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Altstidl JM, Achenbach S, Feyrer J, Nazli JB, Marwan M, Gaede L, Möllmann H, Giesler T, Rittger H, Pauschinger M, Rudolph TK, Moshage W, Brück M, Tröbs M. Use of coronary physiology to guide revascularization in clinical practice: results of the F(FR) 2 registry. Clin Res Cardiol 2024; 113:1081-1091. [PMID: 38832995 PMCID: PMC11219411 DOI: 10.1007/s00392-024-02463-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/15/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Despite the recommendation of coronary physiology to guide revascularization in angiographically intermediate stenoses without established correlation to ischemia, its uptake in clinical practice is slow. AIMS This study aimed to analyze the use of coronary physiology in clinical practice. METHODS Based on a multicenter registry (Fractional Flow Reserve Fax Registry, F(FR)2, ClinicalTrials.gov identifier NCT03055910), clinical use, consequences, and complications of coronary physiology were systematically analyzed. RESULTS F(FR)2 enrolled 2,000 patients with 3,378 intracoronary pressure measurements. Most measurements (96.8%) were performed in angiographically intermediate stenoses. Out of 3,238 lesions in which coronary physiology was used to guide revascularization, revascularization was deferred in 2,643 (78.2%) cases. Fractional flow reserve (FFR) was the most common pressure index used (87.6%), with hyperemia induced by an intracoronary bolus of adenosine in 2,556 lesions (86.4%) and intravenous adenosine used for 384 measurements (13.0%). The route of adenosine administration did not influence FFR results (change-in-estimate -3.1% for regression model predicting FFR from diameter stenosis). Agreement with the subsequent revascularization decision was 93.4% for intravenous and 95.0% for intracoronary adenosine (p = 0.261). Coronary artery occlusion caused by the pressure wire was reported in two cases (0.1%) and dissection in three cases (0.2%), which was fatal once (0.1%). CONCLUSIONS In clinical practice, intracoronary pressure measurements are mostly used to guide revascularization decisions in angiographically intermediate stenoses. Intracoronary and intravenous administration of adenosine seem equally suited. While the rate of serious complications of wire-based intracoronary pressure measurements in clinical practice seems to be low, it is not negligible.
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Affiliation(s)
- J Michael Altstidl
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Stephan Achenbach
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Johannes Feyrer
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - J Benedikt Nazli
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Mohamed Marwan
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Luise Gaede
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Helge Möllmann
- Department of Medicine 1 - Cardiology, Nephrology, Intensive Care and Rhythmology, St. Johannes Hospital Dortmund, Dortmund, Germany
| | - Tom Giesler
- Department of Cardiology, Helios Klinik Jerichower Land, Burg, Germany
| | - Harald Rittger
- Department of Cardiology and Pulmonology, Hospital Fürth, Fürth, Germany
| | - Matthias Pauschinger
- Department of Medicine 8 - Cardiology, Nuremberg Hospital South, Nuremberg, Germany
| | - Tanja K Rudolph
- Department of General and Interventional Cardiology, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
| | - Werner Moshage
- Department of Cardiology, Hospital Traunstein, Traunstein, Germany
| | - Martin Brück
- Department of Medicine 1, Hospital Wetzlar, Wetzlar, Germany
| | - Monique Tröbs
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany.
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2
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Faulder TI, Prematunga K, Moloi SB, Faulder LE, Jones R, Moxon JV. Agreement of Fractional Flow Reserve Estimated by Computed Tomography With Invasively Measured Fractional Flow Reserve: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2024; 13:e034552. [PMID: 38726901 PMCID: PMC11179792 DOI: 10.1161/jaha.124.034552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/21/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Fractional flow reserve (FFR) is the ratio of blood pressure measured distal to a stenosis and pressure proximal to a stenosis. FFR can be estimated noninvasively using computed tomography (CT) although the usefulness of this technique remains controversial. This meta-analysis evaluated the agreement of FFR estimated by CT (FFR-CT) with invasively measured FFR. The study also evaluated the diagnostic accuracy of FFR-CT, defined as the ability of FFR-CT to classify lesions as hemodynamically significant (invasive FFR ≤0.8) or insignificant (invasive FFR >0.8). METHODS AND RESULTS Forty-three studies reporting on 7291 blood vessels from 5236 patients were included. A moderate positive linear relationship between FFR-CT and invasively measured FFR was observed (Spearman correlation coefficient: 0.67). Agreement between the 2 measures increased as invasively measured FFR values approached 1. The overall diagnostic accuracy, sensitivity and specificity of FFR-CT were 82.2%, 80.9%, and 83.1%, respectively. Diagnostic accuracy of 90% could be demonstrated for FFR-CT values >0.90 and <0.49. The diagnostic accuracy of off-site tools was 79.4% and the diagnostic accuracy of on-site tools was 84.1%. CONCLUSIONS The agreement between FFR-CT and invasive FFR is moderate although agreement is highest in vessels with FFR-CT >0.9. Diagnostic accuracy varies widely with FFR-CT value but is above 90% for FFR-CT values >0.90 and <0.49. Furthermore, on-site and off-site tools have similar performance. Ultimately, FFR-CT may be a useful adjunct to CT coronary angiography as a gatekeeper for invasive coronary angiogram.
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Affiliation(s)
- Thomas I Faulder
- College of Medicine and Dentistry James Cook University Townsville QLD Australia
| | | | - Soniah B Moloi
- Department of Cardiology Townsville University Hospital Townsville QLD Australia
| | - Lauren E Faulder
- College of Medicine and Dentistry University of Adelaide Adelaide SA Australia
| | - Rhondda Jones
- Graduate Research School James Cook University Townsville QLD Australia
- Tropical Australian Academic Health Centre James Cook University Townsville QLD Australia
| | - Joseph V Moxon
- College of Medicine and Dentistry James Cook University Townsville QLD Australia
- The Australian Institute of Tropical Health and Medicine James Cook University Townsville QLD Australia
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3
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Ekmejian A, Howden N, Eipper A, Allahwala U, Ward M, Bhindi R. Association between vessel-specific coronary Aggregated plaque burden, Agatston score and hemodynamic significance of coronary disease (The CAPTivAte study). IJC HEART & VASCULATURE 2024; 51:101384. [PMID: 38496257 PMCID: PMC10940135 DOI: 10.1016/j.ijcha.2024.101384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 02/28/2024] [Accepted: 03/06/2024] [Indexed: 03/19/2024]
Abstract
Background CT coronary angiography (CTCA) is a guideline-endorsed assessment for patients with stable angina and suspected coronary disease. Although associated with excellent negative predictive value in ruling out obstructive coronary disease, there are limitations in the ability of CTCA to predict hemodynamically significant coronary disease. The CAPTivAte study aims to assess the utility of Aggregated Plaque Burden (APB) in predicting ischemia based on Fractional Flow Reserve (FFR). Methods In this retrospective study, patients who had a CTCA and invasive FFR of the LAD were included. The entire length of the LAD was analyzed using semi-automated software which characterized total plaque burden and plaque morphological subtype (including Low Attenuation Plaque (LAP), Non-calcific plaque (NCP) and Calcific Plaque (CP). Aggregated Plaque Burden (APB) was calculated. Univariate and multivariate analysis were performed to assess the association between these CT-derived parameters and invasive FFR. Results There were 145 patients included in this study. 84.8 % of patients were referred with stable angina. There was a significant linear association between APB and FFR in both univariate and multivariate analysis (Adjusted R-squared = 0.0469; p = 0.035). Mean Agatston scores are higher in FFR positive vessels compared to FFR negative vessels (371.6 (±443.8) vs 251.9 (±283.5, p = 0.0493). Conclusion CTCA-derived APB is a reliable predictor of ischemia assessed using invasive FFR and may aid clinicians in rationalizing invasive vs non-invasive management strategies. Vessel-specific Agatston scores are significantly higher in FFR-positive vessels than in FFR-negative vessels. Associations between HU-derived plaque subtype and invasive FFR were inconclusive in this study.
