1
|
Tsai TY, Aldujeli A, Haq A, Knokneris A, Briedis K, Hughes D, Unikas R, Renkens M, Revaiah PC, Tobe A, Miyashita K, Sharif F, Garg S, Onuma Y, Serruys PW. The Impact of Microvascular Resistance Reserve on the Outcome of Patients With STEMI. JACC Cardiovasc Interv 2024; 17:1214-1227. [PMID: 38752970 DOI: 10.1016/j.jcin.2024.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/05/2024] [Accepted: 03/19/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Microvascular resistance reserve (MRR) can characterize coronary microvascular dysfunction (CMD); however, its prognostic impact in ST-segment elevation myocardial infarction (STEMI) patients remains undefined. OBJECTIVES This study sought to investigate the prevalence of CMD in STEMI patients and to elucidate the prognostic performance of MRR. METHODS This prospective cohort study enrolled 210 STEMI patients with multivessel disease who underwent successful revascularization and returned at 3 months for coronary physiology assessments with bolus thermodilution. The prevalence of CMD (MRR <3) and the association between MRR and major adverse cardiovascular and cerebrovascular events (MACCEs) at 12 months were investigated. RESULTS The median age of patients was 65 years, and 59.5% were men. At the 3-month follow-up, 56 patients (27%) had CMD (MRR <3.0). The number of MACCEs at 12 months was higher in patients with vs without CMD (48.2% vs 11.0%; P < 0.001). MRR was independently associated with 12-month MACCEs (HR: 0.45 per unit increase; 95% CI: 0.31-0.67; P < 0.001) and with stroke, heart failure, and poorer recovery in left ventricular systolic function. The areas under the receiver-operating characteristic curves for predicting MACCEs at 12 months with fractional flow reserve, coronary flow reserve (CFR), the index of microvascular resistance (IMR), and MRR were 0.609, 0.762, 0.781, and 0.743, respectively. The prognostic performance of CFR, IMR, and MRR were all comparable. CONCLUSIONS The novel parameter MRR is a prognostic marker of MACCEs in STEMI patients with a comparable performance to CFR and IMR. (Impact of TMAO Serum Levels on Hyperemic IMR in STEMI Patients [TAMIR]; NCT05406297).
Collapse
Affiliation(s)
- Tsung-Ying Tsai
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ali Aldujeli
- Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ayman Haq
- Abbott Northwestern Hospital/Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | | | | | | | - Ramunas Unikas
- Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Mick Renkens
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland
| | - Pruthvi C Revaiah
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland
| | - Akihiro Tobe
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland
| | - Kotaro Miyashita
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland
| | - Faisal Sharif
- Department of Cardiology, University Hospital Galway, University of Galway, Galway, Ireland
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Yoshinobu Onuma
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland; Department of Cardiology, University Hospital Galway, University of Galway, Galway, Ireland
| | - Patrick W Serruys
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland.
| |
Collapse
|
2
|
Aldujeli A, Tsai TY, Haq A, Tatarunas V, Knokneris A, Briedis K, Unikas R, Onuma Y, Brilakis ES, Serruys PW. Impact of Coronary Microvascular Dysfunction on Functional Left Ventricular Remodeling and Diastolic Dysfunction. J Am Heart Assoc 2024; 13:e033596. [PMID: 38686863 PMCID: PMC11179865 DOI: 10.1161/jaha.123.033596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/21/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is a common complication of ST-segment-elevation myocardial infarction (STEMI) and can lead to adverse cardiovascular events. Whether CMD after STEMI is associated with functional left ventricular remodeling (FLVR) and diastolic dysfunction, has not been investigated. METHODS AND RESULTS This is a nonrandomized, observational, prospective study of patients with STEMI with multivessel disease. Coronary flow reserve and index of microcirculatory resistance of the culprit vessel were measured at 3 months post-STEMI. CMD was defined as index of microcirculatory resistance ≥25 or coronary flow reserve <2.0 with a normal fractional flow reserve. We examined the association between CMD, LV diastolic dysfunction, FLVR, and major adverse cardiac events at 12-month follow-up. A total of 210 patients were enrolled; 59.5% were men, with a median age of 65 (interquartile range, 58-76) years. At 3-month follow-up, 57 patients (27.14%) exhibited CMD. After 12 months, when compared with patients without CMD, patients with CMD had poorer LV systolic function recovery (-10.00% versus 8.00%; P<0.001), higher prevalence of grade 2 LV diastolic dysfunction (73.08% versus 1.32%; P<0.001), higher prevalence of group 3 or 4 FLVR (11.32% versus 7.28% and 22.64% versus 1.99%, respectively; P<0.001), and higher incidence of major adverse cardiac events (50.9% versus 9.8%; P<0.001). Index of microcirculatory resistance was independently associated with LV diastolic dysfunction and adverse FLVR. CONCLUSIONS CMD is present in ≈1 of 4 patients with STEMI during follow-up. Patients with CMD have a higher prevalence of LV diastolic dysfunction, adverse FLVR, and major adverse cardiac events at 12 months compared with those without CMD. REGISTRATION URL: https://www.clinicaltrials.gov; Unique Identifier: NCT05406297.
Collapse
Affiliation(s)
- Ali Aldujeli
- Lithuanian University of Health Sciences Kaunas Lithuania
| | - Tsung-Ying Tsai
- CORRIB Research Centre for Advanced Imaging and Core Lab University of Galway Galway Ireland
- Cardiovascular center Taichung Veterans General Hospital Taichung Taiwan
| | - Ayman Haq
- Abbott Northwestern Hospital/Minneapolis Heart Institute Foundation Minneapolis MN
| | | | | | | | - Ramunas Unikas
- Lithuanian University of Health Sciences Kaunas Lithuania
| | - Yoshinobu Onuma
- CORRIB Research Centre for Advanced Imaging and Core Lab University of Galway Galway Ireland
- University Hospital Galway Galway Ireland
| | - Emmanouil S Brilakis
- Abbott Northwestern Hospital/Minneapolis Heart Institute Foundation Minneapolis MN
| | - Patrick W Serruys
- CORRIB Research Centre for Advanced Imaging and Core Lab University of Galway Galway Ireland
| |
Collapse
|
3
|
Boutaleb AM, Ghafari C, Ungureanu C, Carlier S. Fractional flow reserve and non-hyperemic indices: Essential tools for percutaneous coronary interventions. World J Clin Cases 2023; 11:2123-2139. [PMID: 37122527 PMCID: PMC10131021 DOI: 10.12998/wjcc.v11.i10.2123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/22/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Hemodynamical evaluation of a coronary artery lesion is an important diagnostic step to assess its functional impact. Fractional flow reserve (FFR) received a class IA recommendation from the European Society of Cardiology for the assessment of angiographically moderate stenosis. FFR evaluation of coronary artery disease offers improvement of the therapeutic strategy, deferring unnecessary procedures for lesions with a FFR > 0.8, improving patients' management and clinical outcome. Post intervention, an optimal FFR > 0.9 post stenting should be reached and > 0.8 post drug eluting balloons. Non-hyperemic pressure ratio measurements have been validated in previous studies with a common threshold of 0.89. They might overestimate the hemodynamic significance of some lesions but remain useful whenever hyperemic agents are contraindicated. FFR remains the gold standard reference for invasive assessment of ischemia. We illustrate this review with two cases introducing the possibility to estimate also non-invasively FFR from reconstructed 3-D angiograms by quantitative flow ratio. We conclude introducing a hybrid approach to intermediate lesions (DFR 0.85-0.95) potentially maximizing clinical decision from all measurements.
Collapse
Affiliation(s)
- Amine Mamoun Boutaleb
- Department of Cardiology, Ibn Rochd University Hospital, Casablanca 20230, Casablanca, Morocco
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
| | - Chadi Ghafari
- Department of Cardiology, University of Mons, Mons 7000, Belgium
| | - Claudiu Ungureanu
- Department of Cardiology, University of Mons, Mons 7000, Belgium
- Catheterization Unit, Jolimont Hospital, La Louvière 7100, Belgium, Belgium
| | - Stéphane Carlier
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
- Department of Cardiology, University of Mons, Mons 7000, Belgium
| |
Collapse
|
4
|
Novel Method to Detect Pitfalls of Intracoronary Pressure Measurements by Pressure Waveform Analysis. J Pers Med 2022; 12:jpm12122035. [PMID: 36556256 PMCID: PMC9784866 DOI: 10.3390/jpm12122035] [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: 11/07/2022] [Revised: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
Potential pitfalls of fractional flow reserve (FFR) measurements are well-known drawbacks of invasive physiology measurement, e.g., significant drift of the distal pressure trace may lead to the misclassification of stenoses. Thus, a simultaneous waveform analysis of the pressure traces may be of help in the quality control of these measurements by online detection of such artefacts as the drift or the wedging of the catheter. In the current study, we analysed the intracoronary pressure waveform with a dedicated program. In 130 patients, 232 FFR measurements were performed and derivative pressure curves were calculated. Local amplitude around the dicrotic notch was calculated from the distal intracoronary pressure traces (δdPn/dt). A unidimensional arterial network model of blood flow was employed to simulate the intracoronary pressure traces at different flow rates. There was a strong correlation between δdPn/dt values measured during hyperaemia and FFR (r = 0.88). Diagnostic performance of distal δdPn/dt ≤ 3.52 for the prediction of FFR ≤ 0.80 was 91%. The correlation between the pressure gradient and the corresponding δdPn/dt values obtained from all measurements independently of the physiological phase was also significant (r = 0.80). During simulation, the effect of flow rate on δdPn/dt further supported the close correlation between the pressure ratios and δdPn/dt. Discordance between the FFR and the δdPn/dt can be used as an indicator of possible technical problems of FFR measurements. Hence, an online calculation of the δdPn/dt may be helpful in avoiding some pitfalls of FFR evaluation.
