%-70%) pretest likelihood of coronary artery disease (CAD) underwent PET imaging during adenosine stress using (15)O-water and dynamic imaging. Absolute myocardial blood flow was calculated from which both standard relative myocardial perfusion images and images scaled to a known absolute scale were produced. The patients and the regions then were classified as normal or abnormal and compared against the reference of conventional angiography with fractional flow reserve. In patient-based analysis, the positive predictive value, negative predictive value, and accuracy of absolute perfusion in the detection of any obstructive CAD were 86%, 97%, and 92%, respectively, with absolute quantification. The corresponding values with relative analysis were 61%, 83%, and 73%, respectively. In region-based analysis, the receiver operating characteristic curves confirmed that the absolute quantification was superior to relative assessment. In particular, the specificity and positive predictive value were low using just relative differences in flow. Only 9 of 24 patients with 3-vessel disease were correctly assessed using relative analysis. CONCLUSIONS The measurement of myocardial blood flow in absolute terms has a significant impact on the interpretation of myocardial perfusion. As expected, multivessel disease is more accurately detected.
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Nam CW, Mangiacapra F, Entjes R, Chung IS, Sels JW, Tonino PA, De Bruyne B, Pijls NH, Fearon WF. Functional SYNTAX Score for Risk Assessment in Multivessel Coronary Artery Disease. J Am Coll Cardiol 2011; 58:1211-8. [DOI: 10.1016/j.jacc.2011.06.020] [Citation(s) in RCA: 212] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 06/02/2011] [Accepted: 06/14/2011] [Indexed: 11/24/2022]
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Na SH, Koo BK, Kim JC, Yang HM, Park KW, Kang HJ, Kim HS, Oh BH, Park YB. Evaluation of local flow conditions in jailed side branch lesions using computational fluid dynamics. Korean Circ J 2011; 41:91-6. [PMID: 21430994 PMCID: PMC3053566 DOI: 10.4070/kcj.2011.41.2.91] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Accepted: 01/03/2011] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives Lesions of vascular bifurcation and their treatment outcomes have been evaluated by anatomical and physiological methods, such as intravascular ultrasound and fractional flow reserve (FFR). However, local changes in flow dynamics in lesions of bifurcation have not been well evaluated. This study aimed at evaluating changes in the local flow patterns of bifurcation lesions. Materials and Methods Eight (n=8) representative simulation-models were constructed: 1 normal bifurcation, 5 main-branch (MB) stenting models with various side-branch (SB) stenoses (ostial or non-ostial 75% diameter stenosis with 1- or 2-cm lesion lengths, ostial 75% diameter stenosis caused by carina shift), and 2 post-kissing models (no or 50% SB residual stenosis). Pressure, velocity, and wall shear stress (WSS) profiles around the bifurcation sites were investigated using computational fluid dynamics. Results Post-stenting models revealed significant pressure drop in the SB (FFR<0.75), excluding the carina shift model (FFR=0.89). In the post-kissing models, there was no significant pressure drop. All post-stenting models revealed eccentric low velocity flow patterns and areas of low WSS, primarily in the lateral wall on distal MB. Post-kissing angioplasty improved pressure drop in the SB but resulted in alteration of flow distribution in the MB. In the carina shift model, kissing ballooning resulted in deteriorated local flow conditions due to increased area of low velocity and WSS. Conclusion This study suggests that the most commonly used bifurcation intervention strategy may cause local flow disturbances, which may partially explain high restenosis and event rates in patients with bifurcation lesions.
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Affiliation(s)
- Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Morphology of coronary artery lesions assessed by virtual histology intravascular ultrasound tissue characterization and fractional flow reserve. Int J Cardiovasc Imaging 2011; 28:221-8. [PMID: 21336551 DOI: 10.1007/s10554-011-9816-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 01/20/2011] [Indexed: 01/07/2023]
Abstract
Fractional flow reserve (FFR) is an index of the physiological significance of a coronary stenosis. Patients who have lesions with a FFR of >0.80, even optimally treated with medication, have however a MACE rate ranging from 8 to 21%. Coronary plaques at high risk of rupture and clinical events can be also identified by virtual histology intravascular ultrasound (IVUS-VH) as plaques with high amount of necrotic core (NC) abutting the lumen. Aim of this exploratory study was to investigate whether the geometry and composition of lesions with FFR ≤ 0.80 were different from their counterparts. Fifty-five consecutive patients in whom FFR was clinically indicated on a moderate angiographic lesion, received also an imaging investigation on the same lesion with IVUS-VH. Data on plaque geometry and composition was analyzed. Patients were subdivided in two groups according to the value of FFR (> or ≤0.80). Lesions with a FFR ≤ 0.80 (n = 17) showed a slightly larger plaque burden than those with FFR > 0.80 (n = 38) (54.6 ± 0.7% vs. 51.7 ± 0.7% P = 0.1). In addition, they tend to have less content of necrotic core than their counterparts (14.2 ± 8% vs. 19.2 ± 10.2%, P = 0.08). No difference was found in the distribution of NC-rich plaques (fibroatheroma and thin-capped fibroatheroma) between groups (82% in FFR ≤ 0.80 vs. 79% in FFR > 0.80, P = 0.5). Although FFR ≤ 0.80 lesions have larger plaque size, they do not differ in composition from the ones with FFR > 0.80. Further exploration in a large prospective study is needed to study whether the lesions with FFR > 0.80 that are NC rich are the ones associated with the presence of clinical events at follow-up.
