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Fezzi S, Ding D, Mahfoud F, Huang J, Lansky AJ, Tu S, Wijns W. Illusion of revascularization: does anyone achieve optimal revascularization during percutaneous coronary intervention? Nat Rev Cardiol 2024; 21:652-662. [PMID: 38710772 DOI: 10.1038/s41569-024-01014-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 05/08/2024]
Abstract
This Perspective article is a form of 'pastiche', inspired by the 1993 review by Lincoff and Topol entitled 'Illusion of reperfusion', and explores how their concept continues to apply to percutaneous revascularization in patients with coronary artery disease and ischaemia. Just as Lincoff and Topol argued that reperfusion of acute myocardial infarction was facing unresolved obstacles that hampered clinical success in 1993, we propose that challenging issues are similarly jeopardizing the potential benefits of stent-based angioplasty today. By analysing the appropriateness and efficacy of percutaneous coronary intervention (PCI), we emphasize the limitations of relying solely on visual angiographic guidance, which frequently leads to inappropriate stenting and overtreatment in up to one-third of patients and the associated increased risk of periprocedural myocardial infarction. The lack of optimal revascularization observed in half of patients undergoing PCI confers risks such as suboptimal physiology after PCI, residual angina and long-term stent-related events, leaving an estimated 76% of patients with an 'illusion of revascularization'. These outcomes highlight the need to refine our diagnostic tools by integrating physiological assessments with targeted intracoronary imaging and emerging strategies, such as co-registration systems and angiography-based computational methods enhanced by artificial intelligence, to achieve optimal revascularization outcomes.
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Affiliation(s)
- Simone Fezzi
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Daixin Ding
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland
- Department of Cardiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Felix Mahfoud
- Saarland University Hospital, Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Homburg/Saar, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- University Heart Center Basel, Department of Cardiology, University Basel, Basel, Switzerland
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Alexandra J Lansky
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Shengxian Tu
- Department of Cardiology, Ren Ji Hospital, School of Medicine, and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.
| | - William Wijns
- The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland.
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2
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Dawson LP, Kobayashi Y, Zimmermann FM, Takahashi T, Wong CC, Theriault-Lauzier P, Pijls NHJ, De Bruyne B, Yeung AC, Woo YJ, Fearon WF. Outcomes According to Coronary Disease Complexity and Optimal Thresholds to Guide Revascularization Approach: FAME 3 Trial. JACC Cardiovasc Interv 2024; 17:1861-1871. [PMID: 39197985 DOI: 10.1016/j.jcin.2024.06.003] [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: 02/27/2024] [Revised: 05/28/2024] [Accepted: 06/04/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND Coronary disease complexity is commonly used to guide revascularization strategy in patients with multivessel disease (MVD). OBJECTIVES The aim of this study was to assess the interactive effects of coronary complexity on percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) outcomes and identify the optimal threshold at which PCI can be considered a reasonable option. METHODS A total of 1,444 of 1,500 patients with MVD from the FAME (Fractional Flow Reserve versus Angiography for Multi-vessel Evaluation) 3 randomized trial were included in the analysis (710 CABG vs 734 PCI). SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were transformed into restricted cubic splines, and logistic regression models were fitted, with multiplicative interaction terms for revascularization strategy. Optimal thresholds at which PCI is a reasonable alternative to CABG were determined on the basis of Cox regression model performance. RESULTS The mean SYNTAX score (SS) was 25.9 ± 7.1. SS was associated with 1-year major adverse cardiac and cerebrovascular events among PCI patients and 3-year death, myocardial infarction, and stroke among CABG patients. Significant interactions were present between revascularization strategy and SS for 1- and 3-year composite endpoints (P for interaction <0.05 for all). In Cox regression models, outcomes were comparable between CABG and PCI for the 3-year primary endpoint for SS ≤24 (P = 0.332), with 44% of patients below this threshold and 32% below the conventional SS threshold of ≤22. CONCLUSIONS In patients with MVD without left main disease, PCI and CABG outcomes remain comparable up to SS values in the mid- rather than low 20s, which allows the identification of a greater proportion of patients in whom PCI may be a reasonable alternative to CABG.
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Affiliation(s)
- Luke P Dawson
- Stanford University School of Medicine, Stanford, California, USA; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Yuhei Kobayashi
- NewYork-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, Brooklyn, New York, USA
| | | | - Tatsunori Takahashi
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | | | | | | - Alan C Yeung
- Stanford University School of Medicine, Stanford, California, USA
| | - Y Joseph Woo
- Stanford University School of Medicine, Stanford, California, USA
| | - William F Fearon
- Stanford University School of Medicine, Stanford, California, USA; VA Palo Alto Medical Systems, Palo Alto, California, USA.
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3
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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).
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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.
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Sakamoto T, Usui E, Hoshino M, Hada M, Nagamine T, Hanyu Y, Nogami K, Ueno H, Setoguchi M, Tahara T, Matsuda K, Mineo T, Wakasa N, Sugiyama T, Yonetsu T, Sasano T, Kakuta T. Association of Coronary Computed Tomography-Defined Myocardial Bridge With Pre- and Post-Procedural Fractional Flow Reserve in Patients Undergoing Elective Percutaneous Coronary Intervention. Circ J 2024:CJ-23-0934. [PMID: 38763754 DOI: 10.1253/circj.cj-23-0934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
BACKGROUND Myocardial bridge (MB) is a common coronary anomaly characterized by a tunneled course through the myocardium. Coronary computed tomography angiography (CCTA) can identify MB. The impact of MB detected by CCTA on coronary physiological parameters before and after percutaneous coronary intervention (PCI) is unknown.Methods and Results: We investigated 141 consecutive patients who underwent pre-PCI CCTA and fractional flow reserve (FFR)-guided elective PCI for de novo single proximal lesions in the left anterior descending artery (LAD). We compared clinical demographics and physiological parameters between patients with and without CCTA-defined MB. MB was identified in 46 (32.6%) patients using pre-PCI CCTA. The prevalence of diabetes was higher among patients with MB. Median post-PCI FFR values were significantly lower among patients with than without MB (0.82 [interquartile range 0.79-0.85] vs. 0.85 [interquartile range 0.82-0.89]; P=0.003), whereas pre-PCI FFR values were similar between the 2 groups. Multivariable linear regression analysis revealed that the presence of MB and greater left ventricular mass volume in the LAD territory were independently associated with lower post-PCI FFR values. Multivariable logistic regression analysis also revealed that the presence of MB and lower pre-PCI FFR values were independent predictors of post-PCI FFR values ≤0.80. CONCLUSIONS CCTA-defined MB independently predicted both lower post-PCI FFR as a continuous variable and ischemic FFR as a categorical variable in patients undergoing elective PCI for LAD.
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Affiliation(s)
- Tatsuya Sakamoto
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Eisuke Usui
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Masahiro Hoshino
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Masahiro Hada
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | - Yoshihiro Hanyu
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Kai Nogami
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Hiroki Ueno
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Mirei Setoguchi
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Tomohiro Tahara
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Kazuki Matsuda
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Takashi Mineo
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Nobutaka Wakasa
- Department of Clinical Laboratory, Tsuchiura Kyodo General Hospital
| | - Tomoyo Sugiyama
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
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Ahn JM, Kang DY, Kim JH, Choi Y, Kim H, Lee J, Park DW, Park SJ. Prognostic Value of Poststenting Fractional Flow Reserve After Imaging-Guided Optimal Stenting. JACC Cardiovasc Interv 2024; 17:907-916. [PMID: 38599694 DOI: 10.1016/j.jcin.2024.01.313] [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: 01/16/2023] [Revised: 12/29/2023] [Accepted: 01/30/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Prognostic value of poststenting fractional flow reserve (FFR) remains uncertain in patients undergoing an imaging-guided optimal stenting strategy. OBJECTIVES The authors evaluated the prognostic value of poststenting FFR according to the intracoronary imaging-guided lesion preparation, stent sizing, and postdilation (iPSP) strategy to optimize stent outcomes. METHODS Poststenting FFR assessment was performed in 1,108 lesions in 1,005 patients from the IRIS-FFR registry. The primary outcome was target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, and target vessel revascularization at 5 years. RESULTS At the index procedure, 326 lesions (29.4%) were treated using all 3 parts of the iPSP strategy. In the overall population, poststenting FFR was significantly associated with the risk of TVF at 5 years (per 0.01 increase of FFR, adjusted HR [aHR]: 0.94; 95% CI: 0.90-0.98; P = 0.004). Significant interaction was detected between poststenting FFR and the iPSP strategy on the risk of TVF at 5 years (P = 0.045 for interaction). In the iPSP group, poststenting FFR was not associated with the risk of TVF at 5 years (per 0.01 increase of FFR, aHR: 1.00; 95% CI: 0.96-1.05; P = 0.95), whereas a significant association between poststenting FFR and TVF at 5 years was observed in the no iPSP group (per 0.01 increase of FFR, aHR: 0.94; 95% CI: 0.90-0.99; P = 0.009). CONCLUSIONS Poststenting FFR showed a significant association with cardiac events. However, its prognostic value appeared to be limited after the application of an imaging-guided optimal stenting strategy.
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Affiliation(s)
- Jung-Min Ahn
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Do-Yoon Kang
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ju Hyeon Kim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yeonwoo Choi
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hoyun Kim
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinho Lee
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Duk-Woo Park
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Jung Park
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Chioncel V, Gherasie FA. The Role of Coronary Physiology Assessment in the Diagnosis and Treatment of Stable Angina. Dive Inside Recent Findings of Diffuse Coronary Disease Treatment. Rev Cardiovasc Med 2024; 25:108. [PMID: 39076937 PMCID: PMC11263821 DOI: 10.31083/j.rcm2503108] [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: 12/03/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 07/31/2024] Open
Abstract
Coronary physiology is widely used to assess epicardial coronary lesions in patients with stable angina. Based on the available evidence, physiology plays a crucial role in diagnosing and treating patients. There have been invasive methods for determining cardiac physiology, such as fractional flow reserve and instantaneous wave-free ratio. Still, new non-invasive approaches provide extra anatomical information, such as fractional flow reserve computed tomography (FFR-CT) based on computed tomography and physiology based on angiography. Even though FFR-guided percutaneous coronary intervention (PCI) is clinically beneficial, one-third of patients retain suboptimal FFR after the procedure, associated with severe adverse events, rendering PCI in diffuse coronary artery disease questionable. Using the pullback pressure gradient (PPG), we can analyze the magnitude and extent of pressure losses; a lower value may indicate diffuse disease, while a high value with an abrupt curve may indicate focal disease. Since PCI is not the best option for treating diffuse coronary disease, current strategies focus on conservatively using medical therapy or bypass surgery. It has been demonstrated that patients with diffuse disease of the left anterior descending (LAD) are at a greater risk of developing occlusion of the left internal mammary artery graft than those with focal disease and that maximal medical therapy may be the most effective treatment for these patients.