Collapse
|
5
|
Keh YS, Pang YZ, Chin CT. Cerebrovascular infarct associated with intracoronary adenosine: a possible rare fractional flow reserve complication. Singapore Med J 2022; 63:699-700. [PMID: 34139803 DOI: 10.11622/smedj.2021085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Yann Shan Keh
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Yu Zhi Pang
- Department of Neurology, Singapore General Hospital, Singapore
| | - Chee Tang Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore
| |
Collapse
|
6
|
Chantadansuwan T, Patumanond J, Charernboon T, Piyayotai D. Factors Predicting 150 and 200 Microgram Adenosine Requirement during Four Increasing Doses of Intracoronary Adenosine Bolus Fractional Flow Reserve Assessment. Diagnostics (Basel) 2022; 12:diagnostics12092076. [PMID: 36140478 PMCID: PMC9498048 DOI: 10.3390/diagnostics12092076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/09/2022] [Accepted: 08/24/2022] [Indexed: 01/09/2023] Open
Abstract
Direct intracoronary adenosine bolus is an excellent alternative to intravenous adenosine fractional flow reserve (FFR) measurement. This study, during four increasing adenosine boluses (50, 100, 150, and 200 mcg), aimed to explore clinical and angiographic predictors of coronary stenotic lesions for which the significant ischemic FFR (FFR ≤ 0.8) occurred at 150 and 200 mcg adenosine doses. Data from 1055 coronary lesions that underwent FFR measurement at the Central Chest Institute of Thailand from August 2011 to July 2021 were included. Baseline clinical and angiographic characteristics were analyzed. The FFR ≤ 0.8 occurred at adenosine 150 and 200 mcg boluses in 47 coronary lesions, while the FFR ≤ 0.8 occurred at adenosine 50 and 100 mcg boluses in 186 coronary lesions. After univariable and multivariable logistic regression analyses, four characteristics, including male sex, younger age, non-smoking status, and FFR procedure of RCA, were predictors of the occurrence of FFR ≤ 0.8 at adenosine 150 and 200 mcg doses. Combining all four predictors as a predictive model resulted in an AuROC of 0.72 (95% CI: 0.68–0.76), an 86% negative predictive value. Comparing these four predictors, the FFR procedure of RCA gave the most predictive power, with the AuROC of 0.60 (95% CI: 0.56–0.63).
Collapse
Affiliation(s)
- Thamarath Chantadansuwan
- Department of Cardiology, Central Chest Institute of Thailand, Nonthaburi 11000, Thailand
- Correspondence:
| | - Jayanton Patumanond
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Thammanard Charernboon
- Department of Clinical Epidemiology, Faculty of Medicine, Thammasat University, Pathum Thani 12121, Thailand
| | - Dilok Piyayotai
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12121, Thailand
| |
Collapse
|
7
|
Li X, Lyu L, Yang W, Pan J, Dong M, Zhang M, Zhang P. Identification of Flow-Limiting Coronary Stenosis With PCS: A New Cost-Effective Index Derived From the Product of Corrected TIMI Frame Count and Percent Diameter Stenosis. Front Cardiovasc Med 2021; 8:718935. [PMID: 34805299 PMCID: PMC8600119 DOI: 10.3389/fcvm.2021.718935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/14/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Identifying functional coronary stenosis with simple and cost-effective methods during invasive coronary angiography is still challenging. Corrected TIMI frame count (CTFC) is considered to be the frame count velocity of coronary blood flow. We aimed to propose a simple and cost-effective index based on CTFC and percent diameter stenosis (DS) to identify flow-limiting coronary stenosis. For this, a new index was put forward as the product of CTFC and DS (PCS). PCS can be regarded as the loss of coronary blood flow due to diameter stenosis. Methods: DS, CTFC, PCS, and Fractional flow reserve (FFR) of 111 vessels in 84 patients with suspected coronary heart disease were measured. FFR ≤0.80 was defined as flow-limiting. Models involving CTFC, DS, and PCS were developed. Logistic regression was performed to evaluate the values on diagnosing flow-limiting stenosis. Results: Vessels with flow-limiting coronary stenosis exhibited higher CTFC values than those without (28.56 vs. 21.64). The performance including the AUC (0.887), sensitivity (87.8%), and Youden index (0.678) for detecting flow-limiting stenosis was improved by adding the CTFC to the DS, while PCS had the largest positive predictive value (PPV) and diagnostic accuracy (DA) being 72.0 and 82.9%, respectively. For vessels with ≥50% lesions, PCS still had the best DA (80.9%), specificity (85.9%), and PPV (72.9%). At the same stenosis severity level, the AUC, Youden index and, DA of PCS were higher than those of CTFC. Conclusions: PCS is simple and accurate to identify flow-limiting coronary stenosis, especially at vessels with moderate to severe stenosis.
Collapse
Affiliation(s)
- Xinhao Li
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Lijuan Lyu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Wei Yang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Jichen Pan
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Mei Dong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Mei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Pengfei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong, China
| |
Collapse
|
8
|
Bouki KP, Vlad DI, Goulas N, Lambadiari VA, Dimitriadis GD, Kotsakis AA, Barοutsi K, Toutouzas KP. Diagnostic Performance of Frequency-Domain Optical Coherence Tomography to Predict Functionally Significant Left Main Coronary Artery Stenosis. J Interv Cardiol 2021; 2021:7108284. [PMID: 34867107 PMCID: PMC8608539 DOI: 10.1155/2021/7108284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/09/2021] [Accepted: 10/22/2021] [Indexed: 11/17/2022] Open
Abstract
AIMS The aim of this study was to assess the safety and diagnostic efficacy of frequency-domain optical coherence tomography (FD-OCT) in identifying functional severity of the left main coronary artery (LM) stenosis determined by fractional flow reserve (FFR). METHODS AND RESULTS 101 patients with LM lesion (20-70% diameter stenosis angiographically) underwent FFR measurement and FD-OCT imaging of the LM. The following parameters were measured by FD-OCT in the LM: reference lumen area (RLA), reference lumen diameter (RLD), minimum lumen area (MLA), minimum lumen diameter (MLD), % lumen area stenosis, and % diameter stenosis. The LM lesions were analyzable by FD-OCT in 88/101 (87.1%) patients. FFR at maximum hyperemia was ≤0.80 in 39/88 (44.3%) patients. FFR values were correlated significantly with FD-OCT-derived LM lumen parameters. An MLA cutoff value of 5.38 mm2 had the highest sensitivity and specificity of 82% and 81%, respectively, followed by an MLD of 2.43 mm (sensitivity 77%, specificity 72%) and AS of 60% (sensitivity 72%, specificity 72%) for predicting FFR <0.80. CONCLUSIONS FD-OCT is a safe and feasible imaging technique for the assessment of LM stenosis. An FD-OCT-derived MLA of ≤5.38 mm2 strongly predicts the functional severity of an LM lesion.
Collapse
Affiliation(s)
| | - Delia I. Vlad
- 2 Department of Cardiology, General Hospital of Nikea-Piraeus, Nikaia, Greece
| | - Nikolaos Goulas
- 2 Department of Cardiology, General Hospital of Nikea-Piraeus, Nikaia, Greece
| | - Vaia A. Lambadiari
- 2 Department of Internal Medicine, University of Athens, Attikon Hospital, Athens, Greece
| | - George D. Dimitriadis
- 2 Department of Internal Medicine, University of Athens, Attikon Hospital, Athens, Greece
| | | | - Kyriaki Barοutsi
- Department of Medical Imaging, General Hospital of Nikea-Piraeus, Nikaia, Greece
| | | |
Collapse
|
9
|
Li C, Yang J, Dong S, Dong L, Chen J, Shen L, Zhang F, Li C, Liu H, Hu X, Hau WK, Qian J, Jeremias A, Wang J, Ge J. Multicenter clinical evaluation of a piezoresistive-MEMS-sensor rapid-exchange pressure microcatheter system for fractional flow reserve measurement. Catheter Cardiovasc Interv 2021; 98:E243-E253. [PMID: 33951285 PMCID: PMC8453920 DOI: 10.1002/ccd.29678] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/02/2021] [Accepted: 03/16/2021] [Indexed: 11/11/2022]
Abstract
Objectives This multicenter, prospective clinical study investigates whether the microelectromechanical‐systems‐(MEMS)‐sensor pressure microcatheter (MEMS‐PMC) is comparable to a conventional pressure wire in fractional flow reserve (FFR) measurement. Background As a conventional tool for FFR measurement, pressure wires (PWs) still have some limitations such as suboptimal handling characteristics and unable to maintain the wire position during pullback assessment. Recently, a MEMS‐PMC compatible with any 0.014″ guidewire is developed. Compared with the existing optical‐sensor PMC, this MEMS‐PMC has smaller profiles at both the lesion crossing and sensor packaging areas. Methods Two hundred and forty‐two patients with visually 30–70% coronary stenosis were enrolled at four centers. FFR was measured first with the MEMS‐PMC, and then with the PW. The primary endpoint was the Bland–Altman mean bias between the MEMS‐PMC and PW FFR. Results From the 224‐patient per‐protocol data, quantitative coronary angiography showed 17.9% and 55.9% vessels had diameter < 2.5 mm and stenosis >50%, respectively. The two systems' mean bias was −0.01 with [−0.08, 0.06] 95% limits‐of‐agreement. Using PW FFR≤0.80 as cutoff, the MEMS‐PMC per‐vessel diagnostic accuracy was 93.4% [95% confidence interval: 89.4–96.3%]. The MEMS‐PMC's success rate was similar to that of PW (97.5 vs. 96.3%, p = .43) with no serious adverse event, and its clinically‐significant (>0.03) drift rate was 43% less (9.5 vs. 16.7%, p = .014). Conclusions Our study showed the MEMS‐PMC is safe to use and has a minimal bias equal to the resolution of current FFR systems. Given the MEMS‐PMC's high measurement accuracy and rapid‐exchange nature, it may become an attractive new tool facilitating routine coronary physiology assessment.