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Affiliation(s)
- Avedis Ekmejian
- Royal North Shore Hospital, Australia
- North Shore Private Hospital, Australia
- University of Sydney Northern Clinical School, Australia
| | - Nicklas Howden
- Royal North Shore Hospital, Australia
- North Shore Private Hospital, Australia
| | | | - Usaid Allahwala
- Royal North Shore Hospital, Australia
- North Shore Private Hospital, Australia
- University of Sydney Northern Clinical School, Australia
| | - Michael Ward
- Royal North Shore Hospital, Australia
- North Shore Private Hospital, Australia
- University of Sydney Northern Clinical School, Australia
| | - Ravinay Bhindi
- Royal North Shore Hospital, Australia
- North Shore Private Hospital, Australia
- University of Sydney Northern Clinical School, Australia
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Tsugu T, Tanaka K, Belsack D, Nagatomo Y, Tsugu M, Argacha JF, Cosyns B, Buls N, De Maeseneer M, De Mey J. Impact of vessel morphology on CT-derived fractional-flow-reserve in non-obstructive coronary artery disease in right coronary artery. Eur Radiol 2024; 34:1836-1845. [PMID: 37658136 PMCID: PMC10873436 DOI: 10.1007/s00330-023-09972-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/16/2023] [Accepted: 05/28/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES Computed tomography (CT)-derived fractional flow reserve (FFRCT) decreases continuously from proximal to distal segments of the vessel due to the influence of various factors even in non-obstructive coronary artery disease (NOCAD). It is known that FFRCT is dependent on vessel-length, but the relationship with other vessel morphologies remains to be explained. PURPOSE To investigate morphological aspects of the vessels that influence FFRCT in NOCAD in the right coronary artery (RCA). METHODS A total of 443 patients who underwent both FFRCT and invasive coronary angiography, with < 50% RCA stenosis, were evaluated. Enrolled RCA vessels were classified into two groups according to distal FFRCT: FFRCT ≤ 0.80 (n = 60) and FFRCT > 0.80 (n = 383). Vessel morphology (vessel length, lumen diameter, lumen volume, and plaque volume) and left-ventricular mass were assessed. The ratio of lumen volume and vessel length was defined as V/L ratio. RESULTS Whereas vessel-length was almost the same between FFRCT ≤ 0.80 and > 0.80, lumen volume and V/L ratio were significantly lower in FFRCT ≤ 0.80. Distal FFRCT correlated with plaque-related parameters (low-attenuation plaque, intermediate-attenuation plaque, and calcified plaque) and vessel-related parameters (proximal and distal vessel diameter, vessel length, lumen volume, and V/L ratio). Among all vessel-related parameters, V/L ratio showed the highest correlation with distal FFRCT (r = 0.61, p < 0.0001). Multivariable analysis showed that calcified plaque volume was the strongest predictor of distal FFRCT, followed by V/L ratio (β-coefficient = 0.48, p = 0.03). V/L ratio was the strongest predictor of a distal FFRCT ≤ 0.80 (cut-off 8.1 mm3/mm, AUC 0.88, sensitivity 90.0%, specificity 76.7%, 95% CI 0.84-0.93, p < 0.0001). CONCLUSIONS Our study suggests that V/L ratio can be a measure to predict subclinical coronary perfusion disturbance. CLINICAL RELEVANCE STATEMENT A novel marker of the ratio of lumen volume to vessel length (V/L ratio) is the strongest predictor of a distal CT-derived fractional flow reserve (FFRCT) and may have the potential to improve the diagnostic accuracy of FFRCT. KEY POINTS • Physiological FFRCT decline depends not only on vessel length but also on the lumen volume in non-obstructive coronary artery disease in the right coronary artery. • FFRCT correlates with plaque-related parameters (low-attenuation plaque, intermediate-attenuation plaque, and calcified plaque) and vessel-related parameters (proximal and distal vessel diameter, vessel length, lumen volume, and V/L ratio). • Of vessel-related parameters, V/L ratio is the strongest predictor of a distal FFRCT and an optimal cut-off value of 8.1 mm3/mm.
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Affiliation(s)
- Toshimitsu Tsugu
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Brussels, Belgium.
| | - Kaoru Tanaka
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Brussels, Belgium
| | - Dries Belsack
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Brussels, Belgium
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College Hospital, Tokorozawa, Japan
| | - Mayuko Tsugu
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Brussels, Belgium
| | - Jean-François Argacha
- Cardiology, Centrum Voor Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Bernard Cosyns
- Cardiology, Centrum Voor Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Nico Buls
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Brussels, Belgium
| | - Michel De Maeseneer
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Brussels, Belgium
| | - Johan De Mey
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Brussels, Belgium
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Fairbairn T, Nørgaard BL. New Ideas from Old Laws. Radiol Cardiothorac Imaging 2023; 5:e230393. [PMID: 38166345 PMCID: PMC11163243 DOI: 10.1148/ryct.230393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 01/04/2024]
Affiliation(s)
- Timothy Fairbairn
- From the Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, United Kingdom (T.F.); and Department of Cardiology, Skejby, Aarhus University Hospital, Aarhus, Denmark (B.L.N.)
| | - Bjarne Linde Nørgaard
- From the Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, United Kingdom (T.F.); and Department of Cardiology, Skejby, Aarhus University Hospital, Aarhus, Denmark (B.L.N.)
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Baruś P, Piasecki A, Gumiężna K, Bednarek A, Dunaj P, Głód M, Sadowski K, Ochijewicz D, Rdzanek A, Pietrasik A, Grabowski M, Kochman J, Tomaniak M. Multimodality OCT, IVUS and FFR evaluation of coronary intermediate grade lesions in women vs. men. Front Cardiovasc Med 2023; 10:1021023. [PMID: 37424919 PMCID: PMC10325624 DOI: 10.3389/fcvm.2023.1021023] [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: 08/16/2022] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Background The pathophysiology of atherosclerotic plaque formation and its vulnerability seem to differ between genders due to contrasting risk profiles and sex hormones, however this process is still insufficiently understood. The aim of the study was to compare the differences between sexes regarding the optical coherence tomography (OCT), intravascular ultrasound (IVUS) and fractional flow reserve (FFR)-derived coronary plaque indices. Methods In this single-center multimodality imaging study patients with intermediate grade coronary stenoses identified in coronary angiogram (CAG) were evaluated using OCT, IVUS and FFR. Stenoses were considered significant when the FFR value was ≤0.8. Minimal lumen area (MLA), was analyzed by OCT in addition to plaque stratification into fibrotic, calcific, lipidic and thin-cap fibroatheroma (TCFA). IVUS was used for evaluation of lumen-, plaque- and vessel volume, as well as plaque burden. Results A total of 112 patients (88 men and 24 women) with chronic coronary syndromes (CCS), who underwent CAG were enrolled. No significant differences in baseline characteristics were present between the study groups. The mean FFR was 0.76 (0.73-0.86) in women and 0.78 ± 0.12 in men (p = 0.695). OCT evaluation showed a higher prevalence of calcific plaques among women than men p = 0.002 whereas lipid plaques were more frequent in men (p = 0.04). No significant differences regarding minimal lumen diameter and minimal lumen area were found between the sexes. In IVUS analysis women presented with significantly smaller vessel area, plaque area, plaque volume, vessel volume (11.1 ± 3.3 mm2 vs. 15.0 ± 4.6 mm2 p = 0.001, 6.04 ± 1.7 mm2 vs. 9.24 ± 2.89 mm2 p < 0.001, 59.8 ± 35.2 mm3 vs. 96.3 (52.5-159.1) mm3 p = 0.005, 106.9 ± 59.8 mm3 vs. 153.3 (103-253.4) mm3 p = 0.015 respectively). At MLA site plaque burden was significantly greater for men than women (61.50 ± 7.7% vs. 55.5 ± 8.0% p = 0.005). Survival did not differ significantly between women and men (94.6 ± 41.9 months and 103.51 ± 36.7 months respectively; p = 0.187). Conclusion The presented study did not demonstrate significant differences in FFR values between women and men, yet a higher prevalence of calcific plaques by OCT and lower plaque burden at the MLA site by IVUS was found in women vs. men.