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Affiliation(s)
- Valentin Chioncel
- Department of Cardiology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Emergency Clinical Hospital Dr. Bagdasar-Arseni, 041915 Bucharest, Romania
| | - Flavius-Alexandru Gherasie
- Department of Cardiology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Emergency Clinical Hospital Dr. Bagdasar-Arseni, 041915 Bucharest, Romania
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7
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Barrera S, de la Torre Hernández JM. Coronary Physiology by Different Approaches to Guide PCI: Adding Allies to Optimize Outcomes. JACC Cardiovasc Interv 2024; 17:288-291. [PMID: 38267143 DOI: 10.1016/j.jcin.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/03/2023] [Accepted: 11/13/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Sergio Barrera
- Hospital Universitario Marques de Valdecilla, Servicio de Cardiología, Unidad de Cardiología Intervencionista, IDIVAL, Santander, Spain
| | - José M de la Torre Hernández
- Hospital Universitario Marques de Valdecilla, Servicio de Cardiología, Unidad de Cardiología Intervencionista, IDIVAL, Santander, Spain.
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Kotoku N, Ninomiya K, Masuda S, O'Leary N, Garg S, Naito M, Miyashita K, Tobe A, Kageyama S, Tsai TY, Revaiah PC, Tu S, Kozuma K, Kawashima H, Ishibashi Y, Nakazawa G, Takahashi K, Okamura T, Miyazaki Y, Tateishi H, Nakamura M, Kogame N, Asano T, Nakatani S, Morino Y, Ishida M, Katagiri Y, Ono M, Hara H, Sotomi Y, Tanabe K, Ozaki Y, Muramatsu T, Dijkstra J, Onuma Y, Serruys PW. Preprocedural physiological assessment of coronary disease patterns to predict haemodynamic outcomes post-PCI. EUROINTERVENTION 2023; 19:e891-e902. [PMID: 37960875 PMCID: PMC10719743 DOI: 10.4244/eij-d-23-00516] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/29/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Even with intracoronary imaging-guided stent optimisation, suboptimal haemodynamic outcomes post-percutaneous coronary intervention (PCI) can be related to residual lesions in non-stented segments. Preprocedural assessment of pathophysiological coronary artery disease (CAD) patterns could help predict the physiological response to PCI. AIMS The aim of this study was to assess the relationship between preprocedural pathophysiological haemodynamic patterns and intracoronary imaging findings, as well as their association with physiological outcomes immediately post-PCI. METHODS Data from 206 patients with chronic coronary syndrome enrolled in the ASET-JAPAN study were analysed. Pathophysiological CAD patterns were characterised using Murray law-based quantitative flow ratio (μQFR)-derived indices acquired from pre-PCI angiograms. The diffuseness of CAD was defined by the pullback pressure gradient (PPG) index. Intracoronary imaging in stented segments after stent optimisation was also analysed. RESULTS In the multivariable analysis, diffuse disease - defined by the pre-PCI μQFR-PPG index - was an independent factor for predicting a post-PCI μQFR <0.91 (per 0.1 decrease of PPG index, odds ratio 1.57, 95% confidence interval: 1.07-2.34; p=0.022), whereas the stent expansion index (EI) was not associated with a suboptimal post-PCI μQFR. Among vessels with an EI ≥80% and post-PCI μQFR <0.91, 84.0% of those vessels had a diffuse pattern preprocedure. There was no significant difference in EI between vessels with diffuse disease and those with focal disease. The average plaque burden in the stented segment was significantly larger in vessels with a preprocedural diffuse CAD pattern. CONCLUSIONS A physiological diffuse pattern preprocedure was an independent factor in predicting unfavourable immediate haemodynamic outcomes post-PCI, even after stent optimisation using intracoronary imaging. Preprocedural assessment of CAD patterns could identify patients who are likely to exhibit superior immediate haemodynamic outcomes following PCI.
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Affiliation(s)
- Nozomi Kotoku
- Department of Cardiology, University of Galway, Galway, Ireland
| | - Kai Ninomiya
- Department of Cardiology, University of Galway, Galway, Ireland
| | | | - Neil O'Leary
- Department of Cardiology, University of Galway, Galway, Ireland
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Mareka Naito
- Department of Cardiology, University of Galway, Galway, Ireland
| | | | - Akihiro Tobe
- Department of Cardiology, University of Galway, Galway, Ireland
| | | | - Tsung Ying Tsai
- Department of Cardiology, University of Galway, Galway, Ireland
| | | | - Shengxian Tu
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Ken Kozuma
- Department of Cardiology, Teikyo University Hospital, Tokyo, Japan
| | | | - Yuki Ishibashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Gaku Nakazawa
- Department of Cardiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Kuniaki Takahashi
- Department of Cardiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Takayuki Okamura
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University, Graduate School of Medicine, Yamaguchi, Japan
| | - Yosuke Miyazaki
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University, Graduate School of Medicine, Yamaguchi, Japan
| | - Hiroki Tateishi
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University, Graduate School of Medicine, Yamaguchi, Japan
- Department of Cardiology, Shibata Hospital, Yamaguchi, Japan
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Norihiro Kogame
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
- Department of Cardiology, Tokyo Rosai Hospital, Tokyo, Japan
| | - Taku Asano
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Shimpei Nakatani
- Department of Cardiology, JCHO, Hoshigaoka Medical Center, Osaka, Japan
| | - Yoshihiro Morino
- Department of Cardiology, Iwate Medical University Hospital, Iwate, Japan
| | - Masaru Ishida
- Department of Cardiology, Iwate Medical University Hospital, Iwate, Japan
| | - Yuki Katagiri
- Department of Cardiology, Sapporo Higashi Tokushukai Hospital, Hokkaido, Japan
| | - Masafumi Ono
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Hironori Hara
- Department of Cardiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University, Graduate School of Medicine, Osaka, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Okazaki Medical Center, Aichi, Japan
| | - Takashi Muramatsu
- Department of Cardiology, Fujita Health University Hospital, Toyoake, Japan
| | - Jouke Dijkstra
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Yoshinobu Onuma
- Department of Cardiology, University of Galway, Galway, Ireland
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9
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Kubota M, Oguri A. Diagnostic accuracy of diastolic pressure ratio using a pressure microcatheter for intracoronary physiological assessment. Heart Vessels 2023; 38:1395-1403. [PMID: 37626238 DOI: 10.1007/s00380-023-02301-5] [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: 05/18/2022] [Accepted: 08/02/2023] [Indexed: 08/27/2023]
Abstract
Recently, instantaneous wave-free ratio (iFR) has emerged as an alternative to the fractional flow reserve (FFR) for intracoronary physiological assessment. Although all diastolic resting indices are reportedly identical to the iFR, limited data exist on diastolic pressure ratio (dPR) measured using a microcatheter (dPRmicro). This study aimed to evaluate the diagnostic accuracy of dPRmicro compared to FFR measured using a microcatheter (FFRmicro) in real-world practice for intracoronary physiological assessment. This was a single-center, retrospective, observational study. We identified 103 consecutive suspected angina pectoris patients (107 lesions) who underwent dPRmicro and FFRmicro measurement using the Navvus® catheter at Takasaki Heart Hospital from March 2019 to June 2019. A total of 103 lesions in 103 patients were finally included in the study. The mean FFRmicro and dPRmicro values were 0.80 and 0.88, respectively. With an FFRmicro ≤ 0.80, the dPRmicro showed a diagnostic accuracy of 79.6%, sensitivity of 74.6%, specificity of 87.5%, positive predictive value of 90.4%, and negative predictive value of 68.6%. The area under the receiver operating characteristic (ROC) curve was 0.894 (95% confidence interval, 0.833-0.956), and the optimal cut-off value for dPRmicro derived from the ROC analysis was 0.90. dPRmicro and FFRmicro values were discordant in 21/103 cases (20.4%). As a multivariable logistic regression analysis was performed, the male sex (vs. female) had a statistically significant association with a dPRmicro-FFRmicro discordance (OR 4.91; 95% CI, 1.04-23.0; P = 0.044). No other factors were found to be significantly associated with the discordance. In conclusion, dPRmicro measured using a microcatheter had good diagnostic accuracy and correlation with FFRmicro, hence, it can be useful for making revascularization decisions. However, re-studies in larger populations will be needed to better understand the properties of diastolic resting index measured using a microcatheter in clinical settings.
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Affiliation(s)
- Masayuki Kubota
- Department of Cardiology, Takasaki Heart Hospital, Gumma, Japan
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsushi Oguri
- Department of Cardiology, Takasaki Heart Hospital, Gumma, Japan.
- Department of Cardiovascular Medicine, Don-Don Mamorou Clinic, Tochigi, Japan.