Collapse
Affiliation(s)
- Chenguang Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junqing Yang
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangzhou, Guangdong, China
| | - Shaohong Dong
- Department of Cardiology, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Liang Dong
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangzhou, Guangdong, China
| | - Li Shen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Changling Li
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Huadong Liu
- Department of Cardiology, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - William Kongto Hau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Juying Qian
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Allen Jeremias
- Department of Cardiology, St. Francis Hospital, Roslyn, New York, New York, USA.,Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | | |
Collapse
|
10
|
Haley HA, Ghobrial M, Morris PD, Gosling R, Williams G, Mills MT, Newman T, Rammohan V, Pederzani G, Lawford PV, Hose R, Gunn JP. Virtual (Computed) Fractional Flow Reserve: Future Role in Acute Coronary Syndromes. Front Cardiovasc Med 2021; 8:735008. [PMID: 34746253 PMCID: PMC8569111 DOI: 10.3389/fcvm.2021.735008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/22/2021] [Indexed: 12/17/2022] Open
Abstract
The current management of acute coronary syndromes (ACS) is with an invasive strategy to guide treatment. However, identifying the lesions which are physiologically significant can be challenging. Non-invasive imaging is generally not appropriate or timely in the acute setting, so the decision is generally based upon visual assessment of the angiogram, supplemented in a small minority by invasive pressure wire studies using fractional flow reserve (FFR) or related indices. Whilst pressure wire usage is slowly increasing, it is not feasible in many vessels, patients and situations. Limited evidence for the use of FFR in non-ST elevation (NSTE) ACS suggests a 25% change in management, compared with traditional assessment, with a shift from more to less extensive revascularisation. Virtual (computed) FFR (vFFR), which uses a 3D model of the coronary arteries constructed from the invasive angiogram, and application of the physical laws of fluid flow, has the potential to be used more widely in this situation. It is less invasive, fast and can be integrated into catheter laboratory software. For severe lesions, or mild disease, it is probably not required, but it could improve the management of moderate disease in 'real time' for patients with non-ST elevation acute coronary syndromes (NSTE-ACS), and in bystander disease in ST elevation myocardial infarction. Its practicability and impact in the acute setting need to be tested, but the underpinning science and potential benefits for rapid and streamlined decision-making are enticing.
Collapse
Affiliation(s)
- Hazel Arfah Haley
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in silico Medicine, Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Mina Ghobrial
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in silico Medicine, Sheffield, United Kingdom
| | - Paul D. Morris
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in silico Medicine, Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Rebecca Gosling
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in silico Medicine, Sheffield, United Kingdom
| | - Gareth Williams
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in silico Medicine, Sheffield, United Kingdom
| | - Mark T. Mills
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Tom Newman
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Vignesh Rammohan
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in silico Medicine, Sheffield, United Kingdom
| | - Giulia Pederzani
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in silico Medicine, Sheffield, United Kingdom
| | - Patricia V. Lawford
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in silico Medicine, Sheffield, United Kingdom
| | - Rodney Hose
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in silico Medicine, Sheffield, United Kingdom
| | - Julian P. Gunn
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in silico Medicine, Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
- *Correspondence: Julian P. Gunn
| |
Collapse
|
11
|
Fractional Flow Reserve following Percutaneous Coronary Intervention. J Interv Cardiol 2020; 2020:7467943. [PMID: 32565755 PMCID: PMC7293753 DOI: 10.1155/2020/7467943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 11/18/2022] Open
Abstract
Fractional flow reserve (FFR) is routinely used to determine lesion severity prior to percutaneous coronary intervention (PCI). However, there is an increasing recognition that FFR may also be useful following PCI to identify mechanisms leading to restenosis and the need for repeat revascularization. Post-PCI FFR is associated with the presence and severity of stent under-expansion and may help identify peri-stent-related complications. FFR pullback may also unmask other functionally significant lesions within the target vessel that were not appreciable on angiography. Recent studies have confirmed the prognostic utility of performing routine post-PCI FFR and suggest possible interventional targets that would improve stent durability. In this review, we detail the theoretical basis underlying post-PCI FFR, provide practical tips to facilitate measurement, and discuss the growing evidence supporting its use.
Collapse
|
12
|
Matsumoto H, Mikuri M, Masaki R, Tanaka H, Ogura K, Arai T, Sakai R, Oishi Y, Okada N, Shinke T. Feasibility of intracoronary nicorandil for inducing hyperemia on fractional flow reserve measurement: Comparison with intracoronary papaverine. Int J Cardiol 2020; 314:1-6. [PMID: 32387252 DOI: 10.1016/j.ijcard.2020.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/22/2020] [Accepted: 05/04/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adenosine and adenosine triphosphate (ATP) are widely used to induce hyperemia for fractional flow reserve (FFR) measurements. Caffeine attenuates their hyperemic effects, but not those of nicorandil and papaverine. No studies have systematically compared the hyperemic efficacies of nicorandil, papaverine, and ATP with and without caffeine abstention. METHODS FFRs were measured using nicorandil 2 mg (FFRNC2), nicorandil 4 mg (FFRNC4), and papaverine (FFRPAP) in 40 patients (group 1), and using nicorandil 2 mg, ATP (FFRATP), ATP plus nicorandil (FFRATP+NC2), and papaverine in 20 patients with (group 2) and in 20 patients without caffeine abstention (group 3). RESULTS In group 1, FFRNC2 and FFRNC4 did not differ (p = 0.321) and were higher than FFRPAP (p < 0.001 and p = 0.0026). Likewise, FFRNC2 was higher than FFRPAP in groups 2 (p = 0.049) and 3 (p < 0.010). In the whole group, Bland-Altman analysis showed a modest mean difference (0.015, p < 0.001) and narrow 95% limits of agreement (-0.025 and 0.056). FFRNC2 and FFRPAP strongly correlated (r = 0.975, p < 0.001). Compared with FFRPAP, FFRATP and FFRATP+NC2 did not differ in group 2 (p = 1.0 and p = 0.780), but they were higher (p = 0.002 and p = 0.02) in group 3. Adjunctive nicorandil did not decline FFR further in groups 2 (p = 0.942) and 3 (p = 0.294). CONCLUSIONS Nicorandil 2 mg is a safe and practical alternative for patients who consume caffeine-containing products before the test or have contraindications for adenosine/ATP. Increasing the nicorandil dose to 4 mg or administering adjunctive nicorandil during ATP infusions does not offer any clinical advantages compared with administering nicorandil 2 mg alone.
Collapse
Affiliation(s)
- Hidenari Matsumoto
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan.
| | - Mikiko Mikuri
- Department of Cardiology, Kyojinkai Komatsu Hospital, Neyagawa, Japan
| | - Ryota Masaki
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Hideaki Tanaka
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Kunihiro Ogura
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Taitou Arai
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Rikuo Sakai
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Yosuke Oishi
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Natsumi Okada
- Department of Hospital Pharmaceutics, Showa University School of Pharmacy, Tokyo, Japan
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| |
Collapse
|
13
|
van der Hoeven NW, de Waard GA, Quirós A, De Hoyos A, Broyd CJ, Nijjer SS, van de Hoef TP, Petraco R, Driessen RS, Mejía-Rentería H, Kikuta Y, Echavarría Pinto M, van de Ven PM, Meuwissen M, Knaapen P, Piek JJ, Davies JE, van Royen N, Escaned J. Comprehensive physiological evaluation of epicardial and microvascular coronary domains using vascular conductance and zero flow pressure. EUROINTERVENTION 2019; 14:e1593-e1600. [PMID: 29688179 DOI: 10.4244/eij-d-18-00021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Assessment of the coronary circulation has been based largely on pressure ratios (epicardial) and resistance (micro-vessels). Simultaneous assessment of epicardial (CEPI) and microvascular conductance (CMICRO) provides an intuitive approach using the same units for both coronary domains and expressing the actual deliverability of blood. The aim of this study was to develop a novel integral method for assessing the functional severity of epicardial and microvascular disease. METHODS AND RESULTS We performed intracoronary pressure and Doppler flow velocity measurements in 403 vessels in 261 patients with stable coronary artery disease. Hyperaemic mid-to-late diastolic pressure and flow velocity (PV) relationships were calculated. The slope of the aortic PV indicates the overall conductance and the slope of the distal PV relationship represents CMICRO. The intercept with the x-axis represents zero-flow pressure (Pzf). CEPI was derived from microvascular and overall conductance. Median CEPI was higher compared to CMICRO (4.2 [2.1-8.0] versus 1.3 [1.0-1.7] cm/s/mmHg, p<0.001). CMICRO was independent of stenosis severity (1.3 [1.0-1.7] in FFR ≤0.80 versus 1.4 [1.0-1.8] in FFR >0.8, p=0.797). ROC curves (using FFR and HSR concordant vessels as standard) demonstrated an excellent ability of CEPI to characterise significant stenoses (AUC 0.93). When CEPI<CMICRO, a decrease in flow velocity and coronary pressure (optimal cut-off value 0.97, AUC 0.90) was demonstrated. CONCLUSIONS A comprehensive assessment of separate CEPI and CMICRO was feasible. CEPI has a remarkable diagnostic efficiency to detect a clinically relevant stenosis. When CEPI<CMICRO, distal flow and pressure decrease steeply, indicating myocardial ischaemia. CMICRO can be used to explore the severity of microvascular disease.