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Hirsch D, Lau B, Kushwaha V, Yong K. The Controversies of Coronary Artery Disease in End-Stage Kidney Disease Patients: A Narrative Review. Rev Cardiovasc Med 2023; 24:181. [PMID: 39077541 PMCID: PMC11264163 DOI: 10.31083/j.rcm2406181] [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: 02/01/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 07/31/2024] Open
Abstract
Cardiovascular disease (CVD) accounts for more than 50% of deaths among patients with end-stage kidney disease (ESKD). Approximately 40-50% of ESKD patients have clinically significant coronary artery disease (CAD) due to atherosclerosis which accounts for a significant proportion of CVD risk. However, other CVD pathologies including myocardial fibrosis, vascular calcification and arterial stiffening play important contributory roles. The pathophysiology of CAD in ESKD is distinct from the general population. ESKD patients is typically have diffuse multi-vessel involvement with increased calcification that involves both intimal and medial layers of the arterial wall. There is a complex interplay between an increased burden of traditional Framingham risk factors and exposure to non-traditional risk factors including chronic inflammation and dialysis per se. Established treatments for CAD risk factors including cholesterol lowering with statin therapy have attenuated effects and ESKD patients also have worse outcomes after revascularisation. Recent trials such as the Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS) have established that direct modulation of inflammation improves CVD outcomes in the general population, which may prove to be a potential attractive therapeutic target in ESKD patients. Multiple retrospective observational studies comparing mortality outcomes between haemodialysis (HD) and peritoneal dialysis (PD) patients have been inconclusive. Randomised trials on this issue of clinical equipoise are clearly warranted but are unlikely to be feasible. Screening for stable CAD in asymptomatic ESKD patients remains a clinical dilemma which is unique to chronic dialysis patients being assessed for kidney transplantation. This has become particularly relevant in light of the recent ISCHEMIA-CKD trial which demonstrated no difference between optimal medical therapy and revascularisation upon CVD outcomes or mortality. The optimal strategy for screening is currently being investigated in the ongoing large international multi-centre CARSK trial. Here we discuss the pathophysiology, risk modification, treatment, screening and future directions of CAD in ESKD.
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Affiliation(s)
- Daniel Hirsch
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW 2031, Australia
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
| | - Brandon Lau
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
| | - Virag Kushwaha
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
- Department of Cardiology, Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Kenneth Yong
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW 2031, Australia
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
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Colbert CM, Hollowed JJ, Nguyen DN, Duarte-Vogel S, Dahlbom M, Hu P, Nguyen KL. Fractional myocardial blood volume by ferumoxytol-enhanced MRI: Estimation of ischemic burden. Magn Reson Med 2023; 89:1557-1566. [PMID: 36382769 PMCID: PMC10166270 DOI: 10.1002/mrm.29530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE To investigate model-fitted fractional myocardial blood volume (fMBV) derived from ferumoxytol-enhanced MRI as a measure of myocardial tissue hypoperfusion at rest. METHODS We artificially induced moderate to severe focal coronary stenosis in the left anterior descending artery of 19 swine by percutaneous delivery of a 3D-printed coronary implant. Using the MOLLI pulse sequence, we acquired T1 maps at 3 T after multiple incremental ferumoxytol doses (0.0-4.0 mg/kg). We computed pixel-wise fMBV using a multi-compartmental modeling approach in 19 ischemic swine and 4 healthy swine. RESULTS Ischemic myocardial segments showed a mean MRI-fMBV of 11.72 ± 3.00%, compared with 8.23 ± 2.12% in remote segments and 8.38 ± 2.23% in normal segments. Ischemic segments showed a restricted transvascular water-exchange rate (ki = 15.32 ± 8.69 s-1 ) relative to remote segments (ki = 17.78 [11.60, 26.36] s-1 ). A mixed-effects model found significant difference in fMBV (p = 0.002) and water-exchange rate (p < 0.001) between ischemic and remote myocardial regions after adjusting for biological sex and slice location. Analysis of fMBV as a predictor of impaired myocardial contractility using receiver operating characteristics showed an area under the curve of 0.89 (95% confidence interval [CI] 0.80, 0.95). An MRI-fMBV threshold of 9.60% has a specificity of 90.0% (95% CI 76.3, 97.2) and a sensitivity of 72.5% (95% CI 56.1, 83.4) for prediction of impaired myocardial contractility. CONCLUSIONS Model-fitted fMBV derived from ferumoxytol-enhanced MRI can distinguish regions of ischemia from remote myocardium in a swine model of myocardial hypoperfusion.
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Affiliation(s)
- Caroline M. Colbert
- Physics and Biology in Medicine Graduate Program, David Geffen School of Medicine at UCLA
- Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System
| | - John J. Hollowed
- Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System
| | - Dylan N. Nguyen
- Department of Computer Science and Engineering, Samueli School of Engineering at UCLA
| | - Sandra Duarte-Vogel
- Division of Laboratory Animal Medicine, David Geffen School of Medicine at UCLA
| | - Magnus Dahlbom
- Physics and Biology in Medicine Graduate Program, David Geffen School of Medicine at UCLA
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA
| | - Peng Hu
- Physics and Biology in Medicine Graduate Program, David Geffen School of Medicine at UCLA
- Diagnostic Cardiovascular Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA
| | - Kim-Lien Nguyen
- Physics and Biology in Medicine Graduate Program, David Geffen School of Medicine at UCLA
- Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System
- Diagnostic Cardiovascular Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA
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Wada S, Iwanaga Y, Nakai M, Nakao YM, Miyamoto Y, Noguchi T. Combination of coronary CT angiography, FFR CT , and risk factors in the prediction of major adverse cardiovascular events in patients suspected CAD. Clin Cardiol 2023; 46:494-501. [PMID: 36860175 DOI: 10.1002/clc.23989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/18/2023] [Accepted: 01/29/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND To examine the utility of fractional flow reserve by coronary computed tomography (CT) angiography (FFRCT ) for predicting major adverse cardiovascular events (MACE) in patients with suspected coronary artery disease (CAD). METHODS This was a nationwide multicenter prospective cohort study including consecutive 1187 patients aged 50-74 years with suspected CAD and had available coronary CT angiography (CCTA). In patients with ≥50% coronary artery stenosis (CAS), FFRCT was further analyzed. The Cox proportional hazards model was used to examine the association of FFRCT and cardiovascular risk factors with incident MACE within 2 years. RESULTS Among 933 patients with available information on MACE within 2 years after enrollment, the incidence rate of MACE was higher in 281 patients with CAS than in those without CAS (6.11 vs. 1.16 per 100 patient-year). In 241 patients with CAS, the Cox proportional hazards analysis showed that FFRCT as well as diabetes mellitus and low high-density lipoprotein cholesterol level were independently associated with incident MACE. Moreover, the hazard ratio was significantly higher in patients harboring all three factors compared to those harboring 0-2 of the three factors (6.01; 95% confidence interval: 2.77-13.03). CONCLUSIONS Combinatorial assessment using CCTA for stenosis, FFRCT , and risk factors was useful for more accurate prediction of MACE in patients with suspected CAD. Among patients with CAS, those with lower FFRCT , diabetes mellitus, and low high-density lipoprotein cholesterol level were at highest risk for MACE during the 2-year period following enrollment.
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Affiliation(s)
- Shinichi Wada
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Cardiology, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoko M Nakao
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruo Noguchi
- Department of Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
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Sharifkazemi M, Hooshanginezhad Z, Zoroufian A, Shamsa K. Is it the Time to Move Towards Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve Guided Percutaneous Coronary Intervention? The Pros and Cons. Curr Cardiol Rev 2023; 19:e190123212887. [PMID: 36658709 PMCID: PMC10494271 DOI: 10.2174/1573403x19666230119115228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/08/2022] [Accepted: 11/21/2022] [Indexed: 01/21/2023] Open
Abstract
Coronary artery disease is the leading cause of mortality worldwide. Diagnosis is conventionally performed by direct visualization of the arteries by invasive coronary angiography (ICA), which has inherent limitations and risks. Measurement of fractional flow reserve (FFR) has been suggested for a more accurate assessment of ischemia in the coronary artery with high accuracy for determining the severity and decision on the necessity of intervention. Nevertheless, invasive coronary angiography-derived fractional flow reserve (ICA-FFR) is currently used in less than one-third of clinical practices because of the invasive nature of ICA and the need for additional equipment and experience, as well as the cost and extra time needed for the procedure. Recent technical advances have moved towards non-invasive high-quality imaging modalities, such as magnetic resonance, single-photon emission computed tomography, and coronary computed tomography (CT) scan; however, none had a definitive modality to confirm hemodynamically significant coronary artery stenosis. Coronary computed tomography angiography (CCTA) can provide accurate anatomic and hemodynamic data about the coronary lesion, especially calculating fractional flow reserve derived from CCTA (CCTA-FFR). Although growing evidence has been published regarding CCTA-FFR results being comparable to ICA-FFR, CCTA-FFR has not yet replaced the invasive conventional angiography, pending additional studies to validate the advantages and disadvantages of each diagnostic method. Furthermore, it has to be identified whether revascularization of a stenotic lesion is plausible based on CCTA-FFR and if the therapeutic plan can be determined safely and accurately without confirmation from invasive methods. Therefore, in the present review, we will outline the pros and cons of using CCTA-FFR vs. ICA-FFR regarding diagnostic accuracy and treatment decision-making.