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10
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Groenland FT, Ziedses des Plantes AC, Scoccia A, Neleman T, Masdjedi K, Kardys I, Diletti R, Van Mieghem NM, Daemen J. Post percutaneous coronary intervention physiology in patients presenting with ST-segment elevation myocardial infarction. IJC HEART & VASCULATURE 2023; 49:101319. [PMID: 38143782 PMCID: PMC10746447 DOI: 10.1016/j.ijcha.2023.101319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/26/2023]
Affiliation(s)
- Frederik T.W. Groenland
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Alessandra Scoccia
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tara Neleman
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kaneshka Masdjedi
- Department of Cardiology, Admiraal de Ruyter Hospital, Goes, the Netherlands
| | - Isabella Kardys
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M. Van Mieghem
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
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11
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Collet C, Johnson NP, Mizukami T, Fearon WF, Berry C, Sonck J, Collison D, Koo BK, Meneveau N, Agarwal SK, Uretsky B, Hakeem A, Doh JH, Da Costa BR, Oldroyd KG, Leipsic JA, Morbiducci U, Taylor C, Ko B, Tonino PAL, Perera D, Shinke T, Chiastra C, Sposito AC, Leone AM, Muller O, Fournier S, Matsuo H, Adjedj J, Amabile N, Piróth Z, Alfonso F, Rivero F, Ahn JM, Toth GG, Ihdayhid A, West NEJ, Amano T, Wyffels E, Munhoz D, Belmonte M, Ohashi H, Sakai K, Gallinoro E, Barbato E, Engstrøm T, Escaned J, Ali ZA, Kern MJ, Pijls NHJ, Jüni P, De Bruyne B. Impact of Post-PCI FFR Stratified by Coronary Artery. JACC Cardiovasc Interv 2023; 16:2396-2408. [PMID: 37821185 DOI: 10.1016/j.jcin.2023.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Low fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) has been associated with adverse clinical outcomes. Hitherto, this assessment has been independent of the epicardial vessel interrogated. OBJECTIVES This study sought to assess the predictive capacity of post-PCI FFR for target vessel failure (TVF) stratified by coronary artery. METHODS We performed a systematic review and individual patient-level data meta-analysis of randomized clinical trials and observational studies with protocol-recommended post-PCI FFR assessment. The difference in post-PCI FFR between left anterior descending (LAD) and non-LAD arteries was assessed using a random-effect models meta-analysis of mean differences. TVF was defined as a composite of cardiac death, target vessel myocardial infarction, and clinically driven target vessel revascularization. RESULTS Overall, 3,336 vessels (n = 2,760 patients) with post-PCI FFR measurements were included in 9 studies. The weighted mean post-PCI FFR was 0.89 (95% CI: 0.87-0.90) and differed significantly between coronary vessels (LAD = 0.86; 95% CI: 0.85 to 0.88 vs non-LAD = 0.93; 95% CI: 0.91-0.94; P < 0.001). Post-PCI FFR was an independent predictor of TVF, with its risk increasing by 52% for every reduction of 0.10 FFR units, and this was mainly driven by TVR. The predictive capacity for TVF was poor for LAD arteries (AUC: 0.52; 95% CI: 0.47-0.58) and moderate for non-LAD arteries (AUC: 0.66; 95% CI: 0.59-0.73; LAD vs non-LAD arteries, P = 0.005). CONCLUSIONS The LAD is associated with a lower post-PCI FFR than non-LAD arteries, emphasizing the importance of interpreting post-PCI FFR on a vessel-specific basis. Although a higher post-PCI FFR was associated with improved prognosis, its predictive capacity for events differs between the LAD and non-LAD arteries, being poor in the LAD and moderate in the non-LAD vessels.
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Affiliation(s)
- Carlos Collet
- Cardiovascular Center Aalst, onze lieve vrouw Clinic, Aalst, Belgium.
| | - Nils P Johnson
- Division of Cardiology, Department of Medicine, McGovern Medical School at University of Texas Health and Memorial Hermann Hospital, Houston, Texas, USA
| | - Takuya Mizukami
- Cardiovascular Center Aalst, onze lieve vrouw Clinic, Aalst, Belgium; Department of Pharmacology, Showa University School of Medicine, Tokyo, Japan
| | - William F Fearon
- Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Colin Berry
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom; West of Scotland Regional Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom
| | - Jeroen Sonck
- Cardiovascular Center Aalst, onze lieve vrouw Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Damien Collison
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom; West of Scotland Regional Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; University of Burgundy Franche-Comté, Besançon, France
| | - Shiv Kumar Agarwal
- Division of Cardiology, Central Arkansas Veterans Health System, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Barry Uretsky
- Division of Cardiology, Central Arkansas Veterans Health System, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Abdul Hakeem
- Division of Cardiovascular Diseases and Cardiovascular Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Bruno R Da Costa
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Keith G Oldroyd
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom; West of Scotland Regional Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom
| | - Jonathon A Leipsic
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Umberto Morbiducci
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | | | - Brian Ko
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Victoria, Australia
| | - Pim A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Divaka Perera
- National Institute for Health Research Guy's and St Thomas' Biomedical Research Centre, King's College London and Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Claudio Chiastra
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Andrei C Sposito
- Department of Internal Medicine, Discipline of Cardiology, University of Campinas, Campinas, Brazil
| | - Antonio Maria Leone
- Center of Excellence in Cardiovascular Sciences, Ospedale Fatebenefratelli Isola Tiberina Gemelli Isola, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Julien Adjedj
- Department of Cardiology, Arnault Tzanck Institute Saint Laurent du Var, France
| | - Nicolas Amabile
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
| | - Zsolt Piróth
- Gottsegen National Cardiovascular Center, Budapest, Hungary
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, Madrid, Spain
| | - Fernando Rivero
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, Madrid, Spain
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gabor G Toth
- Division of Cardiology, University Heart Center Graz, Medical University of Graz, Graz, Austria
| | - Abdul Ihdayhid
- Fiona Stanley Hospital, Harry Perkins Institute of Medical Research, Curtin University, Perth, Australia
| | | | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Eric Wyffels
- Cardiovascular Center Aalst, onze lieve vrouw Clinic, Aalst, Belgium
| | - Daniel Munhoz
- Cardiovascular Center Aalst, onze lieve vrouw Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy; Department of Internal Medicine, Discipline of Cardiology, University of Campinas, Campinas, Brazil
| | - Marta Belmonte
- Cardiovascular Center Aalst, onze lieve vrouw Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Hirofumi Ohashi
- Cardiovascular Center Aalst, onze lieve vrouw Clinic, Aalst, Belgium; Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Koshiro Sakai
- Cardiovascular Center Aalst, onze lieve vrouw Clinic, Aalst, Belgium; Division of Cardiology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, onze lieve vrouw Clinic, Aalst, Belgium; Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Emanuele Barbato
- Cardiovascular Center Aalst, onze lieve vrouw Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Thomas Engstrøm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Javier Escaned
- Instituto de Investigacion Sanitaria Del Hospital Clinico San Carlos, Complutense University, Madrid, Spain
| | - Ziad A Ali
- St. Francis Hospital & Heart Center, Roslyn, NY, USA
| | - Morton J Kern
- University of California Irvine and Veterans Affairs Long Beach Healthcare System, Irvine, California, USA
| | - Nico H J Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Peter Jüni
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, onze lieve vrouw Clinic, Aalst, Belgium; Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.
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12
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Ilic I, Timcic S, Milosevic M, Boskovic S, Odanovic N, Furtula M, Dobric M, Aleksandric S, Otasevic P. The imPAct of Trimetazidine on MicrOcirculation after Stenting for stable coronary artery disease (PATMOS study). Front Cardiovasc Med 2023; 10:1112198. [PMID: 37456821 PMCID: PMC10348888 DOI: 10.3389/fcvm.2023.1112198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/06/2023] [Indexed: 07/18/2023] Open
Abstract
Background Myocardial ischemia is caused by epicardial coronary artery stenosis or atherosclerotic disease affecting microcirculation. Trimetazidine (TMZ), promotes glucose oxidation which optimizes cellular energy processes in ischemic conditions. Small studies demonstrated protective effects of TMZ in terms of reducing myocardial injury after percutaneous coronary intervention (PCI), its effect on microcirculation using contemporary investigative methods has not been studied. The aim of the study was to examine effects of trimetazidine, given before elective PCI, on microcirculation using invasively measured index of microcirculatory resistance (IMR). Methods This was prospective, single blinded, randomized study performed in a single university hospital. It included consecutive patients with an indication for PCI of a single, de novo, native coronary artery lesion. Patients were randomly assigned to receive either TMZ plus standard therapy (TMZ group) or just standard therapy. Coronary physiology indices fractional flow reserve (FFR), coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) were measured before and after PCI using coronary pressure wire. Results We randomized 71 patients with similar clinical characteristics and risk profile, previous medications and coronary angiograms. Patientshad similar values of Pd/Pa, FFR and CFR prior to PCI procedure. After PCI, FFR values were higher in TMZ group, while IMR values were lower in this group respectively (FFR TMZ + 0.89 ± 0.05 vs. TMZ - 0.85 ± 0.06, p = 0.007; CFR TMZ + 2.1 ± 0.8 vs. TMZ- 2.3 ± 1.3, p = 0.469; IMR TMZ + 18 ± 9 vs. TMZ- 24 ± 12, p = 0.028). In two-way repeated measures ANOVA PCI was associated with change in FFR values (TMZ p = 0.050; PCI p < 0.001; p for interaction 0.577) and TMZ with change in IMR values (TMZ p = 0.034, PCI p = 0.129, p for interaction 0.344). Conclusion Adding trimetazidine on top of medical treatment prior to elective PCI reduces microvascular dysfunction by lowering postprocedural IMR values when compared to standard therapy alone.
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Affiliation(s)
- Ivan Ilic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Stefan Timcic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Maja Milosevic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Srdjan Boskovic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Natalija Odanovic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Matija Furtula
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Milan Dobric
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Srdjan Aleksandric
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Petar Otasevic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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13
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Neleman T, Scoccia A, Groenland FTW, Ziedses des Plantes AC, van Zandvoort LJC, Ligthart JMR, Witberg KT, Lenzen MJ, Boersma E, Nuis RJ, den Dekker WK, Diletti R, Wilschut J, Zijlstra F, Van Mieghem NM, Daemen J. Validation of Segmental Post-PCI Physiological Gradients With IVUS-Detected Focal Lesions and Stent Underexpansion. JACC Cardiovasc Interv 2023:S1936-8798(23)00676-3. [PMID: 37354158 DOI: 10.1016/j.jcin.2023.03.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Segmental post-percutaneous coronary intervention (PCI) pressure gradients may detect residual disease and potential targets for optimization. However, universal definitions of relevant segmental gradients are lacking. OBJECTIVES The study sought to evaluate the diagnostic performance of post-PCI fractional flow reserve (FFR), distal coronary pressure-to-aortic pressure ratio (Pd/Pa), and diastolic pressure ratio (dPR) gradients to detect residual focal lesions and stent underexpansion as observed by intravascular ultrasound (IVUS). METHODS Patients from the IVUS-guided optimization arm of the FFR REACT (FFR-guided PCI Optimization Directed by High-Definition IVUS Versus Standard of Care) trial with complete IVUS and FFR pullback data were included. Patients with angiographically successful PCI and post-PCI FFR <0.90 underwent FFR, Pd/Pa, and IVUS pullbacks. dPR was calculated offline using dedicated software. Segmental pressure gradients (distal, in stent, and proximal) in segments ≥5 mm were evaluated against IVUS-detected residual disease (distal or proximal focal lesions and stent underexpansion). RESULTS A total of 139 vessels were included (mean post-PCI FFR: 0.83 ± 0.05, range 0.56-0.89). Focal distal and proximal lesions were detected by IVUS in 23 (17.4%) of 132 and 14 (12.6%) of 111 vessels, respectively, whereas stent underexpansion was present in 86 (61.9%) vessels. Diagnostic ability of segmental FFR gradients to predict IVUS-detected distal and proximal lesions was moderate to good (area under the curve [AUC]: 0.69 and 0.84, respectively) and poor to moderate for segmental Pd/Pa and dPR gradients (AUC ranging from 0.58 to 0.69). In-stent gradients had no discriminative ability to detect stent underexpansion (FFR AUC: 0.52; Pd/Pa AUC: 0.54; dPR AUC: 0.55). CONCLUSIONS In patients with post-PCI FFR <0.90, segmental post-PCI pressure gradients have moderate discriminative ability to identify IVUS-detected focal lesions but no discriminative ability to identify IVUS-detected stent underexpansion.