Collapse
|
14
|
Fournier S, Harbaoui B, Muller O. Letter by Fournier et al Regarding Article, "Functional Assessment of Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Implantation: Influence of Pressure Overload on the Evaluation of Lesions Severity". Circ Cardiovasc Interv 2019; 10:CIRCINTERVENTIONS.116.004772. [PMID: 28400463 DOI: 10.1161/circinterventions.116.004772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Stephane Fournier
- Cardiology Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Brahim Harbaoui
- Cardiology Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Olivier Muller
- Cardiology Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| |
Collapse
|
15
|
Casadonte L, Piek JJ, VanBavel E, Spaan JAE, Siebes M. Discordance between pressure drift after wire pullback and intracoronary distal pressure offset affects stenosis physiology appraisal. Int J Cardiol 2018; 277:29-34. [PMID: 30173920 DOI: 10.1016/j.ijcard.2018.08.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/07/2018] [Accepted: 08/17/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Drift is a well-known issue affecting intracoronary pressure measurements. A small pressure offset at the end of the procedure is generally considered acceptable, while repeat assessment is advised for drift exceeding ±2 mmHg. This practice implies that drift assessed after wire pullback equals that at the time of stenosis appraisal, but this assumption has not been systematically investigated. Our aim was to compare intra-and post-procedural pressure sensor drift and assess benefits of correction for intra-procedural drift and its effect on diagnostic classification. METHODS In 70 patients we compared intra- and post-procedural pressure drift for 120 hemodynamic tracings obtained at baseline and throughout the hyperemic response to intracoronary adenosine. Intra-procedural drift was derived from the intercept of the stenosis pressure gradient-velocity relationship. Diagnostic reclassification after correction for intra-procedural drift was assessed for the mean distal-to-aortic pressure ratio at baseline (Pd/Pa) and hyperemia (fractional flow reserve, FFR), and corresponding stenosis resistances. RESULTS Post- and intra-procedural drift exceeding the tolerated threshold was observed in 73% and 64% of the hemodynamic tracings, respectively. Discordance in terms of acceptable drift level was present for 42% of the tracings, with avoidable repeat physiological assessment in 25% and unacceptable intra-procedural drift unrecognized at final drift check in 17% of the tracings. Correction for intra-procedural drift caused higher reclassification rates for baseline than hyperemic functional indices. CONCLUSIONS Post-procedural pressure drift frequently does not match drift during physiological assessment. Tracing-specific correction for intra-procedural drift can potentially lower the risk of inadvertent diagnostic misclassification and prevent unnecessary repeats.
Collapse
Affiliation(s)
- Lorena Casadonte
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Ed VanBavel
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jos A E Spaan
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Maria Siebes
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, the Netherlands.
| |
Collapse
|
16
|
Yang HM, Lim HS, Seo KW, Choi BJ, Choi SY, Yoon MH, Hwang GS, Tahk SJ. Intravascular ultrasound characteristics in patients with intermediate coronary lesions and borderline fractional flow reserve measurements. Medicine (Baltimore) 2018; 97:e11901. [PMID: 30142793 PMCID: PMC6112921 DOI: 10.1097/md.0000000000011901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Revascularization of borderline fractional flow reserve (FFR) is controversial and the morphologic characteristics of borderline FFR lesions are not well known. The objective of this study was to determine the intravascular ultrasound (IVUS) characteristics in intermediate coronary lesions with borderline FFR in patients with intermediate coronary artery stenosis (40%-70% diameter stenosis).Both IVUS and FFR were performed in a total of 228 left anterior descending arteries. We divided them into 3 groups by FFR value: ischemic (n = 46, FFR < 0.75), borderline (n = 71, FFR 0.75 to ≤0.80), and non-ischemic (n = 111, FFR > 0.80). We compared the IVUS parameters, including minimum lumen area, lesion length, plaque burden, and volumetric analysis among the 3 groups.In the IVUS analysis, the minimum lumen area was smaller (2.5 ± 0.6 vs. 2.7 ± 0.7 vs. 3.4 ± 1.2 mm, P < .001); lesion length was longer (23.6 ± 8.4 vs. 23.6 ± 7.4 vs. 17.4 ± 6.8 mm, P < .001); plaque burden was larger (76.1 ± 9.6 vs. 73.9 ± 7.5 vs. 69.8 ± 9.5%, P < .001); plaque volume was larger (173.0 ± 78.3 vs. 167.7 ± 75.0 vs. 129.5 ± 79.1 mm, P < .01); and percent atheroma volume was larger (57.9 ± 7.5 vs. 57.6 ± 6.6 vs. 53.9 ± 8.0%, P < .01) in the ischemic and borderline groups compared with the non-ischemic group, respectively. However, post-hoc analyses showed there were no significant differences between the ischemic and borderline group for all IVUS parameters.There were no differences in IVUS characteristics between borderline and functionally significant FFR, but the amount of atheromatous plaque was more severe in these 2 groups than in the non-ischemic group.
Collapse
|
17
|
Pothineni NVK, Edupuganti MM, Almomani A, Payne J, Raina S, Fnu S, Abualsuod A, Wong J, Uretsky BF, Hakeem A. Comparison of the prognostic value of non-ischaemic fractional flow reserve using intracoronary versus intravenous adenosine. EUROINTERVENTION 2018; 13:1680-1687. [DOI: 10.4244/eij-d-16-00375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
18
|
Picard F, Pighi M, Ly HQ. Fractional flow reserve and resting indices for coronary physiologic assessment: Practical guide, tips, and tricks. Catheter Cardiovasc Interv 2017; 90:598-611. [PMID: 28160376 DOI: 10.1002/ccd.26933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 11/19/2016] [Accepted: 12/22/2016] [Indexed: 01/10/2023]
Abstract
Physiologic assessment using fractional flow reserve (FFR) to guide percutaneous coronary interventions (PCI) has been demonstrated to improve clinical outcomes, compared to angiography-guided PCI. Recently, resting indices such as resting Pd/Pa, "instantaneous wave-free ratio", and contrast medium induced FFR have been evaluated for the assessment of the functional consequences of coronary lesions. Herein, we review and discuss the use of FFR and other indices for the functional assessment of coronary lesions. This review will cover theoretical aspects, as well as practical points and common pitfalls related to coronary physiological assessment. © 2017 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Fabien Picard
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Qubec, Canada
| | - Michele Pighi
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Qubec, Canada
| | - Hung Q Ly
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Qubec, Canada
| |
Collapse
|
19
|
Rigattieri S, Biondi Zoccai G, Sciahbasi A, Di Russo C, Cera M, Patrizi R, Fedele S, Berni A, Pugliese FR. Meta-Analysis of Head-to-Head Comparison of Intracoronary Versus Intravenous Adenosine for the Assessment of Fractional Flow Reserve. Am J Cardiol 2017; 120:563-568. [PMID: 28651849 DOI: 10.1016/j.amjcard.2017.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 05/04/2017] [Accepted: 05/04/2017] [Indexed: 02/08/2023]
Abstract
Intravenous (IV) infusion of adenosine represents the gold standard for measuring fractional flow reserve (FFR). However, IV adenosine is more expensive and time-consuming compared with intracoronary (IC) boluses of adenosine. We conducted a meta-analysis of studies comparing IC with IV adenosine for FFR assessment in the same coronary lesions. We searched for studies comparing IC with IV adenosine and reporting absolute FFR values or rate of abnormal FFR for both routes. Prespecified subgroup analysis was performed to appraise studies using low-dose (<100 μg) or high-dose IC adenosine (≥100 μg). We retrieved 11 studies amounting to 587 patients and 621 lesions. Six studies evaluated low-dose IC boluses (15 to 80 μg) and 5 studies high-dose boluses (120 to 600 μg). Absolute FFR values were slightly, yet significantly lower with IV adenosine compared with IC adenosine (mean difference 0.02, 95% confidence interval [CI] 0.00 to 0.03, p = 0.02). This difference, however, did not translate into a significant difference in the rate of abnormal FFR between IC and IV adenosine (hazard ratio 0.93, 95% CI 0.76 to 1.13, p = 0.57); moreover, no statistically significant difference was observed between low-dose and high-dose IC adenosine subgroups. Adverse events were less frequent with IC adenosine compared with IV adenosine (risk ratio 0.17, 95% CI 0.07 to 0.43, p <0.001). In conclusion, IC administration of adenosine, although inducing a slightly lower amount of hyperemia compared with IV infusion of adenosine, yields a similar diagnostic accuracy in identifying hemodynamically significant coronary stenosis and is better tolerated by the patients.
Collapse
|
20
|
Samady H, Kumar A. Fractional Flow Reserve. JACC Cardiovasc Interv 2017; 10:1402-1404. [DOI: 10.1016/j.jcin.2017.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 01/16/2023]
|
21
|
Toth GG, Johnson NP, Jeremias A, Pellicano M, Vranckx P, Fearon WF, Barbato E, Kern MJ, Pijls NHJ, De Bruyne B. Standardization of Fractional Flow Reserve Measurements. J Am Coll Cardiol 2017; 68:742-53. [PMID: 27515335 DOI: 10.1016/j.jacc.2016.05.067] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Abstract
Pressure wire-based fractional flow reserve is considered the standard of reference for evaluation of the ischemic potential of coronary stenoses and the expected benefit from revascularization. Accordingly, its application in daily practice or for research purposes has to be as standardized as possible to avoid technical or operator-related artifacts in pressure recordings. This document proposes a standardized way of acquiring, recording, interpreting, and archiving the pressure tracings for daily practice and for the purpose of clinical research involving a core laboratory. Proposed standardized steps enhance the uniformity of clinical practices and data interpretation.