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Affiliation(s)
| | - Zahra Hooshanginezhad
- Division of Cardiology, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arezou Zoroufian
- Division of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Shamsa
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
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11
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Tsugu T, Tanaka K, Nagatomo Y, Belsack D, Devos H, Buls N, Cosyns B, Argacha JF, De Maeseneer M, De Mey J. Impact of coronary bifurcation angle on computed tomography derived fractional flow reserve in coronary vessels with no apparent coronary artery disease. Eur Radiol 2023; 33:1277-1285. [PMID: 36114847 PMCID: PMC9889442 DOI: 10.1007/s00330-022-09125-3] [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: 01/27/2022] [Revised: 07/04/2022] [Accepted: 08/19/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Computed tomography (CT) derived fractional flow reserve (FFRCT) decreases from the proximal to the distal part due to a variety of factors. The energy loss due to the bifurcation angle may potentially contribute to a progressive decline in FFRCT. However, the association of the bifurcation angle with FFRCT is still not entirely understood. This study aimed to investigate the impact of various bifurcation angles on FFRCT decline below the clinically crucial relevance of 0.80 in vessels with no apparent coronary artery disease (CAD). METHODS A total of 83 patients who underwent both CT angiography including FFRCT and invasive coronary angiography, exhibiting no apparent CAD were evaluated. ΔFFRCT was defined as the change in FFRCT from the proximal to the distal in the left anterior descending artery (LAD) and left circumflex artery (LCX). The bifurcation angle was calculated from three-dimensional volume rendered images. Vessel morphology and plaque characteristics were also assessed. RESULTS ΔFFRCT significantly correlated with the bifurcation angle (LAD angle, r = 0.35, p = 0.001; LCX angle, r = 0.26, p = 0.02) and vessel length (LAD angle, r = 0.30, p = 0.005; LCX angle, r = 0.49, p < 0.0001). In LAD, vessel length was the strongest predictor for distal FFRCT of ≤ 0.80 (β-coefficient = 0.55, p = 0.0003), immediately followed by the bifurcation angle (β-coefficient = 0.24, p = 0.02). The bifurcation angle was a good predictor for a distal FFRCT ≤ 0.80 (LAD angle, cut-off 31.0°, AUC 0.70, sensitivity 74%, specificity 68%; LCX angle, cut-off 52.6°, AUC 0.86, sensitivity 88%, specificity 85%). CONCLUSIONS In vessels with no apparent CAD, vessel length was the most influential factor on FFRCT, directly followed by the bifurcation angle. KEY POINTS • Both LAD and LCX bifurcation angles are factors influencing FFR CT. • Bifurcation angle is one of the predictors of a distal FFRCT of ≤ 0.80 and an optimal cut-off value of 31.0° for the LAD and 52.6° for the LCX. • Bifurcation angle should be taken into consideration when interpreting numerical values of FFRCT.
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Affiliation(s)
- Toshimitsu Tsugu
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Brussels, Belgium
| | - Kaoru Tanaka
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Brussels, Belgium
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College Hospital, Tokorozawa, Japan
| | - Dries Belsack
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Brussels, Belgium
| | - Hannes Devos
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Brussels, Belgium
| | - Nico Buls
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Brussels, Belgium
| | - Bernard Cosyns
- Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jean-François Argacha
- Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Michel De Maeseneer
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Brussels, Belgium
| | - Johan De Mey
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Brussels, Belgium
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12
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Flores Marcial HB, Choi J, Ham D, Kim J, Jeong P, Choi J, Park WT. Influence of multiple stenoses on thrombosis formation: an in vitro study. MICRO AND NANO SYSTEMS LETTERS 2022. [DOI: 10.1186/s40486-022-00159-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AbstractMultiple lesions in the same vessel is one of the most common situations found in patients suffering from cardiovascular diseases, this complicates not only the assessment of the severity of each one but also their treatment. To date, the effect of multiple stenoses on different parameters has been simulated by numerical studies. Few others have implemented in vitro platforms for their investigation. However, visualization of thrombosis formation in this kind of lesion is still needed. This in vitro study monitors the formation of thrombus inside microchannels having one, two, and three stenoses. Whole blood was perfused through each channel at high shear rates (> 12,000 s−1), generating thrombosis. Flow changes across each lesion as well as the final percentage of aggregations were monitored. Thus, the location where total occlusion could be produced was found to be the first stenosis for all the cases. Less flow reaching the second and third stenoses was observed which demonstrates that aggregations were growing at the first one. This was verified by measuring the percentage of aggregations at the end of the test.
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13
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Brandt V, Schoepf UJ, Aquino GJ, Bekeredjian R, Varga-Szemes A, Emrich T, Bayer RR, Schwarz F, Kroencke TJ, Tesche C, Decker JA. Impact of machine-learning-based coronary computed tomography angiography-derived fractional flow reserve on decision-making in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. Eur Radiol 2022; 32:6008-6016. [PMID: 35359166 DOI: 10.1007/s00330-022-08758-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/17/2022] [Accepted: 03/21/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To evaluate feasibility and diagnostic performance of coronary CT angiography (CCTA)-derived fractional flow reserve (CT-FFR) for detection of significant coronary artery disease (CAD) and decision-making in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) to potentially avoid additional pre-TAVR invasive coronary angiography (ICA). METHODS Consecutive patients with severe AS (n = 95, 78.6 ± 8.8 years, 53% female) undergoing pre-procedural TAVR-CT followed by ICA with quantitative coronary angiography were retrospectively analyzed. CCTA datasets were evaluated using CAD Reporting and Data System (CAD-RADS) classification. CT-FFR measurements were computed using an on-site machine-learning algorithm. A combined algorithm was developed for decision-making to determine if ICA is needed based on pre-TAVR CCTA: [1] all patients with CAD-RADS ≥ 4 are referred for ICA; [2] patients with CAD-RADS 2 and 3 are evaluated utilizing CT-FFR and sent to ICA if CT-FFR ≤ 0.80; [3] patients with CAD-RADS < 2 or CAD-RADS 2-3 and normal CT-FFR are not referred for ICA. RESULTS Twelve patients (13%) had significant CAD (≥ 70% stenosis) on ICA and were treated with PCI. Twenty-eight patients (30%) showed CT-FFR ≤ 0.80 and 24 (86%) of those were reported to have a maximum stenosis ≥ 50% during ICA. Using the proposed algorithm, significant CAD could be identified with a sensitivity, specificity, and positive and negative predictive value of 100%, 78%, 40%, and 100%, respectively, potentially decreasing the number of necessary ICAs by 65 (68%). CONCLUSION Combination of CT-FFR and CAD-RADS is able to identify significant CAD pre-TAVR and bears potential to significantly reduce the number of needed ICAs. KEY POINTS • Coronary CT angiography-derived fractional flow reserve (CT-FFR) using machine learning together with the CAD Reporting and Data System (CAD-RADS) classification safely identifies significant coronary artery disease based on quantitative coronary angiography in patients prior to transcatheter aortic valve replacement. • The combination of CT-FFR and CAD-RADS enables decision-making and bears the potential to significantly reduce the number of needed invasive coronary angiographies.
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Affiliation(s)
- Verena Brandt
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 5 Courtenay Drive, Charleston, SC, 29425-2260, USA
- Department of Cardiology and Angiology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 5 Courtenay Drive, Charleston, SC, 29425-2260, USA.