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Affiliation(s)
- Tara Neleman
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Alessandra Scoccia
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | | | - Jurgen M R Ligthart
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Karen T Witberg
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mattie J Lenzen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wijnand K den Dekker
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen Wilschut
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
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14
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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.
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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
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15
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Andersen BK, Ding D, Mogensen LJH, Tu S, Holm NR, Westra J, Wijns W. Predictive value of post-percutaneous coronary intervention fractional flow reserve: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:99-108. [PMID: 36026514 DOI: 10.1093/ehjqcco/qcac053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/14/2022] [Accepted: 08/17/2022] [Indexed: 11/12/2022]
Abstract
AIMS We aimed to investigate the relationship between post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) and clinical outcome using a systematic review with a study-level meta-analysis. METHODS AND RESULTS MEDLINE, Embase, and CENTRAL were systematically searched for articles with clinical follow-up reporting mean or median final post-PCI FFR. The main outcome was a composite of major adverse cardiac events (MACE) including all-cause death, myocardial infarction (MI), and target vessel revascularization (TVR). Meta-regression analyses were performed on mean post-PCI FFR values. A total of 62 studies with 12 340 patients and 12 923 stented vessels were included, with follow-ups ranging from 1 to 89 months. Post-PCI FFR was not continuously associated with the rate of 1-year MACE or 1-year TVR using meta-regression models accounting for heterogeneous follow-up lengths. For studies comparing high vs. low post-PCI FFR, low post-PCI FFR was associated with high risk ratio for MACE {1.97 [95% confidence interval (CI):1.45-2.67]}, all-cause death [1.59 (95% CI: 1.08-2.34)], MI [3.18 (95% CI: 1.84-5.50)], TVR [2.08 (95% CI: 1.63-2.65)] and angina status [2.50 (95% CI: 1.53-4.06)] using different optimal cut-off values spanning from 0.80 to 0.95. CONCLUSION We found no clear continuous association between post-PCI FFR and clinical outcomes in this systematic study-level meta-analysis. In a subset of studies investigating binary classification, high post-PCI FFR was associated with a better clinical outcome than low post-PCI FFR.We investigated the relationship between post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) and rate of major adverse cardiac events (MACE), including all-cause death, myocardial infarction (MI), and target vessel revascularization (TVR), using a systematic review and study-level meta-analysis, pooling 12 340 patients from 62 studies. Mean post-PCI FFR was not continuously associated with a 1-year MACE rate accounting for heterogenous follow-up lengths. Still, the risk ratio favoured high post-PCI FFR for reduced MACE, all-cause death, MI, TVR, and better angina status using different cut-offs.
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Affiliation(s)
- Birgitte Krogsgaard Andersen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 69, 8200 Aarhus, Skejby, Denmark.,Department of Internal Medicine, Horsens Regional Hospital, Horsens, Denmark
| | - Daixin Ding
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland Galway, Galway, Ireland.,Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Lone Juul Hune Mogensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 69, 8200 Aarhus, Skejby, Denmark
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Niels Ramsing Holm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 69, 8200 Aarhus, Skejby, Denmark
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 69, 8200 Aarhus, Skejby, Denmark
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland Galway, Galway, Ireland
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16
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Fawaz S, Cook CM. Understanding the Basis for Hyperemic and Nonhyperemic Coronary Pressure Assessment. Interv Cardiol Clin 2023; 12:1-12. [PMID: 36372454 DOI: 10.1016/j.iccl.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Despite the now routine integration of invasive physiologic systems into coronary catheter laboratories worldwide, it remains critical that all operators maintain a sound understanding of the fundamental physiologic basis for coronary pressure assessment. More specifically, performing operators should be well informed regarding the basis for hyperemic (ie, fractional flow reserve) and nonhyperemic (ie, instantaneous wave-free ratio and other nonhyperemic pressure ratio) coronary pressure assessment. In this article, we provide readers a comprehensive history charting the inception, development, and validation of hyperemic and nonhyperemic coronary pressure assessment.
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Affiliation(s)
- Samer Fawaz
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom
| | - Christopher M Cook
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom.
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17
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Mizukami T, Sonck J, Sakai K, Ko B, Maeng M, Otake H, Koo B, Nagumo S, Nørgaard BL, Leipsic J, Shinke T, Munhoz D, Mileva N, Belmonte M, Ohashi H, Barbato E, Johnson NP, De Bruyne B, Collet C. Procedural Outcomes After Percutaneous Coronary Interventions in Focal and Diffuse Coronary Artery Disease. J Am Heart Assoc 2022; 11:e026960. [PMID: 36444858 PMCID: PMC9851458 DOI: 10.1161/jaha.122.026960] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Coronary artery disease (CAD) patterns play an essential role in the decision-making process about revascularization. The pullback pressure gradient (PPG) quantifies CAD patterns as either focal or diffuse based on fractional flow reserve (FFR) pullbacks. The objective of this study was to evaluate the impact of CAD patterns on acute percutaneous coronary intervention (PCI) results considered surrogates of clinical outcomes. Methods and Results This was a prospective, multicenter study of patients with hemodynamically significant CAD undergoing PCI. Motorized FFR pullbacks and optical coherence tomography (OCT) were performed before and after PCI. Post-PCI FFR >0.90 was considered an optimal result. Focal disease was defined as PPG >0.73 (highest PPG tertile). Overall, 113 patients (116 vessels) were included. Patients with focal disease were younger than those with diffuse CAD (61.4±9.9 versus 65.1±8.7 years, P=0.042). PCI in vessels with high PPG (focal CAD) resulted in higher post-PCI FFR (0.91±0.07 in the focal group versus 0.86±0.05 in the diffuse group, P<0.001) and larger minimal stent area (6.3±2.3 mm2 in focal versus 5.3±1.8 mm2 in diffuse CAD, P=0.015) compared withvessels with low PPG (diffuse CAD). The PPG was associated with the change in FFR after PCI (R2=0.51, P<0.001). The PPG significantly improved the capacity to predict optimal PCI results compared with an angiographic assessment of CAD patterns (area under the curvePPG 0.81 [95% CI, 0.73-0.88] versus area under the curveangio 0.51 [95% CI, 0.42-0.60]; P<0.001). Conclusions PCI in vessels with focal disease defined by the PPG resulted in greater improvement in epicardial conductance and larger minimal stent area compared with diffuse disease. PPG, but not angiographically defined CAD patterns, distinguished patients attaining superior procedural outcomes. Registration URL: https://clinicaltrials.gov/ct2/show/NCT03782688.
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Affiliation(s)
- Takuya Mizukami
- Cardiovascular Center AalstOLV ClinicAalstBelgium,Department of Clinical PharmacologyShowa UniversityTokyoJapan
| | - Jeroen Sonck
- Cardiovascular Center AalstOLV ClinicAalstBelgium
| | - Koshiro Sakai
- Cardiovascular Center AalstOLV ClinicAalstBelgium,Division of Cardiology, Department of MedicineShowa University School of MedicineTokyoJapan
| | - Brian Ko
- Monash Cardiovascular Research CentreMonash University and Monash Heart, Monash HealthClaytonVictoriaAustralia
| | - Michael Maeng
- Department of CardiologyAarhus University HospitalAarhusDenmark
| | - Hiromasa Otake
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Bon‐Kwon Koo
- Department of Internal Medicine and Cardiovascular CenterSeoul National University HospitalSeoulKorea
| | - Sakura Nagumo
- Cardiovascular Center AalstOLV ClinicAalstBelgium,Division of Cardiology, Department of Internal MedicineShowa University Fujigaoka HospitalYokohamaJapan
| | | | - Jonathon Leipsic
- Department of Medicine and RadiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Toshiro Shinke
- Division of Cardiology, Department of MedicineShowa University School of MedicineTokyoJapan
| | - Daniel Munhoz
- Cardiovascular Center AalstOLV ClinicAalstBelgium,Department of Internal Medicine, Discipline of CardiologyUniversity of Campinas (Unicamp)CampinasBrazil,Department of Advanced Biomedical SciencesUniversity of Naples, Federico IINaplesItaly
| | - Niya Mileva
- Cardiovascular Center AalstOLV ClinicAalstBelgium,Cardiology Clinic Alexandrovska University HospitalSofiaBulgaria
| | - Marta Belmonte
- Cardiovascular Center AalstOLV ClinicAalstBelgium,Department of CardiologyUniversity of MilanMilanItaly
| | - Hirofumi Ohashi
- Cardiovascular Center AalstOLV ClinicAalstBelgium,Department of CardiologyAichi Medical UniversityNagakuteJapan
| | - Emanuele Barbato
- Cardiovascular Center AalstOLV ClinicAalstBelgium,Department of Advanced Biomedical SciencesUniversity of Naples, Federico IINaplesItaly
| | - Nils P. Johnson
- Division of Cardiology, Department of Medicine, Weatherhead PET CenterMcGovern Medical School at UTHealth and Memorial Hermann HospitalHoustonTX
| | - Bernard De Bruyne
- Cardiovascular Center AalstOLV ClinicAalstBelgium,Department of CardiologyLausanne University Center HospitalLausanneSwitzerland
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18
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Tehrani DM, Seto AH. The future of angiography: Estimates of FFR pre- and post-PCI. Catheter Cardiovasc Interv 2022; 100:1218-1219. [PMID: 36521181 PMCID: PMC10108314 DOI: 10.1002/ccd.30492] [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: 11/08/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022]
Affiliation(s)
- David M Tehrani
- Department of Medicine, Division of Cardiology, University of California Los Angeles Health, Los Angeles, California, USA
| | - Arnold H Seto
- Department of Medicine, VA Long Beach Healthcare System, Long Beach, CA, United States.,Department of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA.,Department of Medicine, University of California, Irvine, California, USA
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19
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Scoccia A, Scarparo P, Neleman T, Kakar H, Wilschut J, Den Dekker WK, Zijlstra F, Van Mieghem NM, Daemen J, Diletti R. Diagnostic accuracy of angiography‐based vessel fractional flow reserve after chronic coronary total occlusion recanalization. Catheter Cardiovasc Interv 2022; 100:964-970. [PMID: 36321612 PMCID: PMC10092024 DOI: 10.1002/ccd.30439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/08/2022] [Accepted: 10/02/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Angiography-based vessel fractional flow reserve (vFFR) demonstrated a strong correlation with invasive fractional flow reserve (FFR) in both a pre- and post-percutaneous coronary intervention (PCI) setting. However, the role of vFFR and its correlation with post-PCI FFR in chronic coronary occlusions (CTO) has not been evaluated yet. We sought to investigate the diagnostic performance of post-PCI vFFR with post-PCI FFR as a reference in patients undergoing successful CTO PCI. METHODS Between March 2016 and April 2020, a total of 80 patients from the FFR-SEARCH (prospective registry) and FFR REACT (randomized controlled trial) studies underwent successful CTO recanalization with post-PCI FFR measurements. RESULTS A total of 50 patients (median age 66 (interquartile range [IQR]: 56-74) years, 76% were male) were eligible for the analysis. Median post-PCI FFR was 0.89 (IQR: 0.84-0.94), while median post-PCI vFFR was 0.91 (IQR: 0.85-0.94) (p 0.10). Suboptimal physiological results, defined as FFR and vFFR <0.90, were identified in 26 (52%) and in 21 (42%) patients, respectively. A strong correlation (r = 0.82) was found between vFFR and FFR with a mean bias of 0.013 ± 0.051. Receiver-operating characteristics curve analysis revealed an excellent accuracy of vFFR in predicting FFR <0.90 (area under the curve: 0.97; 95% confidence interval: 0.93-1.00). CONCLUSION Post-PCI vFFR shows a good correlation with post-PCI FFR and a high diagnostic accuracy for post-PCI FFR ≤0.90 in patients undergoing successful PCI of a CTO lesion.