Collapse
Affiliation(s)
| | - Nils P Johnson
- Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Division of Cardiology, Department of Medicine, University of Texas Medical School and Memorial Hermann Hospital, Houston, Texas
| | - Allen Jeremias
- Stony Brook University and Cardiovascular Research Foundation, New York, New York
| | | | - Pascal Vranckx
- Hartcentrum Hasselt, Division of Cardiology and Critical Care Medicine, Hasselt, Belgium
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California
| | - Emanuele Barbato
- Cardiovascular Center Aalst, Aalst, Belgium; Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Morton J Kern
- Irvine Medical Center, University of California, Irvine, California
| | - Nico H J Pijls
- Irvine Medical Center, University of California, Irvine, California; Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | | |
Collapse
|
22
|
Corcoran D, Hennigan B, Berry C. Fractional flow reserve: a clinical perspective. Int J Cardiovasc Imaging 2017; 33:961-974. [PMID: 28577046 PMCID: PMC5489582 DOI: 10.1007/s10554-017-1159-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 01/02/2017] [Indexed: 01/10/2023]
Abstract
Fractional flow reserve (FFR) is a reference invasive diagnostic test to assess the physiological significance of an epicardial coronary artery stenosis. FFR-guided percutaneous coronary intervention in stable coronary artery disease has been assessed in three seminal clinical trials and the indications for FFR assessment are expanding into other clinical scenarios. In this article we review the theoretical, experimental and clinical basis for FFR measurement. We place FFR measurement in the context of the comprehensive invasive assessment of coronary physiology in patients presenting with known or suspected angina pectoris in daily clinical practice, and review the recent developments in FFR assessment.
Collapse
Affiliation(s)
- David Corcoran
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Barry Hennigan
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK. .,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| |
Collapse
|
23
|
Casadonte L, Marques KM, Spaan JAE, Siebes M. Temporal dissociation between the minimal distal-to-aortic pressure ratio and peak hyperemia during intravenous adenosine infusion. Am J Physiol Heart Circ Physiol 2017; 312:H992-H1001. [DOI: 10.1152/ajpheart.00632.2016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 01/30/2017] [Accepted: 02/11/2017] [Indexed: 01/09/2023]
Abstract
The present study sought to compare the temporal relation between maximal coronary flow (peak hyperemia) and minimal coronary-to-aortic pressure ratio (Pd/Pa) for intracoronary (IC) and intravenous (IV) adenosine administration. Peak hyperemia is assumed to coincide with the minimal Pd/Pa value. However, this has not been confirmed for systemic hemodynamic variations during IV adenosine infusion. Hemodynamic responses to IV and IC adenosine administration were obtained in 12 patients (14 lesions) using combined IC pressure and flow velocity measurements. A fluid dynamic model was used to predict the change in Pd/Pa for different stenosis severities and varying Pa. Hemodynamic variability during IV adenosine hyperemia was greater than during IC adenosine, as assessed by the coefficient of variation. During IV adenosine, flow velocity peaked 28 ± 4 (SE) s after the onset of hyperemia, while Pd/Pa reached a minimum (0.82 ± 0.01) 22 ± 7 s later ( P < 0.05), when Pa had declined by 6.1% and hyperemic velocity by 4.5% ( P < 0.01). Model outcomes corroborated the role of variable Pa in this dissociation. In contrast, maximal flow and minimal Pd/Pa coincided for IC adenosine, with IV-equivalent peak velocities and a higher Pd/Pa ratio (0.86 ± 0.01, P < 0.01). Hemodynamic variability during continuous IV adenosine infusion can lead to temporal dissociation of minimal Pd/Pa and peak hyperemia, in contrast to IC adenosine injection, where maximal velocity and minimal Pd/Pa coincide. Despite this variability, stenosis hemodynamics remained stable with both ways of adenosine administration. Our findings suggest advantages of IC over IV adenosine to identify maximal hyperemia from pressure-only measurements. NEW & NOTEWORTHY Systemic hemodynamic variability during intravenous adenosine infusion produces substantial temporal dissociation between peak hyperemia appraised by coronary flow velocity and the minimal distal-to-aortic pressure ratio commonly used to determine functional stenosis severity. This dissociation was absent for intracoronary adenosine administration and tended to be mitigated in patients receiving Ca2+ antagonists.
Collapse
Affiliation(s)
- Lorena Casadonte
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and
| | - Koen M. Marques
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Jos A. E. Spaan
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and
| | - Maria Siebes
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and
| |
Collapse
|
24
|
Lim J, Tekes C, Degertekin FL, Ghovanloo M. Towards a Reduced-Wire Interface for CMUT-Based Intravascular Ultrasound Imaging Systems. IEEE TRANSACTIONS ON BIOMEDICAL CIRCUITS AND SYSTEMS 2017; 11:400-410. [PMID: 27662686 PMCID: PMC5359084 DOI: 10.1109/tbcas.2016.2592525] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Having intravascular ultrasound (IVUS) imaging capability on guide wires used in cardiovascular interventions may eliminate the need for separate IVUS catheters and expand the use of IVUS in a larger portion of the vasculature. High frequency capacitive micro machined ultrasonic transducer (CMUT) arrays should be integrated with interface electronics and placed on the guide wire for this purpose. Besides small size, this system-on-a-chip (SoC) front-end should connect to the back-end imaging system with a minimum number of wires to preserve the critical mechanical properties of the guide wire. We present a 40 MHz CMUT array interface SoC, which will eventually use only two wires for power delivery and transmits image data using a combination of analog-to-time conversion (ATC) and an impulse radio ultra-wideband (IR-UWB) wireless link. The proof-of-concept prototype ASIC consumes only 52.8 mW and occupies 4.07 [Formula: see text] in a 0.35- [Formula: see text] standard CMOS process. A rectifier and regulator power the rest of the SoC at 3.3 V from a 10 MHz power carrier that is supplied through a 2.4 m micro-coax cable with an overall efficiency of 49.1%. Echo signals from an 8-element CMUT array are amplified by a transimpedance amplifier (TIA) array and down-converted to baseband by quadrature sampling using a 40 MHz clock, derived from the power carrier. The ATC generates pulse-width-modulated (PWM) samples at 2 × 10 MS/s with 6 bit resolution, while the entire system achieved 5.1 ENOB. Preliminary images from the prototype system are presented, and alternative data transmission and possible future directions towards practical implementation are discussed.
Collapse
|
25
|
Hofmann N, Hardt S, Erbacher M, Dickhaus H, Katus H, Korosoglou G. Quantitative myocardial blush grade reserve during pharmacologic hyperaemia: a way to perform a real wireless fractional flow reserve measurement in patients with coronary artery disease and intermediate coronary lesions. EUROINTERVENTION 2017; 12:e2219-e2227. [DOI: 10.4244/eij-d-16-00460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
26
|
Echavarria-Pinto M, Petraco R, van de Hoef TP, Gonzalo N, Nijjer S, Tarkin JM, Ibanez B, Sen S, Jimenez-Quevedo P, Nunez-Gil IJ, Nombela-Franco L, Alfonso F, Fernandez-Ortiz A, Macaya C, Piek JJ, Davies J, Escaned J. Fractional flow reserve and minimum Pd/Pa ratio during intravenous adenosine infusion: very similar but not always the same. EUROINTERVENTION 2017; 11:1013-9. [PMID: 25366652 DOI: 10.4244/eijy14m10_09] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Maximum and stable hyperaemia are critical prerequisites for the accurate measurement of fractional flow reserve (FFR). However, in some patients in whom hyperaemia is induced through a central vein (IV) the minimum distal coronary pressure to aortic pressure ratio (Pd/Pa ratio) develops before the stabilisation of hyperaemia. We sought to describe the prevalence, magnitude and clinical implications of this phenomenon. METHODS AND RESULTS The FFR tracing archive of a single institution was reviewed and a total of 104 high-quality IV-FFR recordings from 90 patients were identified. Whenever the minimum Pd/Pa ratio was found before the onset of stable hyperaemia, a search for the lowest Pd/Pa ratio within the steady-state hyperaemic plateau was performed and labelled as FFRstable. Whilst in most cases the minimum Pd/Pa ratio developed during stable hyperaemia, in 19 cases (prevalence of 18.3% [95% CI: 12.0% to 26.8%]) this value was found before the stabilisation of the hyperaemic state. In such cases, the minimum Pd/Pa ratio stabilised later at a higher level (0.77±0.09 vs. 0.81±0.08, p<0.001) (mean difference, 0.03±0.02, range, 0.01 to 0.10). In terms of dichotomous classification of stenosis severity and if FFRstable had been used to decide on revascularisation, reclassification would have occurred in three (2.9%) cases, all presenting a minimum Pd/Pa ratio ≤0.80 with FFRstable >0.80. CONCLUSIONS During IV adenosine infusion, the minimum Pd/Pa ratio occurs before the stabilisation of hyperaemia in a significant proportion of cases. While the overall difference between the minimum Pd/Pa ratio and its FFRstable counterpart is small, reclassification of stenosis severity might occur, if choosing between the minimum and stable values of FFR within the same trace.
Collapse
Affiliation(s)
- Mauro Echavarria-Pinto
- Hospital Clinico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Cook CM, Ahmad Y, Shun-Shin MJ, Nijjer S, Petraco R, Al-Lamee R, Mayet J, Francis DP, Sen S, Davies JE. Quantification of the Effect of Pressure Wire Drift on the Diagnostic Performance of Fractional Flow Reserve, Instantaneous Wave-Free Ratio, and Whole-Cycle Pd/Pa. Circ Cardiovasc Interv 2016; 9:e002988. [PMID: 27076571 PMCID: PMC4836560 DOI: 10.1161/circinterventions.115.002988] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 02/22/2016] [Indexed: 01/10/2023]
Abstract
Background— Small drifts in intracoronary pressure measurements (±2 mm Hg) can affect stenosis categorization using pressure indices. This has not previously been assessed for fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), and whole-cycle distal pressure/proximal pressure (Pd/Pa) indices. Methods and Results—Four hundred forty-seven stenoses were assessed with FFR, iFR, and whole-cycle Pd/Pa. Cut point values for significance were predefined as ≤0.8, <0.90, and <0.93, respectively. Pressure wire drift was simulated by offsetting the distal coronary pressure trace by ±2 mm Hg. FFR, iFR, and whole-cycle Pd/Pa indices were recalculated and stenosis misclassification quantified. Median (±median absolute deviation) values for FFR, iFR, and whole-cycle Pd/Pa were 0.81 (±0.11), 0.90 (±0.07), and 0.93 (±0.06), respectively. For the cut point of FFR, iFR, and whole-cycle Pd/Pa, 34.6% (155), 50.1% (224), and 62.2% (278) of values, respectively, lay within ±0.05 U. With ±2 mm Hg pressure wire drift, 21% (94), 25% (110), and 33% (148) of the study population were misclassified with FFR, iFR, and whole-cycle Pd/Pa, respectively. Both FFR and iFR had significantly lower misclassification than whole-cycle Pd/Pa (P<0.001). There was no statistically significant difference between the diagnostic performance of FFR and iFR (P=0.125). Conclusions— In a substantial proportion of cases, small amounts of pressure wire drift are enough to cause stenoses to change classification. Whole-cycle Pd/Pa is more vulnerable to such reclassification than FFR and iFR.