| | - Gilberto J Aquino
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 5 Courtenay Drive, Charleston, SC, 29425-2260, USA
| | - Raffi Bekeredjian
- Department of Cardiology and Angiology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 5 Courtenay Drive, Charleston, SC, 29425-2260, USA
| | - Tilman Emrich
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 5 Courtenay Drive, Charleston, SC, 29425-2260, USA
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
| | - Richard R Bayer
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 5 Courtenay Drive, Charleston, SC, 29425-2260, USA
| | - Florian Schwarz
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Thomas J Kroencke
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Christian Tesche
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 5 Courtenay Drive, Charleston, SC, 29425-2260, USA
- Department of Cardiology, Clinic Augustinum Munich, Munich, Germany
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany
| | - Josua A Decker
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 5 Courtenay Drive, Charleston, SC, 29425-2260, USA
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
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14
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Myocardial deformation indices for detection of the functional significance of intermediate left anterior descending coronary artery stenosis: FFR guided study. Int J Cardiovasc Imaging 2022; 38:2625-2633. [DOI: 10.1007/s10554-022-02668-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/30/2022] [Indexed: 11/25/2022]
Abstract
AbstractThis study aimed to investigate the diagnostic performance of non-invasive resting myocardial deformation indices in identifying functional significance of intermediate stenosis of the left anterior descending (LAD) artery. Patients with 50–70% LAD stenosis upon coronary angiography were enrolled and divided into group I with fractional flow reserve (FFR) > 0.8 and group II with FFR ≤ 0.8. Patients were subjected to conventional and speckle tracking echocardiography with measurement of myocardial deformation indices including regional peak longitudinal strain (PLS), global longitudinal strain (GLS), Post-systolic strain index (PSI), and time interval between Aortic valve closure (AVC) and PLS. The current study included 200 patients. Group II patients had significantly lower absolute mean values of regional (PLS) and (GLS) compared to group I (− 14.98 ± 5.05 and − 18.73 ± 3.92 vs. − 17.59 ± 3.62 and − 19.20 ± 2.61, p = 0.001 and 0.02, respectively). The FFR values of LAD correlated significantly and negatively with the time interval between AVC and regional PLS (r = − 0.201, p = 0.004) as well as PSI (r = − 0.257, p < 0.001). For identifying cases with FFR ≤ 0.8, the optimal cut-off value of the time interval between AVC and PLS was 76 ms with 77.8% sensitivity and 93.8% specificity. The best cut-off value of PSI was 13%, yielding 50% sensitivity and 87.5% specificity. In patients with intermediate 50–70% LAD coronary artery stenotic lesions, the PSI and the duration between AVC and regional PLS enabled the identification of functionally significant lesions with reasonable diagnostic accuracy.Trial registration ZU-IRB#3199-20-11-2015 Registered 20 November 2015, IRB_123@medicine.zu.edu.eg.
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15
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Altstidl JM, Achenbach S, Marwan M, Tröbs M, Schacher N, Ferstl P, Gerlach A, Schlundt C, Gaede L. Comparison of adenosine-independent pressure indices to fractional flow reserve in stent-jailed bifurcation side branches. Catheter Cardiovasc Interv 2022; 100:369-377. [PMID: 35723275 DOI: 10.1002/ccd.30298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 05/14/2022] [Accepted: 05/29/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES AND BACKGROUND This study aims to evaluate whether the high correlation and classification agreement of the instantaneous wave-free ratio (iFR) and the resting distal coronary to aortic pressure ratio (Pd /Pa ) with the fractional flow reserve (FFR) can be confirmed in stent-jailed side branches (J-SB). METHODS Consecutive patients (n = 49) undergoing provisional stenting were prospectively enrolled and a physiological assessment of the J-SB (n = 51) was performed. FFR, iFR, and Pd /Pa were measured and the hemodynamic relevance was determined using cutoff values of ≤0.80, ≤0.89, and ≤0.92, respectively. RESULTS Both iFR (r = 0.75) and Pd /Pa (r = 0.77) correlated closely with FFR. Classification agreement with FFR was 78% for iFR (81% sensitivity, 77% specificity) and 75% for Pd /Pa (63% sensitivity and 80% specificity). However, angiographic diameter stenosis and pressure indices correlated poorly. For a threshold of ≥70% stenosis, agreement concerning hemodynamic relevance was found in 59% for FFR, 69% for iFR, and 61% for Pd /Pa . CONCLUSION As reported for other lesion types, FFR and the adenosine-independent pressure indices iFR and Pd /Pa show close correlation and a high classification agreement of approximately 75%-80% in J-SB. Therefore, iFR can be regarded as a recommendable alternative to FFR for the guidance of provisional stenting in bifurcation lesions.
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Affiliation(s)
- Johannes Michael Altstidl
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan Achenbach
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Mohamed Marwan
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Monique Tröbs
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Nora Schacher
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Paul Ferstl
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas Gerlach
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christian Schlundt
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Luise Gaede
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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16
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Bularga A, Hung J, Daghem M, Stewart S, Taggart C, Wereski R, Singh T, Meah MN, Fujisawa T, Ferry AV, Chiong J, Jenkins WS, Strachan FE, Semple S, van Beek EJ, Williams M, Dey D, Tuck C, Baker AH, Newby DE, Dweck MR, Mills NL, Chapman AR. Coronary Artery and Cardiac Disease in Patients With Type 2 Myocardial Infarction: A Prospective Cohort Study. Circulation 2022; 145:1188-1200. [PMID: 35341327 PMCID: PMC9010024 DOI: 10.1161/circulationaha.121.058542] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/25/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Type 2 myocardial infarction is caused by myocardial oxygen supply-demand imbalance, and its diagnosis is increasingly common with the advent of high-sensitivity cardiac troponin assays. Although this diagnosis is associated with poor outcomes, widespread uncertainty and confusion remain among clinicians as to how to investigate and manage this heterogeneous group of patients with type 2 myocardial infarction. METHODS In a prospective cohort study, 8064 consecutive patients with increased cardiac troponin concentrations were screened to identify patients with type 2 myocardial infarction. We excluded patients with frailty or renal or hepatic failure. All study participants underwent coronary (invasive or computed tomography angiography) and cardiac (magnetic resonance or echocardiography) imaging, and the underlying causes of infarction were independently adjudicated. The primary outcome was the prevalence of coronary artery disease. RESULTS In 100 patients with a provisional diagnosis of type 2 myocardial infarction (median age, 65 years [interquartile range, 55-74 years]; 43% women), coronary and cardiac imaging reclassified the diagnosis in 7 patients: type 1 or 4b myocardial infarction in 5 and acute myocardial injury in 2 patients. In those with type 2 myocardial infarction, median cardiac troponin I concentrations were 195 ng/L (interquartile range, 62-760 ng/L) at presentation and 1165 ng/L (interquartile range, 277-3782 ng/L) on repeat testing. The prevalence of coronary artery disease was 68% (63 of 93), which was obstructive in 30% (28 of 93). Infarct-pattern late gadolinium enhancement or regional wall motion abnormalities were observed in 42% (39 of 93), and left ventricular systolic dysfunction was seen in 34% (32 of 93). Only 10 patients had both normal coronary and normal cardiac imaging. Coronary artery disease and left ventricular systolic dysfunction were previously unrecognized in 60% (38 of 63) and 84% (27 of 32), respectively, with only 33% (21 of 63) and 19% (6 of 32) on evidence-based treatments. CONCLUSIONS Systematic coronary and cardiac imaging of patients with type 2 myocardial infarction identified coronary artery disease in two-thirds and left ventricular systolic dysfunction in one-third of patients. Unrecognized and untreated coronary or cardiac disease is seen in most patients with type 2 myocardial infarction, presenting opportunities for initiation of evidence-based treatments with major potential to improve clinical outcomes. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03338504.
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Affiliation(s)
- Anda Bularga
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - John Hung
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Marwa Daghem
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Stacey Stewart
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
- Edinburgh Imaging (S.S., E.J.R.v.B., M.W.), University of Edinburgh, United Kingdom
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Trisha Singh
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Mohammed N. Meah
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Takeshi Fujisawa
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Amy V. Ferry
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Justin Chiong
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - William S. Jenkins
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Fiona E. Strachan
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Scott Semple
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Edwin J.R. van Beek
- Edinburgh Imaging (S.S., E.J.R.v.B., M.W.), University of Edinburgh, United Kingdom
| | - Michelle Williams
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
- Edinburgh Imaging (S.S., E.J.R.v.B., M.W.), University of Edinburgh, United Kingdom
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.D.)
| | - Chris Tuck
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Andrew H. Baker
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - David E. Newby
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | - Marc R. Dweck
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
| | | | - Andrew R. Chapman
- BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom
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Tsugu T, Tanaka K, Belsack D, Devos H, Nagatomo Y, Michiels V, Argacha JF, Cosyns B, Buls N, De Maeseneer M, De Mey J. Effects of left ventricular mass on computed tomography derived fractional flow reserve in significant obstructive coronary artery disease. Int J Cardiol 2022; 355:59-64. [DOI: 10.1016/j.ijcard.2022.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/27/2022] [Accepted: 03/07/2022] [Indexed: 12/13/2022]
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18
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Peper J, Becker LM, van Kuijk JP, Leiner T, Swaans MJ. Fractional Flow Reserve: Patient Selection and Perspectives. Vasc Health Risk Manag 2021; 17:817-831. [PMID: 34934324 PMCID: PMC8684425 DOI: 10.2147/vhrm.s286916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/30/2021] [Indexed: 01/10/2023] Open
Abstract
The aim of this review was to discuss the current practice and patient selection for invasive FFR, new techniques to estimate invasive FFR and future of coronary physiology tests. We elaborate on the indication and application of FFR and on the contraindications and concerns in certain patient populations.