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Affiliation(s)
- Alessandra Scoccia
- Department of Cardiology Erasmus Medical University Center Rotterdam The Netherlands
| | - Paola Scarparo
- Department of Cardiology Erasmus Medical University Center Rotterdam The Netherlands
| | - Tara Neleman
- Department of Cardiology Erasmus Medical University Center Rotterdam The Netherlands
| | - Hala Kakar
- Department of Cardiology Erasmus Medical University Center Rotterdam The Netherlands
| | - Jeroen Wilschut
- Department of Cardiology Erasmus Medical University Center Rotterdam The Netherlands
| | - Wijnand K. Den Dekker
- Department of Cardiology Erasmus Medical University Center Rotterdam The Netherlands
| | - Felix Zijlstra
- Department of Cardiology Erasmus Medical University Center Rotterdam The Netherlands
| | | | - Joost Daemen
- Department of Cardiology Erasmus Medical University Center Rotterdam The Netherlands
| | - Roberto Diletti
- Department of Cardiology Erasmus Medical University Center Rotterdam The Netherlands
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20
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Functional Patterns of Coronary Disease. JACC Cardiovasc Interv 2022; 15:2174-2191. [DOI: 10.1016/j.jcin.2022.07.015] [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: 03/31/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 11/09/2022]
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21
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Griffioen AM, van den Oord SC, Teerenstra S, Damman P, van Royen N, van Geuns RJM. Clinical Relevance of Impaired Physiological Assessment After Percutaneous Coronary Intervention: A Meta-analysis. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100448. [PMID: 39132337 PMCID: PMC11307483 DOI: 10.1016/j.jscai.2022.100448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 08/13/2024]
Abstract
Background Despite the optimal angiographic result of percutaneous coronary intervention (PCI), residual disease at the site of the culprit lesion can lead to major adverse cardiac events. Post-PCI physiological assessment can identify residual stenosis. This meta-analysis aims to investigate data of studies examining post-PCI physiological assessment in relation to long-term outcomes. Methods Studies were included in the meta-analysis after performing a systematic literature search on July 1, 2022. The primary end point was the incidence of major adverse cardiac events, vessel-orientated cardiac events, or target vessel failure. Results Low post-PCI fractional flow reserve, reported in 7 studies with fractional flow reserve cutoff values between 0.84 and 0.90, including 4017 patients, was associated with an increased rate of the primary end point (hazard ratio [HR], 2.06; 95% CI, 1.37-3.08). One study reported about impaired post-PCI instantaneous wave-free ratio with instantaneous wave-free ratio cutoff value of 0.95 in relation to major adverse cardiac events, showing a significant association (HR, 3.38; 95% CI, 0.99-11.6; P = .04). Low post-PCI quantitative flow ratio, reported in 3 studies with quantitative flow ratio cutoff value between 0.89 and 0.91, including 1181 patients, was associated with an increased rate of vessel-orientated cardiac events (HR, 3.01; 95% CI, 2.10-4.32). Combining data of all modalities, impaired physiological assessment showed an increased rate of the primary end point (HR, 2.32; 95% CI, 1.71-3.16) and secondary end points, including death (HR, 1.41; 95% CI, 1.04-1.89), myocardial infarction (HR, 2.70; 95% CI, 1.34-5.42) and target vessel revascularization (HR, 2.88; 95% CI, 1.91-4.35). Conclusions Impaired post-PCI physiological assessment is associated with increased adverse cardiac events and individual end points, including death, myocardial infarction, and target vessel revascularization. Therefore, prospective studies are awaited on whether physiology-based optimization of PCI results in better clinical outcomes.
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Affiliation(s)
| | - Stijn C.H. van den Oord
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Cardiology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Steven Teerenstra
- Section Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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22
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Mavromatis K, Sandesara PB. The Trans-Stent FFR Gradient. JACC Cardiovasc Interv 2022; 15:2203-2205. [DOI: 10.1016/j.jcin.2022.10.001] [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: 09/10/2022] [Revised: 10/03/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
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23
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Piroth Z, Otsuki H, Zimmermann FM, Ferenci T, Keulards DCJ, Yeung AC, Pijls NHJ, De Bruyne B, Fearon WF. Prognostic Value of Measuring Fractional Flow Reserve After Percutaneous Coronary Intervention in Patients With Complex Coronary Artery Disease: Insights From the FAME 3 Trial. Circ Cardiovasc Interv 2022; 15:884-891. [PMID: 36121706 DOI: 10.1161/circinterventions.122.012542] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND We evaluate the prognostic value of measuring fractional flow reserve (FFR) after percutaneous coronary intervention (post-PCI FFR) and intravascular imaging in patients undergoing PCI for 3-vessel coronary artery disease in the FAME 3 trial (Fractional Flow Reserve versus Angiography for Multivessel Evaluation). METHODS The FAME 3 trial is a multicenter, international, randomized study comparing FFR-guided PCI with coronary artery bypass grafting in patients with multivessel coronary artery disease. PCI was not noninferior with respect to the primary end point of death, myocardial infarction, stroke, or repeat revascularization at 1 year. Post-PCI FFR data were acquired on a patient and vessel-related basis. Intravascular imaging guidance was tracked. The primary end point is a comparison of target vessel failure (TVF) defined as a composite of cardiac death, target vessel myocardial infarction, and target vessel revascularization at 1 year based on post-PCI FFR values. Cox regression with robust SEs was used for analysis. RESULTS Of the 757 patients randomized to PCI, 461 (61%) had post-PCI FFR measurement and 11.1% had intravascular imaging performed. The median post-PCI FFR was 0.89 [IQR' 0.85-0.94]. On a vessel-level, post-PCI FFR was found to be a significant predictor of TVF univariately (hazard ratio=0.67 [95% CI' 0.48-0.93] for 0.1 unit increase, P=0.0165). On a patient-level, the single lowest post-PCI FFR value was also found to be a significant predictor of TVF univariately (hazard ratio=0.65 [95% CI' 0.48-0.89] for 0.1 unit increase, P=0.0074). Post-PCI FFR was an independent predictor of TVF in multivariable analysis adjusted for key clinical parameters. Outcomes were similar between patients who had intravascular imaging guidance and those who did not. CONCLUSIONS Post-PCI FFR measurement was a significant predictor of TVF on a vessel and patient level and an independent predictor of outcomes in a population with complex 3-vessel coronary artery disease eligible for coronary artery bypass grafting. The limited use of intravascular imaging did not affect outcomes. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02100722.
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Affiliation(s)
- Zsolt Piroth
- Gottsegen National Cardiovascular Center, Budapest' Hungary (Z.P.)
| | - Hisao Otsuki
- Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University, CA (H.O., A.C.Y., W.F.F.)
| | | | - Tamás Ferenci
- Physiological Controls Research Center, Obuda University and Department of Statistics, Corvinus University of Budapest, Hungary (T.F.)
| | | | - Alan C Yeung
- Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University, CA (H.O., A.C.Y., W.F.F.)
| | - Nico H J Pijls
- Physiological Controls Research Center, Obuda University and Department of Statistics, Corvinus University of Budapest, Hungary (T.F.)
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Aalst, Belgium and Lausanne University Centre Hospital, Switzerland (B.D.B.)
| | - William F Fearon
- Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University, CA (H.O., A.C.Y., W.F.F.).,Stanford University School of Medicine, Stanford Cardiovascular Institute, and VA Palo Alto Health Care System, CA (W.F.F.)
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24
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Munhoz D, Sakai K, Collet C, Mizukami T. Triggering Stent Optimization by Coronary Physiology. JACC Cardiovasc Interv 2022; 15:2228. [DOI: 10.1016/j.jcin.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 09/06/2022] [Indexed: 11/09/2022]
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25
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Fezzi S, Huang J, Lunardi M, Ding D, Ribichini FL, Tu S, Wijns W. Coronary physiology in the catheterisation laboratory: an A to Z practical guide. ASIAINTERVENTION 2022; 8:86-109. [PMID: 36798834 PMCID: PMC9890586 DOI: 10.4244/aij-d-22-00022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/21/2022] [Indexed: 11/16/2022]
Abstract
Coronary revascularisation, either percutaneous or surgical, aims to improve coronary flow and relieve myocardial ischaemia. The decision-making process in patients with coronary artery disease (CAD) remains largely based on invasive coronary angiography (ICA), even though until recently ICA could not assess the functional significance of coronary artery stenoses. Invasive wire-based approaches for physiological evaluations were developed to properly assess the ischaemic relevance of epicardial CAD. Fractional flow reserve (FFR) and later, instantaneous wave-free ratio (iFR), were shown to improve clinical outcomes in several patient subsets when used for coronary revascularisation guidance or deferral and for procedural optimisation of percutaneous coronary intervention (PCI) results. Despite accumulating evidence and positive guideline recommendations, the adoption of invasive physiology has remained quite low, mainly due to technical and economic issues as well as to operator-resistance to change. Coronary image-based computational physiology has been recently developed, with promising results in terms of accuracy and a reduction in computational time, costs, radiation exposure and risks for the patient. Lastly, the integration of intracoronary imaging and physiology allows for individualised PCI treatment, aiming at complete relief of ischaemia through optimised morpho-functional immediate procedural results. Instead of a conventional state-of-the-art review, this A to Z dictionary attempts to provide a practical guide for the application of coronary physiology in the catheterisation laboratory, exploring several methods, their pitfalls, and useful tips and tricks.