Collapse
Affiliation(s)
- Christopher M Cook
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom.
| | - Yousif Ahmad
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Matthew J Shun-Shin
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Sukhjinder Nijjer
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Ricardo Petraco
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Rasha Al-Lamee
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Jamil Mayet
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Darrel P Francis
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Sayan Sen
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| | - Justin E Davies
- From the International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College NHS Trust, United Kingdom
| |
Collapse
|
28
|
Chiţu M, Rat N, Opincariu D, Stănescu A, Mester A, Benedek T, Benedek I. Invasive FFR — Current Applications and New Developments. JOURNAL OF INTERDISCIPLINARY MEDICINE 2016. [DOI: 10.1515/jim-2016-0073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Abstract
Myocardial ischemia caused by coronary atherosclerosis is the main cause of cardiovascular mortality, which is the first cause of death in developed countries. Inducible myocardial ischemia is a negative prognostic factor for coronary artery disease patients, and it represents a major risk stratification marker for predicting mortality. The evolution of these patients depends largely on the extension of the ischemic myocardial mass and the severity of the inducible ischemia. Most patients do not show angiographically significant coronary stenosis. Therefore, such patients do not undergo coronary revascularization therapies, even though they present functional stenoses that trigger myocardial ischemia under stress conditions, which subsequently lead to a high risk for major adverse cardiovascular events. We performed a review that aims to pinpoint invasive techniques used for evaluating the functional impact of a coronary lesion that is considered non-significant upon angiographic examination, but which triggers episodes of myocardial ischemia under stress conditions, and to describe the functional markers that show the highest specificity for predicting ischemic risk, in order to recommend invasive coronary revascularization.
Collapse
Affiliation(s)
- Monica Chiţu
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center, Tîrgu Mureș, Romania
| | - Nora Rat
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center, Tîrgu Mureș, Romania
| | | | | | - András Mester
- University of Medicine and Pharmacy, Tîrgu Mureș, Romania
| | - Theodora Benedek
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center, Tîrgu Mureș, Romania
- University of Medicine and Pharmacy, Tîrgu Mureș, Romania
| | - Imre Benedek
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center, Tîrgu Mureș, Romania
- University of Medicine and Pharmacy, Tîrgu Mureș, Romania
| |
Collapse
|
29
|
Alexopoulos D, Xanthopoulou I, Tsigkas G, Koutsogiannis N, Salata P, Armylagos S, Moulias A, Davlouros P. Effect of High (200 μg/kg per Minute) Adenosine Dose Infusion on Fractional Flow Reserve Variability. J Am Heart Assoc 2016; 5:e004323. [PMID: 27930357 PMCID: PMC5210360 DOI: 10.1161/jaha.116.004323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/07/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Variations in distal coronary pressure (Pd)/aortic pressure (Pa) ratio during steady-state hyperemia with standard (140 μg/kg per minute) adenosine dose may hamper accurate fractional flow reserve assessment. This study investigated to what extent an increased adenosine dose can overcome Pd/Pa variation. METHODS AND RESULTS In a prospective, single-arm study, out of 95 prospectively screened patients, 38 (40.0%) exhibited significant (≥0.05 difference of max Pd/Pa minus min Pd/Pa) variations in Pd/Pa from 15 s post Pd/Pa dip and until the end of a 3-minute adenosine (140 μg/kg per minute) infusion. Thirty patients agreed to participate in a post 5-minute repeat fractional flow reserve assessment using 200 μg/kg per minute 3-minute adenosine infusion. The study's co-primary end point of Pd/Pa coefficient of dispersion was lower for the high versus standard adenosine dose: 1.31 (1.13-2.72) versus 2.76 (2.38-5.60), P=0.002. The study's co-primary end point of ΔPd/Pa was also lower for the high versus standard adenosine dose: 0.065 (0.038-0.10) versus 0.08 (0.06-0.11), P=0.002. This difference was mainly driven by the lowering effect of the high adenosine dose on the maximum Pd/Pa compared to the standard dose: 0.84 (0.81-0.93) versus 0.90 (0.83-0.95), P=0.007, while minimum Pd/Pa remained unaffected. High adenosine dose was adequately tolerated by all patients, without requiring infusion discontinuation in any case. CONCLUSIONS Pd/Pa variability is frequently observed during standard adenosine infusion and is significantly decreased following a high (200 μg/kg per minute) adenosine dose. This is achieved without a significant difference in the minimum Pd/Pa. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02350439.
Collapse
Affiliation(s)
| | | | - Grigorios Tsigkas
- Department of Cardiology, Patras University Hospital, Rion Patras, Greece
| | | | - Paraskevi Salata
- Department of Cardiology, Patras University Hospital, Rion Patras, Greece
| | | | - Athanasios Moulias
- Department of Cardiology, Patras University Hospital, Rion Patras, Greece
| | - Periklis Davlouros
- Department of Cardiology, Patras University Hospital, Rion Patras, Greece
| |
Collapse
|
30
|
Miao Z, Liebeskind DS, Lo W, Liu L, Pu Y, Leng X, Song L, Xu X, Jia B, Gao F, Mo D, Sun X, Liu L, Ma N, Wang B, Wang Y, Wang Y. Fractional Flow Assessment for the Evaluation of Intracranial Atherosclerosis: A Feasibility Study. INTERVENTIONAL NEUROLOGY 2016; 5:65-75. [PMID: 27610123 DOI: 10.1159/000444333] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Current studies on endovascular intervention for intracranial atherosclerosis select patients based on luminal stenosis. Coronary studies demonstrated that fractional flow measurements assess ischemia better than anatomical stenosis and can guide patient selection for intervention. We similarly postulated that fractional flow can be used to assess ischemic stroke risk. METHODS This was a feasibility study to assess the technical use and safety of applying a pressure guidewire to measure fractional flow across intracranial stenoses. Twenty patients with severe intracranial stenosis were recruited. The percentage of luminal stenosis, distal to proximal pressure ratios (fractional flow) and the fractional flow gradients across the stenosis were measured. Procedural success rate and safety outcomes were documented. RESULTS All 20 patients had successful crossing of stenosis by the pressure guidewire. Ten patients underwent angioplasty, and 5 had stenting performed. There was one perforator stroke, but not related to the use of the pressure wire. For the 13 patients with complete pre- and postintervention data, the mean preintervention stenosis, fractional flow and translesional pressure gradient were 76.2%, 0.66 and 29.9 mm Hg, whilst the corresponding postintervention measurements were 24.7%, 0.88 and 10.9 mm Hg, respectively. Fractional flow (r = -0.530, p = 0.001) and the translesional pressure gradient (r = 0.501, p = 0.002) only had a modest correlation with the luminal stenosis. CONCLUSION Fractional flow measurement by floating a pressure guidewire across the intracranial stenosis was technically feasible and safe in this study. Further studies are needed to validate its use for ischemic stroke risk assessment.
Collapse
Affiliation(s)
- ZhongRong Miao
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - WaiTing Lo
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong, SAR, China
| | - LiPing Liu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - YueHua Pu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - XinYi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - LiGang Song
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - XiaoTong Xu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - BaiXue Jia
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Feng Gao
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - DaPeng Mo
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuan Sun
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lian Liu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ning Ma
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Bo Wang
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - YiLong Wang
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - YongJun Wang
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| |
Collapse
|
31
|
Affiliation(s)
- Martijn A van Lavieren
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan J Piek
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| |
Collapse
|
32
|
Biomarkers of coronary endothelial health: correlation with invasive measures of collateral function, flow and resistance in chronically occluded coronary arteries and the effect of recanalization. Coron Artery Dis 2016; 27:287-94. [PMID: 26905422 DOI: 10.1097/mca.0000000000000360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In the presence of a chronically occluded coronary artery, the collateral circulation matures by a process of arteriogenesis; however, there is considerable variation between individuals in the functional capacity of that collateral network. This could be explained by differences in endothelial health and function. We aimed to examine the relationship between the functional extent of collateralization and levels of biomarkers that have been shown to relate to endothelial health. METHODS We measured four potential biomarkers of endothelial health in 34 patients with mature collateral networks who underwent a successful percutaneous coronary intervention (PCI) for a chronic total coronary occlusion (CTO) before PCI and 6-8 weeks after PCI, and examined the relationship of biomarker levels with physiological measures of collateralization. RESULTS We did not find a significant change in the systemic levels of sICAM-1, sE-selectin, microparticles or tissue factor 6-8 weeks after PCI. We did find an association between estimated retrograde collateral flow before CTO recanalization and lower levels of sICAM-1 (r=0.39, P=0.026), sE-selectin (r=0.48, P=0.005) and microparticles (r=0.38, P=0.03). CONCLUSION Recanalization of a CTO and resultant regression of a mature collateral circulation do not alter systemic levels of sICAM-1, sE-selectin, microparticles or tissue factor. The identified relationship of retrograde collateral flow with sICAM-1, sE-selectin and microparticles is likely to represent an association with an ability to develop collaterals rather than their presence and extent.