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Kajander S, Joutsiniemi E, Saraste M, Pietilä M, Ukkonen H, Saraste A, Sipilä H, Teräs M, Mäki M, Airaksinen J, Hartiala J, Knuuti J. Cardiac Positron Emission Tomography/Computed Tomography Imaging Accurately Detects Anatomically and Functionally Significant Coronary Artery Disease. Circulation 2010; 122:603-13. [DOI: 10.1161/circulationaha.109.915009] [Citation(s) in RCA: 289] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background—
Computed tomography (CT) is increasingly used to detect coronary artery disease, but the evaluation of stenoses is often uncertain. Perfusion imaging has an established role in detecting ischemia and guiding therapy. Hybrid positron emission tomography (PET)/CT allows combination angiography and perfusion imaging in short, quantitative, low-radiation-dose protocols.
Methods and Results—
We enrolled 107 patients with an intermediate (30% to 70%) pretest likelihood of coronary artery disease. All patients underwent PET/CT (quantitative PET with
15
O-water and CT angiography), and the results were compared with the gold standard, invasive angiography, including measurement of fractional flow reserve when appropriate. Although PET and CT angiography alone both demonstrated 97% negative predictive value, CT angiography alone was suboptimal in assessing the severity of stenosis (positive predictive value, 81%). Perfusion imaging alone could not always separate microvascular disease from epicardial stenoses, but hybrid PET/CT significantly improved this accuracy to 98%. The radiation dose of the combined PET and CT protocols was 9.3 mSv (86 patients) with prospective triggering and 21.8 mSv (21 patients) with spiral CT.
Conclusion—
Cardiac hybrid PET/CT imaging allows accurate noninvasive detection of coronary artery disease in a symptomatic population. The method is feasible and can be performed routinely with <10 mSv in most patients.
Clinical Trial Registration—
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00627172.
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Affiliation(s)
- S. Kajander
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
| | - E. Joutsiniemi
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
| | - M. Saraste
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
| | - M. Pietilä
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
| | - H. Ukkonen
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
| | - A. Saraste
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
| | - H.T. Sipilä
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
| | - M. Teräs
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
| | - M. Mäki
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
| | - J. Airaksinen
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
| | - J. Hartiala
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
| | - J. Knuuti
- From the Turku PET Centre (S.K., H.T.S., M.T., J.K.), Department of Medicine (E.J., M.P., H.U., A.S., J.A.), and Department of Clinical Physiology and Nuclear Medicine (M.S., M.M., J.H.), University of Turku, Turku, Finland
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Tonino PAL, Fearon WF, De Bruyne B, Oldroyd KG, Leesar MA, Ver Lee PN, Maccarthy PA, Van't Veer M, Pijls NHJ. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J Am Coll Cardiol 2010; 55:2816-21. [PMID: 20579537 DOI: 10.1016/j.jacc.2009.11.096] [Citation(s) in RCA: 879] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Revised: 11/17/2009] [Accepted: 11/24/2009] [Indexed: 01/06/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the relationship between angiographic and functional severity of coronary artery stenoses in the FAME (Fractional Flow Reserve Versus Angiography in Multivessel Evaluation) study. BACKGROUND It can be difficult to determine on the coronary angiogram which lesions cause ischemia. Revascularization of coronary stenoses that induce ischemia improves a patient's functional status and outcome. For stenoses that do not induce ischemia, however, the benefit of revascularization is less clear. METHODS In the FAME study, routine measurement of the fractional flow reserve (FFR) was compared with angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease. The use of the FFR in addition to angiography significantly reduced the rate of all major adverse cardiac events at 1 year. Of the 1,414 lesions (509 patients) in the FFR-guided arm of the FAME study, 1,329 were successfully assessed by the FFR and are included in this analysis. RESULTS Before FFR measurement, these lesions were categorized into 50% to 70% (47% of all lesions), 71% to 90% (39% of all lesions), and 91% to 99% (15% of all lesions) diameter stenosis by visual assessment. In the category 50% to 70% stenosis, 35% were functionally significant (FFR <or=0.80) and 65% were not (FFR >0.80). In the category 71% to 90% stenosis, 80% were functionally significant and 20% were not. In the category of subtotal stenoses, 96% were functionally significant. Of all 509 patients with angiographically defined multivessel disease, only 235 (46%) had functional multivessel disease (>or=2 coronary arteries with an FFR <or=0.80). CONCLUSIONS Angiography is inaccurate in assessing the functional significance of a coronary stenosis when compared with the FFR, not only in the 50% to 70% category but also in the 70% to 90% angiographic severity category.