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Affiliation(s)
- Simone Fezzi
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Mattia Lunardi
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Daixin Ding
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Flavio L Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- Department of Cardiology, Fujian Medical University Union Hospital, Fujian, China
| | - William Wijns
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
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26
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Sumaya W, Mamas MA, Bagur R. Quantitative Flow Ratio and Virtual Percutaneous Coronary Intervention for Serial Coronary Stenoses: Attractive Technology, But Still Crawling. J Am Heart Assoc 2022; 11:e027165. [PMID: 36129036 DOI: 10.1161/jaha.122.027165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Wael Sumaya
- Interventional Cardiology, Division of Cardiology, Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax Nova Scotia Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences Keele University Stoke-on-Trent United Kingdom
| | - Rodrigo Bagur
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences Keele University Stoke-on-Trent United Kingdom.,Interventional Cardiology, Division of Cardiology, London Health Sciences Centre Western University London Ontario Canada
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27
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Hwang D, Koo BK, Zhang J, Park J, Yang S, Kim M, Yun JP, Lee JM, Nam CW, Shin ES, Doh JH, Chen SL, Kakuta T, Toth GG, Piroth Z, Johnson NP, Pijls NHJ, Hakeem A, Uretsky BF, Hokama Y, Tanaka N, Lim HS, Ito T, Matsuo A, Azzalini L, Leesar MA, Neleman T, van Mieghem NM, Diletti R, Daemen J, Collison D, Collet C, De Bruyne B. Prognostic Implications of Fractional Flow Reserve After Coronary Stenting: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2232842. [PMID: 36136329 PMCID: PMC9500557 DOI: 10.1001/jamanetworkopen.2022.32842] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) is generally considered to reflect residual disease. Yet the clinical relevance of post-PCI FFR after drug-eluting stent (DES) implantation remains unclear. OBJECTIVE To evaluate the clinical relevance of post-PCI FFR measurement after DES implantation. DATA SOURCES MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant published articles from inception to June 18, 2022. STUDY SELECTION Published articles that reported post-PCI FFR after DES implantation and its association with clinical outcomes were included. DATA EXTRACTION AND SYNTHESIS Patient-level data were collected from the corresponding authors of 17 cohorts using a standardized spreadsheet. Meta-estimates for primary and secondary outcomes were analyzed per patient and using mixed-effects Cox proportional hazard regression with registry identifiers included as a random effect. All processes followed the Preferred Reporting Items for Systematic Review and Meta-analysis of Individual Participant Data. MAIN OUTCOMES AND MEASURES The primary outcome was target vessel failure (TVF) at 2 years, a composite of cardiac death, target vessel myocardial infarction (TVMI), and target vessel revascularization (TVR). The secondary outcome was a composite of cardiac death or TVMI at 2 years. RESULTS Of 2268 articles identified, 29 studies met selection criteria. Of these, 28 articles from 17 cohorts provided data, including a total of 5277 patients with 5869 vessels who underwent FFR measurement after DES implantation. Mean (SD) age was 64.4 (10.1) years and 4141 patients (78.5%) were men. Median (IQR) post-PCI FFR was 0.89 (0.84-0.94) and 690 vessels (11.8%) had a post-PCI FFR of 0.80 or below. The cumulative incidence of TVF was 340 patients (7.2%), with cardiac death or TVMI occurring in 111 patients (2.4%) at 2 years. Lower post-PCI FFR significantly increased the risk of TVF (adjusted hazard ratio [HR] per 0.01 FFR decrease, 1.04; 95% CI, 1.02-1.05; P < .001). The risk of cardiac death or MI also increased inversely with post-PCI FFR (adjusted HR, 1.03; 95% CI, 1.00-1.07, P = .049). These associations were consistent regardless of age, sex, the presence of hypertension or diabetes, and clinical diagnosis. CONCLUSIONS AND RELEVANCE Reduced FFR after DES implantation was common and associated with the risks of TVF and of cardiac death or TVMI. These results indicate the prognostic value of post-PCI physiologic assessment after DES implantation.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jinlong Zhang
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiesuck Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Minsang Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jun Pil Yun
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan Hospital, Ulsan, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Shao-Liang Chen
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Gabor G. Toth
- University Heart Centre Graz, Medical University Graz, Austria
| | - Zsolt Piroth
- Gottsegen Hungarian Institute of Cardiology, Budapest, Hungary
| | - 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
| | - Nico H. J. Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Abdul Hakeem
- Division of Cardiovascular Diseases & Hypertension, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Barry F. Uretsky
- Central Arkansas VA Health System, Little Rock, Arkansas
- University of Arkansas for Medical Sciences, Little Rock
| | - Yohei Hokama
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Hong-Seok Lim
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea
| | - Tsuyoshi Ito
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Akiko Matsuo
- Department of Cardiology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Lorenzo Azzalini
- Division of Cardiology, Department of Medicine, University of Washington, Seattle
| | - Massoud A. Leesar
- Division of Cardiovascular Diseases, University of Alabama, Birmingham
| | - Tara Neleman
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Nicolas M. van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Damien Collison
- West of Scotland Regional Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | | | - Bernard De Bruyne
- Cardiovascular Center Aalst, Aalst, Belgium
- Department of Cardiology, University of Lausanne, Switzerland
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Neleman T, van Zandvoort LJC, Tovar Forero MN, Masdjedi K, Ligthart JMR, Witberg KT, Groenland FTW, Cummins P, Lenzen MJ, Boersma E, Nuis RJ, den Dekker WK, Diletti R, Wilschut J, Zijlstra F, Van Mieghem NM, Daemen J. FFR-Guided PCI Optimization Directed by High-Definition IVUS Versus Standard of Care: The FFR REACT Trial. JACC Cardiovasc Interv 2022; 15:1595-1607. [PMID: 35981832 DOI: 10.1016/j.jcin.2022.06.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/06/2022] [Accepted: 06/14/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) <0.90 is common and has been related to impaired patient outcome. OBJECTIVES The authors sought to evaluate if PCI optimization directed by intravascular ultrasound (IVUS) in patients with post-PCI FFR <0.90 could improve 1-year target vessel failure (TVF) rates. METHODS In this single-center, randomized, double-blind trial, patients with a post-PCI FFR <0.90 at the time of angiographically successful PCI were randomized to IVUS-guided optimization or the standard of care (control arm). The primary endpoint was TVF (a composite of cardiac death, spontaneous target vessel myocardial infarction, and clinically driven target vessel revascularization) at 1 year. RESULTS A total of 291 patients with post-PCI FFR <0.90 were randomized (IVUS-guided optimization arm: n = 145/152 vessels, control arm: n = 146/157 vessels). The mean post-PCI FFR was 0.84 ± 0.05. A total of 104 (68.4%) vessels in the IVUS-guided optimization arm underwent additional optimization including additional stenting (34.9%) or postdilatation only (33.6%), resulting in a mean increase in post-PCI FFR in these vessels from 0.82 ± 0.06 to 0.85 ± 0.05 (P < 0.001) and a post-PCI FFR ≥0.90 in 20% of the vessels. The 1-year TVF rate was comparable between the 2 study arms (IVUS-guided optimization arm: 4.2%, control arm: 4.8%; P = 0.79). There was a trend toward a lower incidence of clinically driven target vessel revascularization in the IVUS-guided optimization arm (0.7% vs. 4.2%, P = 0.06). CONCLUSIONS IVUS-guided post-PCI FFR optimization significantly improved post-PCI FFR. Because of lower-than-expected event rates, post-PCI FFR optimization did not significantly lower TVF at the 1-year follow-up.
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Affiliation(s)
- Tara Neleman
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Maria N Tovar Forero
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kaneshka Masdjedi
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jurgen M R Ligthart
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Karen T Witberg
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Paul Cummins
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mattie J Lenzen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wijnand K den Dekker
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen Wilschut
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Leone AM, Migliaro S, Zimbardo G, Cialdella P, Basile E, Galante D, Di Giusto F, Anastasia G, Vicere A, Petrolati E, Di Stefano A, Campaniello G, D’Amario D, Vergallo R, Montone RA, Buffon A, Romagnoli E, Aurigemma C, Burzotta F, Trani C, Crea F. Safety and effectiveness of post percutaneous coronary intervention physiological assessment: Retrospective data from the post-revascularization optimization and physiological evaluation of intermediate lesions using fractional flow reserve registry. Front Cardiovasc Med 2022; 9:983003. [PMID: 36061555 PMCID: PMC9433711 DOI: 10.3389/fcvm.2022.983003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background While the importance of invasive physiological assessment (IPA) to choose coronary lesions to be treated is ascertained, its role after PCI is less established. We evaluated feasibility and efficacy of Physiology-guided PCI in the everyday practice in a retrospective registry performed in a single high-volume and “physiology-believer” center. Materials and methods The PROPHET-FFR study (NCT05056662) patients undergoing an IPA in 2015–2020 were retrospectively enrolled in three groups: Control group comprising patients for whom PCI was deferred based on a IPA; Angiography-Guided PCI group comprising patients undergoing PCI based on an IPA but without a post-PCI IPA; Physiology-guided PCI group comprising patients undergoing PCI based on an IPA and an IPA after PCI, followed by a physiology-guided optimization, if indicated. Optimal result was defined by an FFR value ≥ 0.90. Results A total of 1,322 patients with 1,591 lesions were available for the analysis. 893 patients (67.5%) in Control Group, 249 patients (18.8%) in Angiography-guided PCI Group and 180 patients (13.6%) in Physiology-guided PCI group. In 89 patients a suboptimal functional result was achieved that was optimized in 22 cases leading to a “Final FFR” value of 0.90 ± 0.04 in Angiography-Guided PCI group. Procedural time, costs, and rate of complications were similar. At follow up the rate of MACEs for the Physiology-guided PCI group was similar to the Control Group (7.2% vs. 8.2%, p = 0.765) and significantly lower than the Angiography-guided PCI Group (14.9%, p < 0.001), mainly driven by a reduction in TVRs. Conclusion “Physiology-guided PCI” is a feasible strategy with a favorable impact on mid-term prognosis. Prospective studies using a standardized IPA are warrant to confirm these data.