Collapse
|
33
|
Ladwiniec A, Cunnington MS, Rossington J, Mather AN, Alahmar A, Oliver RM, Nijjer SS, Davies JE, Thackray S, Alamgir F, Hoye A. Collateral donor artery physiology and the influence of a chronic total occlusion on fractional flow reserve. Circ Cardiovasc Interv 2016; 8:CIRCINTERVENTIONS.114.002219. [PMID: 25805570 DOI: 10.1161/circinterventions.114.002219] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The presence of a concomitant chronic total coronary occlusion (CTO) and a large collateral contribution might alter the fractional flow reserve (FFR) of an interrogated vessel, rendering the FFR unreliable at predicting ischemia should the CTO vessel be revascularized and potentially affecting the decision on optimal revascularization strategy. We tested the hypothesis that donor vessel FFR would significantly change after percutaneous coronary intervention of a concomitant CTO. METHODS AND RESULTS In consecutive patients undergoing percutaneous coronary intervention of a CTO, coronary pressure and flow velocity were measured at baseline and hyperemia in proximal and distal segments of both nontarget vessels, before and after percutaneous coronary intervention. Hemodynamics including FFR, absolute coronary flow, and the coronary flow velocity-pressure gradient relation were calculated. After successful percutaneous coronary intervention in 34 of 46 patients, FFR in the predominant donor vessel increased from 0.782 to 0.810 (difference, 0.028 [0.012 to 0.044]; P=0.001). Mean decrease in baseline donor vessel absolute flow adjusted for rate pressure product: 177.5 to 139.9 mL/min (difference -37.6 [-62.6 to -12.6]; P=0.005), mean decrease in hyperemic flow: 306.5 to 272.9 mL/min (difference, -33.5 [-58.7 to -8.3]; P=0.011). Change in predominant donor vessel FFR correlated with angiographic (%) diameter stenosis severity (r=0.44; P=0.009) and was strongly related to stenosis severity measured by the coronary flow velocity-pressure gradient relation (r=0.69; P<0.001). CONCLUSIONS Recanalization of a CTO results in a modest increase in the FFR of the predominant collateral donor vessel associated with a reduction in coronary flow. A larger increase in FFR is associated with greater coronary stenosis severity.
Collapse
Affiliation(s)
- Andrew Ladwiniec
- From the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom (A.L., M.S.C., J.R., A.N.M., A.A., R.M.O., S.T., F.A., A.H.); Department of Academic Cardiology, Hull York Medical School, Kingston-upon-Hull, United Kingdom (A.L., A.H.); and Imperial College London, London, United Kingdom (S.S.N., J.E.D.).
| | - Michael S Cunnington
- From the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom (A.L., M.S.C., J.R., A.N.M., A.A., R.M.O., S.T., F.A., A.H.); Department of Academic Cardiology, Hull York Medical School, Kingston-upon-Hull, United Kingdom (A.L., A.H.); and Imperial College London, London, United Kingdom (S.S.N., J.E.D.)
| | - Jennifer Rossington
- From the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom (A.L., M.S.C., J.R., A.N.M., A.A., R.M.O., S.T., F.A., A.H.); Department of Academic Cardiology, Hull York Medical School, Kingston-upon-Hull, United Kingdom (A.L., A.H.); and Imperial College London, London, United Kingdom (S.S.N., J.E.D.)
| | - Adam N Mather
- From the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom (A.L., M.S.C., J.R., A.N.M., A.A., R.M.O., S.T., F.A., A.H.); Department of Academic Cardiology, Hull York Medical School, Kingston-upon-Hull, United Kingdom (A.L., A.H.); and Imperial College London, London, United Kingdom (S.S.N., J.E.D.)
| | - Albert Alahmar
- From the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom (A.L., M.S.C., J.R., A.N.M., A.A., R.M.O., S.T., F.A., A.H.); Department of Academic Cardiology, Hull York Medical School, Kingston-upon-Hull, United Kingdom (A.L., A.H.); and Imperial College London, London, United Kingdom (S.S.N., J.E.D.)
| | - Richard M Oliver
- From the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom (A.L., M.S.C., J.R., A.N.M., A.A., R.M.O., S.T., F.A., A.H.); Department of Academic Cardiology, Hull York Medical School, Kingston-upon-Hull, United Kingdom (A.L., A.H.); and Imperial College London, London, United Kingdom (S.S.N., J.E.D.)
| | - Sukhjinder S Nijjer
- From the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom (A.L., M.S.C., J.R., A.N.M., A.A., R.M.O., S.T., F.A., A.H.); Department of Academic Cardiology, Hull York Medical School, Kingston-upon-Hull, United Kingdom (A.L., A.H.); and Imperial College London, London, United Kingdom (S.S.N., J.E.D.)
| | - Justin E Davies
- From the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom (A.L., M.S.C., J.R., A.N.M., A.A., R.M.O., S.T., F.A., A.H.); Department of Academic Cardiology, Hull York Medical School, Kingston-upon-Hull, United Kingdom (A.L., A.H.); and Imperial College London, London, United Kingdom (S.S.N., J.E.D.)
| | - Simon Thackray
- From the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom (A.L., M.S.C., J.R., A.N.M., A.A., R.M.O., S.T., F.A., A.H.); Department of Academic Cardiology, Hull York Medical School, Kingston-upon-Hull, United Kingdom (A.L., A.H.); and Imperial College London, London, United Kingdom (S.S.N., J.E.D.)
| | - Farquad Alamgir
- From the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom (A.L., M.S.C., J.R., A.N.M., A.A., R.M.O., S.T., F.A., A.H.); Department of Academic Cardiology, Hull York Medical School, Kingston-upon-Hull, United Kingdom (A.L., A.H.); and Imperial College London, London, United Kingdom (S.S.N., J.E.D.)
| | - Angela Hoye
- From the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom (A.L., M.S.C., J.R., A.N.M., A.A., R.M.O., S.T., F.A., A.H.); Department of Academic Cardiology, Hull York Medical School, Kingston-upon-Hull, United Kingdom (A.L., A.H.); and Imperial College London, London, United Kingdom (S.S.N., J.E.D.)
| |
Collapse
|
34
|
Wakasa N, Kuramochi T, Mihashi N, Terada N, Kanaji Y, Murai T, Lee T, Yonetsu T, Kobashi K, Miyamoto K, Tobata H, Kakuta T. Impact of Pressure Signal Drift on Fractional Flow Reserve-Based Decision-Making for Patients With Intermediate Coronary Artery Stenosis. Circ J 2016; 80:1812-9. [DOI: 10.1253/circj.cj-15-1195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Nobutaka Wakasa
- Department of Clinical Laboratory, Tsuchiura Kyodo General Hospital
| | | | - Naoto Mihashi
- Department of Clinical Laboratory, Tsuchiura Kyodo General Hospital
| | - Noriko Terada
- Department of Clinical Laboratory, Tsuchiura Kyodo General Hospital
| | - Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Tadashi Murai
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Tetsumin Lee
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Kazuhiko Kobashi
- Department of Clinical Laboratory, Tsuchiura Kyodo General Hospital
| | | | - Hiroshi Tobata
- The Graduate School of Health Sciences (Division of Distance Education), Kyushu University of Health and Welfare
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| |
Collapse
|
35
|
Briceno N, Lumley M, Perera D. Fractional flow reserve: conundrums, controversies and challenges. Interv Cardiol 2015. [DOI: 10.2217/ica.15.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
|
36
|
Härle T, Meyer S, Vahldiek F, Elsässer A. Differences between automatically detected and steady-state fractional flow reserve. Clin Res Cardiol 2015. [PMID: 26208615 DOI: 10.1007/s00392-015-0894-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Measurement of fractional flow reserve (FFR) has become a standard diagnostic tool in the catheterization laboratory. FFR evaluation studies were based on pressure recordings during steady-state maximum hyperemia. Commercially available computer systems detect the lowest Pd/Pa ratio automatically, which might not always be measured during steady-state hyperemia. We sought to compare the automatically detected FFR and true steady-state FFR. METHODS AND RESULTS Pressure measurement traces of 105 coronary lesions from 77 patients with intermediate coronary lesions or multivessel disease were reviewed. In all patients, hyperemia had been achieved by intravenous adenosine administration using a dosage of 140 µg/kg/min. In 42 lesions (40%) automatically detected FFR was lower than true steady-state FFR. Mean bias was 0.009 (standard deviation 0.015, limits of agreement -0.02, 0.037). In 4 lesions (3.8%) both methods lead to different treatment recommendations, in all 4 cases instantaneous wave-free ratio confirmed steady-state FFR. CONCLUSIONS Automatically detected FFR was slightly lower than steady-state FFR in more than one-third of cases. Consequently, interpretation of automatically detected FFR values closely below the cutoff value requires special attention.
Collapse
Affiliation(s)
- Tobias Härle
- Klinik für Kardiologie, Klinikum Oldenburg gGmbH, European Medical School Oldenburg-Groningen, Carl von Ossietzky Universität Oldenburg, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany.
| | - Sven Meyer
- Klinik für Kardiologie, Klinikum Oldenburg gGmbH, European Medical School Oldenburg-Groningen, Carl von Ossietzky Universität Oldenburg, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany
| | - Felix Vahldiek
- Klinik für Kardiologie, Klinikum Oldenburg gGmbH, European Medical School Oldenburg-Groningen, Carl von Ossietzky Universität Oldenburg, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany
| | - Albrecht Elsässer
- Klinik für Kardiologie, Klinikum Oldenburg gGmbH, European Medical School Oldenburg-Groningen, Carl von Ossietzky Universität Oldenburg, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany
| |
Collapse
|
37
|
Johnson NP, Johnson DT, Kirkeeide RL, Berry C, De Bruyne B, Fearon WF, Oldroyd KG, Pijls NH, Gould KL. Repeatability of Fractional Flow Reserve Despite Variations in Systemic and Coronary Hemodynamics. JACC Cardiovasc Interv 2015. [DOI: 10.1016/j.jcin.2015.01.039] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
|
38
|
Abstract
Intracoronary hemodynamic assessment of the physiologic significance of coronary lesions improves clinical outcomes in patients with coronary artery disease. Coronary flow velocity reserve, fractional flow reserve, instantaneous wave-free ratio, and index of microcirculatory resistance utilize sensor-mounted guidewires to approximate coronary flow. Coronary flow velocity reserve and fractional flow reserve rely on pharmacologic administration of adenosine to achieve hyperemia and diagnose epicardial lesion severity. As an adenosine-free index, the instantaneous wave-free ratio utilizes a wave-free period in the mid-late diastole during which resistance is constant and low to assess lesion significance. The index of microcirculatory resistance combines hyperemic pressure measurements with thermodilution to quantify microvascular resistance. We review the physiology, clinical trials, and clinical applications of these invasive hemodynamic assessments.