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Affiliation(s)
- Pim A L Tonino
- Department of Cardiology, Catharina Hospital, Michelangelolaan 2, Eindhoven 5623 EJ, the Netherlands.
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YE FEI, ZHANG JUNJIE, TIAN NAILIANG, LIN SONG, LIU ZHIZHONG, KAN JING, XU HAIMEI, ZHU ZHONGSHENG, CHEN SHAOLIANG. The Acute Changes of Fractional Flow Reserve in DK (Double Kissing), Crush, and 1-Stent Technique for True Bifurcation Lesions. J Interv Cardiol 2010; 23:341-5. [DOI: 10.1111/j.1540-8183.2010.00568.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Pijls NHJ, Fearon WF, Tonino PAL, Siebert U, Ikeno F, Bornschein B, van't Veer M, Klauss V, Manoharan G, Engstrøm T, Oldroyd KG, Ver Lee PN, MacCarthy PA, De Bruyne B. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study. J Am Coll Cardiol 2010; 56:177-84. [PMID: 20537493 DOI: 10.1016/j.jacc.2010.04.012] [Citation(s) in RCA: 795] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 04/06/2010] [Accepted: 04/14/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate the 2-year outcome of percutaneous coronary intervention (PCI) guided by fractional flow reserve (FFR) in patients with multivessel coronary artery disease (CAD). BACKGROUND In patients with multivessel CAD undergoing PCI, coronary angiography is the standard method for guiding stent placement. The FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study showed that routine FFR in addition to angiography improves outcomes of PCI at 1 year. It is unknown if these favorable results are maintained at 2 years of follow-up. METHODS At 20 U.S. and European medical centers, 1,005 patients with multivessel CAD were randomly assigned to PCI with drug-eluting stents guided by angiography alone or guided by FFR measurements. Before randomization, lesions requiring PCI were identified based on their angiographic appearance. Patients randomized to angiography-guided PCI underwent stenting of all indicated lesions, whereas those randomized to FFR-guided PCI underwent stenting of indicated lesions only if the FFR was <or=0.80. RESULTS The number of indicated lesions was 2.7+/-0.9 in the angiography-guided group and 2.8+/-1.0 in the FFR-guided group (p=0.34). The number of stents used was 2.7+/-1.2 and 1.9+/-1.3, respectively (p<0.001). The 2-year rates of mortality or myocardial infarction were 12.9% in the angiography-guided group and 8.4% in the FFR-guided group (p=0.02). Rates of PCI or coronary artery bypass surgery were 12.7% and 10.6%, respectively (p=0.30). Combined rates of death, nonfatal myocardial infarction, and revascularization were 22.4% and 17.9%, respectively (p=0.08). For lesions deferred on the basis of FFR>0.80, the rate of myocardial infarction was 0.2% and the rate of revascularization was 3.2 % after 2 years. CONCLUSIONS Routine measurement of FFR in patients with multivessel CAD undergoing PCI with drug-eluting stents significantly reduces mortality and myocardial infarction at 2 years when compared with standard angiography-guided PCI. (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation [FAME]; NCT00267774).
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Affiliation(s)
- Nico H J Pijls
- Catharina Hospital, Department of Cardiology, Eindhoven, the Netherlands.
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Iwasaki K, Kusachi S. Coronary pressure measurement based decision making for percutaneous coronary intervention. Curr Cardiol Rev 2009; 5:323-33. [PMID: 21037849 PMCID: PMC2842964 DOI: 10.2174/157340309789317832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 02/12/2009] [Accepted: 02/19/2009] [Indexed: 01/17/2023] Open
Abstract
The fractional flow reserve (FFR) is a simple, reliable, and reproducible physiologic index of lesion severity. In patients with intermediate stenosis, FFR≥0.75 can be used to safely defer percutaneous coronary intervention (PCI), and patients with FFR≥0.75 have a very low cardiac event rate. Coronary pressure measurement can determine which lesion should be treated with PCI in patients with tandem lesions, and PCI on the basis of FFR has been demonstrated to result in an acceptably low repeat PCI rate. FFR can identify patients with equivocal left main coronary artery disease who benefit from coronary bypass surgery. Coronary pressure measurement distinguishes patients with an abrupt pressure drop pattern from those with a gradual pressure drop pattern, and the former group of patients benefit from PCI. Coronary pressure measurement is clinically useful in evaluating sufficient recruitable coronary collateral blood flow for prevention of ischemia, which affects future cardiac events. FFR is useful for the prediction of restenosis after PCI. As an end-point of PCI, FFR ≥0.95 and ≥0.90 would be appropriate for coronary stenting and coronary angioplasty, respectively. In summary, if you encounter a coronary stenosis in doubt you should measure pressure rather than dilate it.