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Affiliation(s)
- Antonio Maria Leone
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli (IRCCS), Rome, Italy
- *Correspondence: Antonio Maria Leone, ,
| | - Stefano Migliaro
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Eloisa Basile
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico Galante
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federico Di Giusto
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianluca Anastasia
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Vicere
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Edoardo Petrolati
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Di Stefano
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giorgia Campaniello
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico D’Amario
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli (IRCCS), Rome, Italy
| | - Rocco Vergallo
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli (IRCCS), Rome, Italy
| | - Rocco Antonio Montone
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli (IRCCS), Rome, Italy
| | - Antonino Buffon
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Enrico Romagnoli
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli (IRCCS), Rome, Italy
| | - Cristina Aurigemma
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli (IRCCS), Rome, Italy
| | - Francesco Burzotta
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carlo Trani
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Crea
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
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Popa-Fotea NM, Scafa-Udriste A, Dorobantu M. The Continuum of Invasive Techniques for the Assessment of Intermediate Coronary Lesions. Diagnostics (Basel) 2022; 12:diagnostics12061492. [PMID: 35741302 PMCID: PMC9221746 DOI: 10.3390/diagnostics12061492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 11/24/2022] Open
Abstract
Ischemic heart disease is one of the most important causes of mortality and morbidity worldwide. Revascularization of coronary stenosis inducing ischemia, either by percutaneous or surgical intervention, significantly reduces major adverse cardiovascular events and improves quality of life. However, in cases of intermediate lesions, classified by a diameter stenosis between 50 and 90% by European guidelines and 40–70% in American counterparts with no clear evidence of ischemia, the indication of revascularization and impact is determined using various methods that altogether comprehensively evaluate the lesions. This review will discuss the various techniques to assess intermediate stenoses, highlighting indications and advantages, but also drawbacks. Fractional flow rate (FFR) and instantaneous wave-free ratio (iFR) are the gold standard for the functional evaluation of intermediate lesions, but there are clinical circumstances in which these pressure-wire-derived indices are not accurate. Complementary invasive investigations, mainly intravascular ultrasound and/or optical coherence tomography, offer parameters that can be correlated with FFR/iFR and additional insights into the morphology of the plaque guiding the eventual percutaneous intervention in terms of length and size of stents, thus improving the outcomes of the procedure. The development of artificial intelligence and machine learning with advanced algorithms of prediction will offer multiple scenarios for treatment, allowing real-time selection of the best strategy for revascularization.
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Affiliation(s)
- Nicoleta-Monica Popa-Fotea
- Cardiothoracic Department, University of Medicine and Pharmacy “Carol Davila”, 8, Bulevardul Eroii Sanitari, 050474 Bucharest, Romania; (A.S.-U.); (M.D.)
- Emergency Clinical Hospital, 10, Calea Floreasca, 014461 Bucharest, Romania
- Correspondence: ; Tel.: +40-724381385
| | - Alexandru Scafa-Udriste
- Cardiothoracic Department, University of Medicine and Pharmacy “Carol Davila”, 8, Bulevardul Eroii Sanitari, 050474 Bucharest, Romania; (A.S.-U.); (M.D.)
- Emergency Clinical Hospital, 10, Calea Floreasca, 014461 Bucharest, Romania
| | - Maria Dorobantu
- Cardiothoracic Department, University of Medicine and Pharmacy “Carol Davila”, 8, Bulevardul Eroii Sanitari, 050474 Bucharest, Romania; (A.S.-U.); (M.D.)
- Romanian Academy, 010071 Bucharest, Romania
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31
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FFRCT Planner. JACC Cardiovasc Imaging 2022; 15:1256-1258. [DOI: 10.1016/j.jcmg.2022.03.011] [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: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 11/21/2022]
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The prognostic value of angiography-based vessel fractional flow reserve after percutaneous coronary intervention: The FAST Outcome study. Int J Cardiol 2022; 359:14-19. [PMID: 35421516 DOI: 10.1016/j.ijcard.2022.04.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/28/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Vessel Fractional Flow Reserve (vFFR) as assessed by three-dimensional quantitative coronary angiography has high correlation with pressure wire-based fractional flow reserve in both a pre- and post-PCI setting. The present study aims to assess the prognostic value of post-PCI vFFR on the incidence of target vessel failure (TVF), a composite endpoint of cardiac death, target vessel myocardial infarction and target vessel revascularization (TVR) at 5-year follow up. METHODS Post-PCI vFFR was calculated after routine PCI in a total of 748 patients (832 vessels) with available orthogonal angiographic projections of the stented segment. RESULTS Median age was 65 (IQR 55-74) years, 18.2% were diabetic, and 29.1% presented with stable angina. Median post-PCI vFFR was 0.91 (IQR 0.86-0.95). Vessels were categorized into tertiles based on post-PCI vFFR: low (vFFR <0.88), middle (vFFR 0.88-0.93), and upper (vFFR ≥0.94). Vessels in the lower and middle tertile were more often LADs and had smaller stent diameters (p-value <0.001). Vessels in the lower and middle tertile had a higher risk of TVF as compared to vessels in the upper tertile (24.6% and 21.5% vs. 17.1%; adjusted HR 1.84 (95%CI 1.15-2.95), p = 0.011, and 1.58 (95%CI 1.02-2.45), p = 0.040) at 5-years follow-up. Additionally, vessels in the lower tertile had higher rates of TVR as compared to vessels in the higher tertile (12.6% vs. 6.5%, adjusted HR 1.93 (95%CI 1.06-3.53), p-value = 0.033). CONCLUSION Lower post-PCI vFFR values are associated with a significantly increased risk of TVF and TVR at 5-years follow-up.
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Zhou Z, Zhu B, Fan F, Yang F, Fang S, Wang Z, Qiu L, Gong Y, Huo Y. Prognostic Value of Coronary Angiography-Derived Fractional Flow Reserve Immediately After Stenting. Front Cardiovasc Med 2022; 9:834553. [PMID: 35387443 PMCID: PMC8978525 DOI: 10.3389/fcvm.2022.834553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/24/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives The aim of this study was to investigate the potential prognostic value of post-percutaneous coronary intervention (PCI) angiography-derived fractional flow reserve (FFR) and its gradient across the stent. Background Post-PCI FFR and its gradient across the stent have been proved to be associated with clinical outcomes. However, little is known about the prognostic value of post-PCI coronary angiography-derived FFR and its gradient across the stent. Methods Patients diagnosed with coronary heart disease and participated in drug-eluting stent (DES) clinical trials for stent implantation in a single center were included for this retrospective analysis. A novel coronary angiography-derived FFR (caFFR) and its gradient across the stent were calculated offline using two projections from coronary angiography performed after PCI. Clinical follow-up was completed at 9 months after the index procedure and the primary outcome was target vessel failure (TVF), defined as a composite of target vessel-related myocardial infarction (MI), target vessel-related revascularization (TVR), and cardiac death. Coronary angiography was also performed at the 9 months follow-up time to get data of late lumen loss (LLL) and percent diameter stenosis (%DS). Results A total of 159 vessels in 136 patients were analyzed. The mean value of post-PCI caFFR was 0.90 ± 0.06. The median value of trans-stent caFFR gradient (ΔcaFFRstent) was 0.04 (interquartile range 0.02-0.08). ΔcaFFRstent>0 was demonstrated in 147 vessels (92.45%). The TVF rate was significantly higher in patients with post-PCI caFFR < 0.90 (4 [8.16%] vs. 1 [1.15%], P = 0.037), which was mainly achieved by the difference between the TVR rate. In the subgroup with lesions located in the left anterior descending coronary artery (LAD), post-PCI caFFR was an independent predictor of LLL (β = -1.07, 95% CI: -1.74 to -0.39, P = 0.002) and %DS at follow-up (β = -30.24, 95% CI: -56.44 to -4.04, P = 0.025), ΔcaFFRstent was an independent predictor of LLL (β=0.98, 95% CI:0.13-1.83, P = 0.026). Conclusion Suboptimal post-PCI caFFR and trans-stent caFFR gradient were common among vessels immediately after stenting. Lower post-PCI caFFR was associated with a higher rate of 9-month TVF. After LAD PCI, both post-PCI caFFR and its gradient across stent were independent predictors of the neointimal proliferation of the target vessel evaluated by LLL and %DS at follow-up.
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Affiliation(s)
- Zuoyi Zhou
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Baozhen Zhu
- Department of Cardiology, Peking University First Hospital, Beijing, China.,Department of Intervention, Tongxin People's Hospital, Tongxin, China
| | - Fangfang Fan
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Fan Yang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Shu Fang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Zhi Wang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Lin Qiu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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Prognostic value of post-percutaneous coronary intervention diastolic pressure ratio. Neth Heart J 2022; 30:352-359. [PMID: 35391616 PMCID: PMC9270544 DOI: 10.1007/s12471-022-01680-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/20/2022] Open
Abstract
Aim To evaluate the distribution of a generic diastolic pressure ratio (dPR) after angiographically successful percutaneous coronary intervention (PCI) and to assess its association with the 2‑year incidence of target vessel failure (TVF), defined as a composite of cardiac mortality, target vessel revascularisation, target vessel myocardial infarction and stent thrombosis. Methods The dPR SEARCH study is a post hoc analysis of the prospective single-centre FFR-SEARCH registry, in which physiological assessment was performed after angiographically successful PCI in a total of 1000 patients, using a dedicated microcatheter. dPR was calculated offline with recently validated software in a subset of 735 patients. Results Mean post-PCI dPR was 0.95 ± 0.06. Post-PCI dPR was ≤ 0.89 in 15.2% of the patients. The cumulative incidence of TVF at 2‑year follow-up was 9.4% in patients with a final post-PCI dPR ≤ 0.89 as compared to 6.1% in patients with a post-PCI dPR > 0.89 (adjusted hazard ratio [HR] for dPR ≤ 0.89: 1.53; 95% CI 0.74–3.13; p = 0.249). dPR ≤ 0.89 was associated with significantly higher cardiac mortality at 2 years; adjusted HR 2.40; 95% CI 1.01–5.68; p = 0.047. Conclusions In a real-world setting, despite optimal angiographic PCI results, 15.2% of the patients had a final post-PCI dPR of ≤ 0.89, which was associated with a higher incidence of TVF and a significantly higher cardiac mortality rate. Supplementary Information The online version of this article (10.1007/s12471-022-01680-0) contains supplementary material, which is available to authorized users.