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Affiliation(s)
- Joyce Peper
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonie M Becker
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan-Peter van Kuijk
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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19
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Antoniades C, West HW. Coronary CT angiography as an 'one-stop shop' to detect the high-risk plaque and the vulnerable patient. Eur Heart J 2021; 42:3853-3855. [PMID: 34389864 PMCID: PMC8486487 DOI: 10.1093/eurheartj/ehab538] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Charalambos Antoniades
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Acute Vascular Imaging Centre, University of Oxford, Oxford, UK
| | - Henry W West
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Acute Vascular Imaging Centre, University of Oxford, Oxford, UK
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20
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Abuouf Y, AlBadawi M, Ookawara S, Ahmed M. Effect of guidewire insertion in fractional flow reserve procedure for real geometry using computational fluid dynamics. Biomed Eng Online 2021; 20:95. [PMID: 34583689 PMCID: PMC8479905 DOI: 10.1186/s12938-021-00935-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/15/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Coronary artery disease is an abnormal contraction of the heart supply blood vessel. It limits the oxygenated blood flow to the heart. Thus, diagnosing its severity helps physicians to select the appropriate treatment plan. Fractional flow reserve (FFR) is the most accurate method to pinpoint the stenosis severity. However, inserting the guidewire across stenosis may cause a false overestimation of severity. METHODS To estimate the errors due to guidewire insertion, reconstructed three-dimensional coronary artery geometry from a patient-specific scan is used. A comprehensive three-dimensional blood flow model is developed. Blood is considered non-Newtonian and the flow is pulsatile. The model is numerically simulated using realistic boundary conditions. RESULTS The FFR value is calculated and compared with the actual flow ratio. Additionally, the ratio between pressure drop and distal dynamic pressure (CDP) is studied. The obtained results for each case are compared and analyzed with the case without a guidewire. It was found that placing the guidewire leads to overestimating the severity of moderate stenosis. It reduces the FFR value from 0.43 to 0.33 with a 23.26% error compared to 0.44 actual flow ratio and the CDP increases from 5.31 to 7.2 with a 35.6% error. FFR value in mild stenosis does not have a significant change due to placing the guidewire. The FFR value decreases from 0.83 to 0.82 compared to the 0.83 actual flow ratio. CONCLUSION Consequently, physicians should consider these errors while deciding the treatment plan.
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Affiliation(s)
- Yasser Abuouf
- Department of Energy Resources Engineering, Egypt-Japan University of Science and Technology (E-JUST), Postal Code 21934, New Borg El-Arab City, P.O. Box 179, Alexandria, Egypt. .,Mechanical Engineering Department, Faculty of Engineering, Alexandria University, Alexandria, Egypt.
| | - Muhamed AlBadawi
- Department of Energy Resources Engineering, Egypt-Japan University of Science and Technology (E-JUST), Postal Code 21934, New Borg El-Arab City, P.O. Box 179, Alexandria, Egypt.,Engineering Mathematics and Physics Department, Faculty of Engineering, Alexandria University, Alexandria, Egypt
| | - Shinichi Ookawara
- Department of Chemical Engineering, Graduate School of Science and Engineering, Tokyo Institute of Technology, O-okayama, Meguro-ku, Tokyo, 152-8552, Japan
| | - Mahmoud Ahmed
- Department of Energy Resources Engineering, Egypt-Japan University of Science and Technology (E-JUST), Postal Code 21934, New Borg El-Arab City, P.O. Box 179, Alexandria, Egypt.,Mechanical Engineering Department, Assiut University, Assiut, 71516, Egypt
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21
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Vardhan M, Gounley J, Chen SJ, Chi EC, Kahn AM, Leopold JA, Randles A. Non-invasive characterization of complex coronary lesions. Sci Rep 2021; 11:8145. [PMID: 33854076 PMCID: PMC8047040 DOI: 10.1038/s41598-021-86360-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/15/2021] [Indexed: 02/02/2023] Open
Abstract
Conventional invasive diagnostic imaging techniques do not adequately resolve complex Type B and C coronary lesions, which present unique challenges, require personalized treatment and result in worsened patient outcomes. These lesions are often excluded from large-scale non-invasive clinical trials and there does not exist a validated approach to characterize hemodynamic quantities and guide percutaneous intervention for such lesions. This work identifies key biomarkers that differentiate complex Type B and C lesions from simple Type A lesions by introducing and validating a coronary angiography-based computational fluid dynamic (CFD-CA) framework for intracoronary assessment in complex lesions at ultrahigh resolution. Among 14 patients selected in this study, 7 patients with Type B and C lesions were included in the complex lesion group including ostial, bifurcation, serial lesions and lesion where flow was supplied by collateral bed. Simple lesion group included 7 patients with lesions that were discrete, [Formula: see text] long and readily accessible. Intracoronary assessment was performed using CFD-CA framework and validated by comparing to clinically measured pressure-based index, such as FFR. Local pressure, endothelial shear stress (ESS) and velocity profiles were derived for all patients. We validates the accuracy of our CFD-CA framework and report excellent agreement with invasive measurements ([Formula: see text]). Ultra-high resolution achieved by the model enable physiological assessment in complex lesions and quantify hemodynamic metrics in all vessels up to 1mm in diameter. Importantly, we demonstrate that in contrast to traditional pressure-based metrics, there is a significant difference in the intracoronary hemodynamic forces, such as ESS, in complex lesions compared to simple lesions at both resting and hyperemic physiological states [n = 14, [Formula: see text]]. Higher ESS was observed in the complex lesion group ([Formula: see text] Pa) than in simple lesion group ([Formula: see text] Pa). Complex coronary lesions have higher ESS compared to simple lesions, such differential hemodynamic evaluation can provide much the needed insight into the increase in adverse outcomes for such patients and has incremental prognostic value over traditional pressure-based indices, such as FFR.
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Affiliation(s)
- Madhurima Vardhan
- Department of Biomedical Engineering, Duke University, Durham, NC, 27705, USA
| | - John Gounley
- Computational Sciences and Engineering Division, Oak Ridge National Laboratory, Oak Ridge, TN, 37830, USA
| | - S James Chen
- Department of Medicine/Cardiology, University of Colorado AMC, Aurora, CO, 80045, USA
| | - Eric C Chi
- Department of Statistics, North Carolina State University, Raleigh, 27695, USA
| | - Andrew M Kahn
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, 92103, USA
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Amanda Randles
- Department of Biomedical Engineering, Duke University, Durham, NC, 27705, USA.
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22
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Shaik A, Mosleh W, Dahal K, Pickett C, Azrin M. The absence of evidence is not the evidence of absence: A case report on the challenges in diagnosing ostial left main stenosis. Catheter Cardiovasc Interv 2021; 97:836-840. [PMID: 32815625 DOI: 10.1002/ccd.29191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/12/2020] [Accepted: 07/19/2020] [Indexed: 11/09/2022]
Abstract
Because left main (LM) coronary artery stenosis is known to have higher mortality and morbidity compared to lesions in other territories, an early diagnosis and management are crucial to prevent worse outcomes. Due to limitations of coronary angiography (CA), the diagnosis of ostial LM stenosis solely based on CA may result in underdiagnosis of such lesions. Therefore, additional testing is often needed either by pressure wire or intravascular ultrasound (IVUS) to make appropriate diagnosis. We, hereby, present a case of left main ostial stenosis in a 56-year-old male that was missed on multiple coronary angiograms, and highlights many of the considerations in the diagnosis of LM disease.