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Affiliation(s)
| | - Shozo Kusachi
- Department of Medical Technology, Okayama University Graduate School of Health Sciences, Japan
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van’t Veer M, Geven MC, Rutten MC, van der Horst A, Aarnoudse WH, Pijls NH, van de Vosse FN. Continuous infusion thermodilution for assessment of coronary flow: Theoretical background and in vitro validation. Med Eng Phys 2009; 31:688-94. [DOI: 10.1016/j.medengphy.2009.01.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Revised: 01/23/2009] [Accepted: 01/25/2009] [Indexed: 10/21/2022]
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Tonino PAL, De Bruyne B, Pijls NHJ, Siebert U, Ikeno F, van' t Veer M, Klauss V, Manoharan G, Engstrøm T, Oldroyd KG, Ver Lee PN, MacCarthy PA, Fearon WF. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009; 360:213-24. [PMID: 19144937 DOI: 10.1056/nejmoa0807611] [Citation(s) in RCA: 2886] [Impact Index Per Article: 192.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with multivessel coronary artery disease who are undergoing percutaneous coronary intervention (PCI), coronary angiography is the standard method for guiding the placement of the stent. It is unclear whether routine measurement of fractional flow reserve (FFR; the ratio of maximal blood flow in a stenotic artery to normal maximal flow), in addition to angiography, improves outcomes. METHODS In 20 medical centers in the United States and Europe, we randomly assigned 1005 patients with multivessel coronary artery disease to undergo PCI with implantation of drug-eluting stents guided by angiography alone or guided by FFR measurements in addition to angiography. Before randomization, lesions requiring PCI were identified on the basis of their angiographic appearance. Patients assigned to angiography-guided PCI underwent stenting of all indicated lesions, whereas those assigned to FFR-guided PCI underwent stenting of indicated lesions only if the FFR was 0.80 or less. The primary end point was the rate of death, nonfatal myocardial infarction, and repeat revascularization at 1 year. RESULTS The mean (+/-SD) number of indicated lesions per patient was 2.7+/-0.9 in the angiography group and 2.8+/-1.0 in the FFR group (P=0.34). The number of stents used per patient was 2.7+/-1.2 and 1.9+/-1.3, respectively (P<0.001). The 1-year event rate was 18.3% (91 patients) in the angiography group and 13.2% (67 patients) in the FFR group (P=0.02). Seventy-eight percent of the patients in the angiography group were free from angina at 1 year, as compared with 81% of patients in the FFR group (P=0.20). CONCLUSIONS Routine measurement of FFR in patients with multivessel coronary artery disease who are undergoing PCI with drug-eluting stents significantly reduces the rate of the composite end point of death, nonfatal myocardial infarction, and repeat revascularization at 1 year. (ClinicalTrials.gov number, NCT00267774.)
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Lindstaedt M. Patient stratification in left main coronary artery disease—Rationale from a contemporary perspective. Int J Cardiol 2008; 130:326-34. [DOI: 10.1016/j.ijcard.2008.05.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2007] [Revised: 04/23/2008] [Accepted: 05/10/2008] [Indexed: 11/16/2022]
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Aqel R, Zoghbi GJ, Hage F, Dell'Italia L, Iskandrian AE. Hemodynamic evaluation of coronary artery bypass graft lesions using fractional flow reserve. Catheter Cardiovasc Interv 2008; 72:479-85. [DOI: 10.1002/ccd.21675] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Affiliation(s)
- Bridget Shoulders-Odom
- Bridget Shoulders-Odom is a cardiology nurse practitioner at Tampa VA Hospital, Tampa, Florida
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Corbett RH. Ethical issues, justification, referral criteria for budget limited and high-dose procedures. RADIATION PROTECTION DOSIMETRY 2008; 130:125-132. [PMID: 18381337 DOI: 10.1093/rpd/ncn089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
This paper reviews some of the issues connected with questions of ethics, health economics, radiation dose and referral criteria arising from a workshop held under the auspices of the Sentinel Research Program FP6-012909. An extensive bibliography of further reading is included.
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Affiliation(s)
- R H Corbett
- Hairmyres Hospital, East Kilbride, Glasgow G75 8RG, Scotland, UK.
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