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Eftekhari A, Westra J, Stegehuis V, Holm NR, van de Hoef TP, Kirkeeide RL, Piek JJ, Lance Gould K, Johnson NP, Christiansen EH. Prognostic value of microvascular resistance and its association to fractional flow reserve: a DEFINE-FLOW substudy. Open Heart 2022; 9:e001981. [PMID: 35410913 PMCID: PMC9003618 DOI: 10.1136/openhrt-2022-001981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the prognostic value of hyperemic microvascular resistance (HMR) and its relationship with hyperemic stenosis resistance (HSR) index and fractional flow reserve (FFR) in stable coronary artery disease. METHODS This is a substudy of the DEFINE-FLOW cohort (NCT02328820), which evaluated the prognosis of lesions (n=456) after combined FFR and coronary flow reserve (CFR) assessment in a prospective, non-blinded, non-randomised, multicentre study in 12 centres in Europe and Japan. Participants (n=430) were evaluated by wire-based measurement of coronary pressure, flow and vascular resistance (ComboWire XT, Phillips Volcano, San Diego, California, USA). RESULTS Mean FFR and CFR were 0.82±0.10 and 2.2±0.6, respectively. When divided according to FFR and CFR thresholds (above and below 0.80 and 2.0, respectively), HMR was highest in lesions with FFR>0.80 and CFR<2.0 (n=99) compared with lesions with FFR≤0.80 and CFR≥2.0 (n=68) (2.92±1.2 vs 1.91±0.64 mm Hg/cm/s, p<0.001). The FFR value was proportional to the ratio between HMR and the HMR+HSR (total resistance), 95% limits of agreement (-0.032; 0.019), bias (-0.003±0.02) and correlation (r2=0.98, p<0.0001). Cox regression model using HMR as continuous parameter for target vessel failure showed an HR of 1.51, 95% CI (0.9 to 2.4), p=0.10. CONCLUSIONS Increased HMR was not associated with a higher rate of adverse clinical events, in this population of mainly stable patients. FFR can be equally well expressed as HMR/HMR+HSR, thereby providing an alternative conceptual formulation linking epicardial severity with microvascular resistance. TRIAL REGISTRATION NUMBER NCT02328820.
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Affiliation(s)
- Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
- Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Valérie Stegehuis
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Niels Ramsing Holm
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Tim P van de Hoef
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Richard L Kirkeeide
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | - Jan J Piek
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - K Lance Gould
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | - Nils P Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
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Tomaniak M, Neleman T, Ziedses des Plantes A, Masdjedi K, van Zandvoort LJC, Kochman J, den Dekker WK, Wilschut JM, Diletti R, Kardys I, Zijlstra F, Van Mieghem NM, Daemen J. Diagnostic Accuracy of Coronary Angiography-Based Vessel Fractional Flow Reserve (vFFR) Virtual Stenting. J Clin Med 2022; 11:jcm11051397. [PMID: 35268488 PMCID: PMC8910880 DOI: 10.3390/jcm11051397] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/20/2022] [Accepted: 02/22/2022] [Indexed: 02/01/2023] Open
Abstract
3D coronary angiography-based vessel fractional flow reserve (vFFR) proved to be an accurate diagnostic alternative to invasively measured pressure wire based fractional flow reserve (FFR). The ability to compute post-PCI vFFR using pre-PCI vFFR virtual stent analysis is unknown. We aimed to assess the feasibility and diagnostic accuracy of pre-PCI vFFR virtual stenting analysis (residual vFFR) with post-PCI FFR as a reference. This is an observational, single-center retrospective cohort study including consecutive patients from the FFR-SEARCH registry. We blindly calculated residual vFFR from pre-PCI angiograms and compared them to invasive pressure-wire based post-PCI FFR. Inclusion criteria involved presentation with either stable or unstable angina or non-ST elevation myocardial infarction (NSTEMI), ≥1 significant stenosis in one of the epicardial coronary arteries (percentage diameter stenosis of >70% by QCA or hemodynamically relevant stenosis with FFR ≤0.80) and pre procedural angiograms eligible for vFFR analysis. Exclusion criteria comprised patients with ST elevation myocardial infarction (STEMI), coronary bypass grafts, cardiogenic shock or severe hemodynamic instability. Eighty-one pre-PCI residual vFFR measurements were compared to post-PCI FFR and post-PCI vFFR measurements. Mean residual vFFR was 0.91 ± 0.06, mean post-PCI FFR 0.91 ± 0.06 and mean post-PCI vFFR was 0.92 ± 0.05. Residual vFFR showed a high linear correlation (r = 0.84) and good agreement (mean difference (95% confidence interval): 0.005 (−0.002−0.012)) with post-PCI FFR, as well as with post-PCI-vFFR (r = 0.77, mean difference −0.007 (−0.015−0.0003)). Residual vFFR showed good accuracy in the identification of lesions with post-PCI FFR < 0.90 (sensitivity 94%, specificity 71%, area under the curve (AUC) 0.93 (95% CI: 0.86−0.99), p < 0.001). Virtual stenting using vFFR provided an accurate estimation of post-PCI FFR and post-PCI vFFR. Further studies are needed to prospectively validate a vFFR-guided PCI strategy.
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Affiliation(s)
- Mariusz Tomaniak
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
- First Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Tara Neleman
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
| | - Anniek Ziedses des Plantes
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
| | - Kaneshka Masdjedi
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
| | - Laurens J. C. van Zandvoort
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
| | - Janusz Kochman
- First Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Wijnand K. den Dekker
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
| | - Jeroen M. Wilschut
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
| | - Isabella Kardys
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
| | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
| | - Nicolas M. Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
| | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center, ThoraxCenter, 3000 CA Rotterdam, The Netherlands; (M.T.); (T.N.); (A.Z.d.P.); (K.M.); (L.J.C.v.Z.); (W.K.d.D.); (J.M.W.); (R.D.); (I.K.); (F.Z.); (N.M.V.M.)
- Correspondence: ; Tel.: +31-10-703-5260
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Improving PCI Outcomes Using Postprocedural Physiology and Intravascular Imaging. JACC Cardiovasc Interv 2021; 14:2415-2430. [PMID: 34794649 DOI: 10.1016/j.jcin.2021.08.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/07/2021] [Accepted: 08/03/2021] [Indexed: 11/24/2022]
Abstract
Although clinical outcomes after percutaneous coronary intervention (PCI) are improving, the long-term risk for target vessel failure remains concerning. Although the application of intravascular imaging and physiological indexes significantly improves outcomes, their routine use in practice remains limited. Nevertheless, merely using these modalities is not enough, and to truly improve patient outcomes, optimal intravascular dimensions with minimal vascular injury should be targeted. When assessing post-PCI results using either type of physiological or imaging technology, a broad spectrum of stent- and vessel-related anomalies can be expected. As not all of these issues warrant treatment, a profound knowledge of what to expect and how to recognize and when to treat these intraluminal problems is needed. Additionally, promising new modalities such as angiography-derived coronary physiology and hybrid imaging catheters are becoming available. The authors provide an overview of the currently available tools and techniques to define suboptimal PCI and when to apply these technologies to improve outcomes.
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Residual Quantitative Flow Ratio to Estimate Post-Percutaneous Coronary Intervention Fractional Flow Reserve. J Interv Cardiol 2021; 2021:4339451. [PMID: 34548847 PMCID: PMC8426071 DOI: 10.1155/2021/4339451] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Quantitative flow ratio (QFR) computes fractional flow reserve (FFR) based on invasive coronary angiography (ICA). Residual QFR estimates post‐percutaneous coronary intervention (PCI) FFR. This study sought to assess the relationship of residual QFR with post-PCI FFR. Methods Residual QFR analysis, using pre-PCI ICA, was attempted in 159 vessels with post-PCI FFR. QFR lesion location was matched with the PCI location to simulate the performed intervention and allow computation of residual QFR. A post-PCI FFR < 0.90 was used to define a suboptimal PCI result. Results Residual QFR computation was successful in 128 (81%) vessels. Median residual QFR was higher than post-PCI FFR (0.96 Q1–Q3: 0.91–0.99 vs. 0.91 Q1–Q3: 0.86–0.96, p < 0.001). A significant correlation and agreement were observed between residual QFR and post-PCI FFR (R = 0.56 and intraclass correlation coefficient = 0.47, p < 0.001 for both). Following PCI, an FFR < 0.90 was observed in 54 (42%) vessels. Specificity, positive predictive value, sensitivity, and negative predictive value of residual QFR for assessment of the PCI result were 96% (95% confidence interval (CI): 87–99%), 89% (95% CI: 72–96%), 44% (95% CI: 31–59%), and 70% (95% CI: 65–75%), respectively. Residual QFR had an accuracy of 74% (95% CI: 66–82%) and an area under the receiver operating characteristic curve of 0.79 (95% CI: 0.71–0.86). Conclusions A significant correlation and agreement between residual QFR and post-PCI FFR were observed. Residual QFR ≥ 0.90 did not necessarily commensurate with a satisfactory PCI (post-PCI FFR ≥ 0.90). In contrast, residual QFR exhibited a high specificity for prediction of a suboptimal PCI result.
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Johnson NP, Collet C. Can FFR After Stenting Help Reduce Target Vessel Failure? JACC Cardiovasc Interv 2021; 14:1901-1903. [PMID: 34503740 DOI: 10.1016/j.jcin.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Nils P Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA.
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
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Zimbardo G, Cialdella P, DI Giusto F, Migliaro S, Anastasia G, Petrolati E, Galante D, D'Amario D, Leone AM. Physiological assessment after percutaneous coronary intervention: the hard truth. Panminerva Med 2021; 63:519-528. [PMID: 34486363 DOI: 10.23736/s0031-0808.21.04363-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Physiologically guided revascularization, using Fractional Flow Reserve (FFR) or instantaneous wave free ratio (iFR) has been demonstrated to be associated with better long-term outcomes compared to an angiographically-guided strategy, mainly avoiding inappropriate coronary stenting and its associated adverse events. On the contrary, the role of invasive physiological assessment after percutaneous coronary intervention (PCI) is much less well established. However, a large body of evidence suggests that a relevant proportion of patients undergoing PCI with a satisfying angiographic result show instead a suboptimal functional product with a potentially negative prognostic impact. For this reason, many efforts have been focused to identify interventional strategies to physiologically optimize PCI. Measuring the functional result after as PCI, especially when performed after a physiological assessment, implies that the operator is ready to accept the hard truth of an unsatisfactory physiological result despite angiographically optimal and, consequently, to optimize the product with some additional effort. The aim of this review is to bridge this gap in knowledge by better defining the paradigm shift of invasive physiological assessment from a simple tool for deciding whether an epicardial stenosis has to be treated to a thoroughly physiological approach to PCI with the suggestion of a practical flow chart.
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Affiliation(s)
| | | | - Federico DI Giusto
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Migliaro
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gianluca Anastasia
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Edoardo Petrolati
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico Galante
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D'Amario
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio M Leone
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy -
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Lee JM, Koo BK. Clinical Implications of Physiologic Assessment After Stenting: Practical Tool Beyond Simple Digits. Circ Cardiovasc Interv 2021; 14:e010592. [PMID: 33685216 DOI: 10.1161/circinterventions.121.010592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.M.L.)
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Korea (B.-K.K.)
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