Collapse
|
39
|
Bucher AM, De Cecco CN, Schoepf UJ, Wang R, Meinel FG, Binukrishnan SR, Spearman JV, Vogl TJ, Ruzsics B. Cardiac CT for myocardial ischaemia detection and characterization--comparative analysis. Br J Radiol 2014; 87:20140159. [PMID: 25135617 DOI: 10.1259/bjr.20140159] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The assessment of patients presenting with symptoms of myocardial ischaemia remains one of the most common and challenging clinical scenarios faced by physicians. Current imaging modalities are capable of three-dimensional, functional and anatomical views of the heart and as such offer a unique contribution to understanding and managing the pathology involved. Evidence has accumulated that visual anatomical coronary evaluation does not adequately predict haemodynamic relevance and should be complemented by physiological evaluation, highlighting the importance of functional assessment. Technical advances in CT technology over the past decade have progressively moved cardiac CT imaging into the clinical workflow. In addition to anatomical evaluation, cardiac CT is capable of providing myocardial perfusion parameters. A variety of CT techniques can be used to assess the myocardial perfusion. The single energy first-pass CT and dual energy first-pass CT allow static assessment of myocardial blood pool. Dynamic cardiac CT imaging allows quantification of myocardial perfusion through time-resolved attenuation data. CT-based myocardial perfusion imaging (MPI) is showing promising diagnostic accuracy compared with the current reference modalities. The aim of this review is to present currently available myocardial perfusion techniques with a focus on CT imaging in light of recent clinical investigations. This article provides a comprehensive overview of currently available CT approaches of static and dynamic MPI and presents the results of corresponding clinical trials.
Collapse
Affiliation(s)
- A M Bucher
- 1 Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Aminian A, Dolatabadi D, Lefebvre P, Khalil G, Zimmerman R, Michalakis G, Lalmand J. Importance of guiding catheter disengagement during measurement of fractional flow reserve in patients with an isolated proximal left anterior descending artery stenosis. Catheter Cardiovasc Interv 2014; 85:595-601. [DOI: 10.1002/ccd.25568] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 05/25/2014] [Indexed: 01/22/2023]
Affiliation(s)
- Adel Aminian
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Dariouch Dolatabadi
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Pascal Lefebvre
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Georges Khalil
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Robert Zimmerman
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Georges Michalakis
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| | - Jacques Lalmand
- Division of Cardiology; Centre Hospitalier Universitaire de Charleroi; Charleroi Belgium
| |
Collapse
|
41
|
van de Hoef TP, van Lavieren MA, Henriques JPS, Piek JJ, Claessen BEPM. Fractional Flow Reserve-Guided Percutaneous Coronary Intervention: Does Coronary Pressure Never Lie? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:294. [DOI: 10.1007/s11936-014-0294-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
42
|
Oi M, Toyofuku M, Matsumura Y, Motohashi Y, Takahashi K, Kawase Y, Ko E, Tanaka M, Kitada M, Yuzuki Y, Tamura T, Tanaka N, Kimura T. Utility of nicorandil for the measurement of coronary fractional flow reserve. Cardiovasc Interv Ther 2013; 29:24-30. [DOI: 10.1007/s12928-013-0207-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 08/21/2013] [Indexed: 10/26/2022]
|
43
|
Palmer S, Wilson A, Judkins C, Williams PD. Ticagrelor's Adenosine-Mediated Effect and the Accuracy of Fractional Flow Reserve. J Am Coll Cardiol 2013; 62:646-7. [DOI: 10.1016/j.jacc.2013.04.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 04/01/2013] [Indexed: 10/26/2022]
|
44
|
Left ventricular end-diastolic pressure affects measurement of fractional flow reserve. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2013; 14:218-22. [PMID: 23886870 DOI: 10.1016/j.carrev.2013.06.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 06/04/2013] [Accepted: 06/10/2013] [Indexed: 01/17/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR), the hyperemic ratio of distal (Pd) to proximal (Pa) coronary pressure, is used to identify the need for coronary revascularization. Changes in left ventricular end-diastolic pressure (LVEDP) might affect measurements of FFR. METHODS AND MATERIALS LVEDP was recorded simultaneously with Pd and Pa during conventional FFR measurement as well as during additional infusion of nitroprusside. The relationship between LVEDP, Pa, and FFR was assessed using linear mixed models. RESULTS Prospectively collected data for 528 cardiac cycles from 20 coronary arteries in 17 patients were analyzed. Baseline median Pa, Pd, FFR, and LVEDP were 73 mmHg, 49 mmHg, 0.69, and 18 mmHg, respectively. FFR<0.80 was present in 14 arteries (70%). With nitroprusside median Pa, Pd, FFR, and LVEDP were 61 mmHg, 42 mmHg, 0.68, and 12 mmHg, respectively. In a multivariable model for the entire population LVEDP was positively associated with FFR such that FFR increased by 0.008 for every 1-mmHg increase in LVEDP (beta=0.008; P<0.001), an association that was greater in obstructed arteries with FFR<0.80 (beta=0.01; P<0.001). Pa did not directly affect FFR in the multivariable model, but an interaction between LVEDP and Pa determined that LVEDP's effect on FFR is greater at lower Pa. CONCLUSIONS LVEDP was positively associated with FFR. The association was greater in obstructive disease (FFR<0.80) and at lower Pa. These findings have implications for the use of FFR to guide revascularization in patients with heart failure. SUMMARY FOR ANNOTATED TABLE OF CONTENTS The impact of left ventricular diastolic pressure on measurement of fractional flow reserve (FFR) is not well described. We present a hemodynamic study of the issue, concluding that increasing left ventricular diastolic pressure can increase measurements of FFR, particularly in patients with FFR<0.80 and lower blood pressure.
Collapse
|
45
|
van de Hoef TP, Meuwissen M, Escaned J, Davies JE, Siebes M, Spaan JAE, Piek JJ. Fractional flow reserve as a surrogate for inducible myocardial ischaemia. Nat Rev Cardiol 2013; 10:439-52. [DOI: 10.1038/nrcardio.2013.86] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
46
|
López-Palop R, Carrillo P, Frutos A, Cordero A, Agudo P, Mashlab S, Bertomeu-Martínez V. Comparison of effectiveness of high-dose intracoronary adenosine versus intravenous administration on the assessment of fractional flow reserve in patients with coronary heart disease. Am J Cardiol 2013; 111:1277-83. [PMID: 23415635 DOI: 10.1016/j.amjcard.2013.01.270] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 01/02/2013] [Accepted: 01/02/2013] [Indexed: 01/10/2023]
Abstract
Intravenous adenosine is considered the drug of choice to obtain maximum hyperemia in the measurement of the fractional flow reserve (FFR). However, comparative studies performed between intravenous and intracoronary administration have not used high doses of intracoronary adenosine. The present study compared the efficacy and safety of high doses of intracoronary adenosine to intravenous administration when calculating the FFR. Intracoronary bolus doses of 60, 180, 300, and 600 μg adenosine were compared to an intravenous administration of 140 μg/kg/min, 200 μg/kg/min, and 140 μg/kg/min plus an intracoronary bolus of 120 μg. All the cases were performed using the radial approach. FFR was assessed in 102 patients with 108 intermediate lesions by an intracoronary pressure wire. The intracoronary dose of 60 μg was associated with a significantly greater FFR compared to the intravenous infusion (0.02 ± 0.03, p = 0.001). The intracoronary doses of 300 (-0.01 ± 0.00; p = 0.006) and 600 μg (-0.02 ± 0.00; p <0.0005) were significantly associated with a smaller FFR compared to the intravenous infusion. An intracoronary dose of 600 μg revealed a significantly greater percentage of lesions with an FFR <0.80 compared to intravenous infusion at 140 μg/kg/min (37.6 vs 31.5%; p <0.05) and 200 μg/kg/min (37.6 vs 32.4%; p <0.05) and compared to intracoronary doses of 60 (26.9%) and 180 μg (31.5%). In conclusion, an intracoronary bolus dose >300 μg can be equal to or more effective than an intravenous infusion of adenosine in achieving maximum hyperemia when calculating the FFR. Its use could simplify these procedures without having an effect on safety.
Collapse
Affiliation(s)
- Ramón López-Palop
- Department of Cardiology, Hospital Universitario San Juan de Alicante, Alicante, Spain.
| | | | | | | | | | | | | |
Collapse
|
47
|
Michiels V, Eeckhout E, Muller O. Letter by Michiels et al Regarding Article, “Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions: Adenosine-Free Assessment of Functional Coronary Lesion Severity”. Circ Cardiovasc Interv 2012; 5:e84; author reply e86-7. [DOI: 10.1161/circinterventions.112.973255] [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: 01/10/2023]
Affiliation(s)
- Vincent Michiels
- Department of Cardiology University of Lausanne Hospital Center (CHUV) Lausanne, Switzerland
| | - Eric Eeckhout
- Department of Cardiology University of Lausanne Hospital Center (CHUV) Lausanne, Switzerland
| | - Olivier Muller
- Department of Cardiology University of Lausanne Hospital Center (CHUV) Lausanne, Switzerland
| |
Collapse
|