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Affiliation(s)
- Ayesha Shaik
- Department of Internal Medicine, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Wassim Mosleh
- Division of Cardiology, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Khagendra Dahal
- Division of Cardiology, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Christopher Pickett
- Division of Cardiology, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Michael Azrin
- Division of Cardiology, University of Connecticut Health Center, Farmington, Connecticut, USA
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Usefulness of the Hybrid RFR-FFR Approach: Results of a Prospective and Multicenter Analysis of Diagnostic Agreement between RFR and FFR-The RECOPA (REsting Full-Cycle Ratio Comparation versus Fractional Flow Reserve (A Prospective Validation)) Study. J Interv Cardiol 2021; 2021:5522707. [PMID: 34007248 PMCID: PMC8026323 DOI: 10.1155/2021/5522707] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/10/2021] [Accepted: 03/20/2021] [Indexed: 01/10/2023] Open
Abstract
Background The resting full‐cycle ratio (RFR) is a novel resting index which in contrast to the gold standard (fractional flow reserve (FFR)) does not require maximum hyperemia induction. The objectives of this study were to evaluate the agreement between RFR and FFR with the currently recommended thresholds and to design a hybrid RFR-FFR ischemia detection strategy, allowing a reduction of coronary vasodilator use. Materials and Methods Patients subjected to invasive physiological study in 9 Spanish centers were prospectively recruited between April 2019 and March 2020. Sensitivity and specificity studies were made to assess diagnostic accuracy between the recommended levels of RFR ≤0.89 and FFR ≤0.80 (primary objective) and to determine the RFR “grey zone” in order to define a hybrid strategy with FFR affording 95% global agreement compared with FFR alone (secondary objective). Results A total of 380 lesions were evaluated in 311 patients. Significant correlation was observed (R2 = 0.81; P < 0.001) between the two techniques, with 79% agreement between RFR ≤ 0.89 and FFR ≤ 0.80 (positive predictive value, 68%, and negative predictive value, 80%). The hybrid RFR-FFR strategy, administering only adenosine in the “grey zone” (RFR: 0.86 to 0.92), exhibited an agreement of over 95% with FFR, with high predictive values (positive predictive value, 91%, and negative predictive value, 92%), reducing the need for vasodilators by 58%. Conclusions Dichotomous agreement between RFR and FFR with the recommended thresholds is significant but limited. The adoption of a hybrid RFR-FFR strategy affords very high agreement, with minimization of vasodilator use.
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Koubaissi SA, Kamar Z, El Ankouni M, Degheili JA, Haddad A. Coronary Computed Tomographic Angiography Imaging as a Prognostic Indicator for Coronary Artery Disease: Data from a Lebanese Tertiary Center. Heart Views 2021; 21:239-244. [PMID: 33986921 PMCID: PMC8104316 DOI: 10.4103/heartviews.heartviews_87_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/27/2020] [Indexed: 11/05/2022] Open
Abstract
Background: Coronary artery disease (CAD) is a major cause of death and disability worldwide. Coronary computed tomographic angiography (CCTA) is a noninvasive imaging technique with a high negative predictive value (NPV). Most studies were done in developed countries, where the prevalence of CAD does not reflect the actual disease burden in developing countries, such as Lebanon. Methods: We retrospectively evaluated the prognostic value of CCTA in predicting acute myocardial events (AMEs) in 200 Lebanese patients. We determined if specific medical and radiological characteristics are linked with AME and looked for any association between the patient's medical risk factors and the type/location of detected atheromatous plaques. Patients' records were reviewed, and the follow-up period of 5–8 years ensued. Chi-square/Fisher test and Student's t-test were used, in addition to multinomial logistic regression to adjust for the confounding variables. P <0.05 was considered statistically significant. Results: Our study showed that CCTA had a NPV that reaches 97.9% in asymptomatic patients, a positive predictive value (PPV) of 76.4% for symptomatic patients, a sensitivity of 88.9%, and a specificity of 52.5%. AMEs were significantly increased in patients with a mixed plaque type and/or a moderate-to-severe lumen reduction on CCTA. Conclusions: CCTA is a sensitive modality for plaque detection and is found to have a remarkably high NPV for asymptomatic patients. A CCTA, along with a low pretest clinical probability of CAD, can be sufficient to rule out an AME for up to 8 years.
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Affiliation(s)
- Salwa A Koubaissi
- Department of Internal Medicine, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Zeinab Kamar
- Department of Anaesthesiology, Lebanese University, Beirut, Lebanon
| | - Mahdi El Ankouni
- Department of Internal Medicine, Lebanese University, Beirut, Lebanon
| | - Jad A Degheili
- Department of Surgery, Division of Urology, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Antoine Haddad
- Department of Radiology, Saint Joseph University, Beirut, Lebanon
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Levett JY, Windle SB, Filion KB, Cabaussel J, Eisenberg MJ. Meta-Analysis of Complete versus Culprit-Only Revascularization in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Disease. Am J Cardiol 2020; 135:40-49. [PMID: 32871112 DOI: 10.1016/j.amjcard.2020.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/09/2020] [Accepted: 08/11/2020] [Indexed: 12/15/2022]
Abstract
Approximately half of patients with ST-segment elevation myocardial infarction (STEMI) present with noninfarct related multivessel coronary artery disease (CAD) during primary percutaneous coronary intervention (PCI). However, questions remain concerning whether patients with STEMI and multivessel CAD should routinely undergo complete revascularization. Our objective was to compare the risks of major cardiovascular outcomes and procedural complications in patients with STEMI and multivessel CAD randomized to complete revascularization versus culprit-only PCI. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing complete revascularization to culprit-only PCI. RCTs were identified via a systematic search of MEDLINE, Embase, and Cochrane CENTRAL. Count data were pooled using DerSimonian and Laird random-effects models with inverse variance weighting to obtain relative risks (RRs) and 95% confidence intervals (CIs). A total of 9 RCTs (n = 6,751) were included, with mean/median follow-up times ranging from 6 to 36 months. Compared with culprit-only PCI, complete revascularization was associated with a substantial reduction in major adverse cardiovascular events (13.1% vs 22.1%; RR: 0.54; 95%CI: 0.43 to 0.66), repeat myocardial infarction (4.9% vs 6.8%; RR: 0.64; 95%CI: 0.48 to 0.84), and repeat revascularization (3.7% vs 12.3%; RR: 0.33; 95%CI: 0.25 to 0.44). Complete revascularization may have beneficial effects on all-cause and cardiovascular mortality, but 95%CIs were wide. Findings for stroke, major bleeding, and contrast-induced acute kidney injury were inconclusive. In conclusion, complete coronary artery revascularization appears to confer benefit over culprit-only PCI in patients with STEMI and multivessel CAD, and should be considered a first-line strategy in these patients.
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27
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A case report of significant progression after FFR-guided deferred PCI. J Geriatr Cardiol 2020; 17:649-652. [PMID: 33224187 PMCID: PMC7657948 DOI: 10.11909/j.issn.1671-5411.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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28
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Fairbairn TA, Dobson R, Hurwitz-Koweek L, Matsuo H, Norgaard BL, Rønnow Sand NP, Nieman K, Bax JJ, Pontone G, Raff G, Chinnaiyan KM, Rabbat M, Amano T, Kawasaki T, Akasaka T, Kitabata H, Binukrishnan S, Rogers C, Berman D, Patel MR, Douglas PS, Leipsic J. Sex Differences in Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve: Lessons From ADVANCE. JACC Cardiovasc Imaging 2020; 13:2576-2587. [PMID: 32861656 DOI: 10.1016/j.jcmg.2020.07.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study is to determine the management and clinical outcomes of patients investigated with coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) according to sex. BACKGROUND Women are underdiagnosed with conventional ischemia testing, have lower rates of obstructive coronary artery disease (CAD) at invasive coronary angiography (ICA), yet higher mortality compared to men. Whether FFRCT improves sex-based patient management decisions compared to CCTA alone is unknown. METHODS Subjects with symptoms and CAD on CCTA were enrolled (2015 to 2017). Demographics, symptom status, CCTA anatomy, coronary volume to myocardial mass ratio (V/M), lowest FFRCT values, and management plans were captured. Endpoints included reclassification rate between CCTA and FFRCT management plans, incidence of ICA demonstrating obstructive CAD (≥50% stenosis) and revascularization rates. RESULTS A total of 4,737 patients (n = 1,603 females, 33.8%) underwent CCTA and FFRCT. Women were older (age 68 ± 10 years vs. 65 ± 10 years; p < 0.0001) with more atypical symptoms (41.5% vs. 33.9%; p < 0.0001). Women had less obstructive CAD (65.4% vs. 74.7%; p < 0.0001) at CCTA, higher FFRCT (0.76 ± 0.10 vs. 0.73 ± 0.10; p < 0.0001), and lower likelihood of positive FFRCT ≤ 0.80 for the same degree stenosis (p < 0.0001). A positive FFRCT ≤0.80 resulted in equal referral to ICA (n = 510 [54.5%] vs. n = 1,249 [56.5%]; p = 0.31), but more nonobstructive CAD (n = 208 [32.1%] vs. n = 354 [24.5%]; p = 0.0003) and less revascularization (n = 294 [31.4%] vs. n = 800 [36.2%]; p < 0.0001) in women, unless the FFRCT was ≤0.75 where revascularization rates were similar (n = 253 [41.9%] vs. n = 715 [46.4%]; p = 0.06). Women have a higher V/M ratio (26.17 ± 7.58 mm3/g vs. 24.76 ± 7.22 mm3/g; p < 0.0001) that is associated with higher FFRCT independent of degree stenosis (p < 0.001). Predictors of revascularization included stenosis severity, FFRCT, symptoms, and V/M ratio (p < 0.001) but not female sex (p = 0.284). CONCLUSIONS FFRCT differs between the sexes, as women have a higher FFRCT for the same degree of stenosis. In FFRCT-positive CAD, women have less obstructive CAD at ICA and less revascularization, which is associated with higher V/M ratio. The findings suggest that CAD and FFRCT variations by sex need specific interpretation as these differences may affect therapeutic decision making and clinical outcomes. (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care [ADVANCE]; NCT02499679).
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Affiliation(s)
| | - Rebecca Dobson
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Hitoshi Matsuo
- Wakayama Medical University, Wakayama, Japan; Gifu Heart Center, Gifu, Japan
| | | | | | - Koen Nieman
- Stanford University Medical Center, Palo Alto, California, USA
| | - Jeroen J Bax
- Leiden University Medical Center, Leiden, the Netherlands
| | - Gianluca Pontone
- Centro Cardiologico Monzino, IRCCS, University of Milan, Milan, Italy
| | - Gilbert Raff
- William Beaumont Hospital, Royal Oaks, Michigan, USA
| | | | - Mark Rabbat
- Loyola University Medical Center, Maywood, Illinois, USA
| | | | | | | | | | | | | | - Daniel Berman
- Cedars Sinai Medical Centre, Beverly Hills, California, USA
| | - Manesh R Patel
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
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Abuouf Y, Ookawara S, Ahmed M. Analysis of the effect of guidewire position on stenosis diagnosis using computational fluid dynamics. Comput Biol Med 2020; 121:103777. [PMID: 32568672 DOI: 10.1016/j.compbiomed.2020.103777] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/22/2020] [Accepted: 04/22/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Fractional flow reserve is an accurate method for diagnosing stenosis. The difficulty in using this procedure lies in placing the guidewire precisely at the blood vessel centerline. Owing to the long distance between the insertion point and the stenosis, a guidewire inclination can occur. Therefore, the main objective of this study is to investigate how the measured pressure in a blood vessel varies with the guidewire position. METHODS A three-dimensional model of blood flow is developed and numerically simulated. Two positions and two inclination angles from the blood vessel centerline and three throat diameters are investigated. The predicted results are validated using the available experimental data. The predicted results and actual measurements are observed to agree well with each other. RESULTS The pressure drop coefficient (CDP) increases because of guidewire insertion. When the guidewire is placed at inclined positions in moderate stenosis, the values of CDP are 66 and 68, depending on the inclination angle; the errors in CDP are 69% and 76%, respectively. At a high flow rate, the errors are reduced to 67% and 70%, respectively. The error in the CDP ranges from 42% to 61% when the guidewire is placed parallel to the centerline. For severe stenosis, the CDP is nearly the same at all positions and varies between 240 and 250; without a guidewire, the CDP is 163. CONCLUSIONS The findings confirmed that practitioners should be aware of the guidewire position during the operation. The displacement of the guidewire should be estimated, and the corresponding error must be considered.
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Affiliation(s)
- Yasser Abuouf
- Department of Energy Resources Engineering, Egypt-Japan University of Science and Technology (E-JUST), P.O. Box 179, New Borg El-Arab City, Postal Code 21934, Alexandria, Egypt.
| | - Shinichi Ookawara
- Department of Energy Resources Engineering, Egypt-Japan University of Science and Technology (E-JUST), P.O. Box 179, New Borg El-Arab City, Postal Code 21934, Alexandria, Egypt; Department of Chemical Engineering, Graduate School of Science and Engineering, Tokyo Institute of Technology, O-okayama, Meguro-ku, Tokyo, 152-8552, Japan.
| | - Mahmoud Ahmed
- Department of Energy Resources Engineering, Egypt-Japan University of Science and Technology (E-JUST), P.O. Box 179, New Borg El-Arab City, Postal Code 21934, Alexandria, Egypt; Mechanical Engineering Department, Assiut University, Assiut, 71516, Egypt.
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Schiopu SRI, Zacherl M, Todica A, Bartenstein P, Milger K, Leuschner G, Munker D, Bauer M, Massberg S, Behr J, Neurohr C, Huber BC, Kneidinger N. Feasibility and accuracy of SPECT myocardial perfusion imaging in end-stage lung disease. J Nucl Cardiol 2020; 27:903-911. [PMID: 31428982 DOI: 10.1007/s12350-019-01851-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 07/25/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) is associated with increased mortality in patients with chronic lung disease. However, non-invasive diagnostic of CAD is difficult, especially in patients with more advanced disease. Therefore, we aimed to assess the feasibility and accuracy of SPECT-myocardial perfusion imaging (MPI) stress testing with regadenoson in patients with end-stage lung disease (ELD) undergoing assessment of stable CAD. METHODS Between January 2012 and May 2018, 102 patients with ELD, who were referred to our institution for lung transplant evaluation, were assessed retrospectively. All patients underwent both stress SPECT-MPI as well as coronary angiography. RESULTS The mean age in our population was 57±6 years. All patients had severe pulmonary function impairment. During stress SPECT-MPI 14 patients (14%) reported regadenoson-related symptoms, but only 2 patients (2%) required medical treatment. Coronary angiography revealed obstructive CAD in 20 patients (20%). Among those, 5 patients had abnormal SPECT-MPI and PCI was performed in 3 patients accordingly. In 14 patients with obstructive CAD, revascularization was deferred based on normal SPECT-MPI findings. CONCLUSIONS SPECT-MPI using regadenoson is well tolerated in patients with ELD and can help to make decisions about coronary revascularization before lung transplant.
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Affiliation(s)
- Sanziana R I Schiopu
- Department of Internal Medicine V, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany.
- Comprehensive Pneumology Centre (CPC-M), Member of the German Centre for Lung Research (DZL), Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Mathias Zacherl
- Department of Nuclear Medicine, Ludwig-Maximilians-University Munich, Marchioninistrasse. 15, 81377, Munich, Germany
| | - Andrei Todica
- Department of Nuclear Medicine, Ludwig-Maximilians-University Munich, Marchioninistrasse. 15, 81377, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, Ludwig-Maximilians-University Munich, Marchioninistrasse. 15, 81377, Munich, Germany
| | - Katrin Milger
- Department of Internal Medicine V, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
- Comprehensive Pneumology Centre (CPC-M), Member of the German Centre for Lung Research (DZL), Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Gabriela Leuschner
- Department of Internal Medicine V, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
- Comprehensive Pneumology Centre (CPC-M), Member of the German Centre for Lung Research (DZL), Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Dieter Munker
- Department of Internal Medicine V, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
- Comprehensive Pneumology Centre (CPC-M), Member of the German Centre for Lung Research (DZL), Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Matthäus Bauer
- Medical Controlling Unit, Department for Patient Management, Munich University Hospital (TM), 81366, Munich, Germany
| | - Steffen Massberg
- Medical Department I, Campus Grosshadern and Campus Innenstadt, Ludwig-Maximilians-University, Munich, Marchioninistrasse 15, Munich, Germany
| | - Jürgen Behr
- Department of Internal Medicine V, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
- Comprehensive Pneumology Centre (CPC-M), Member of the German Centre for Lung Research (DZL), Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
- Asklepios Clinic München, Gauting, Germany
| | - Claus Neurohr
- Department for Pneumology and Respiratory Medicine, Robert-Bosch-Hospital, Schillerhöhe Clinic, Solitudestr. 18, 70839, Gerlingen, Germany
| | - Bruno C Huber
- Medical Department I, Campus Grosshadern and Campus Innenstadt, Ludwig-Maximilians-University, Munich, Marchioninistrasse 15, Munich, Germany
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
- Comprehensive Pneumology Centre (CPC-M), Member of the German Centre for Lung Research (DZL), Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
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Ng MY, Zhou W, Vardhanabhuti V, Lee CH, Yu EYT, Wan EYF, Chan K, Yan AT, Ip TP, Yiu KH, Wintersperger BJ. Cardiac magnetic resonance for asymptomatic patients with type 2 diabetes and cardiovascular high risk (CATCH): a pilot study. Cardiovasc Diabetol 2020; 19:42. [PMID: 32234045 PMCID: PMC7110673 DOI: 10.1186/s12933-020-01019-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/19/2020] [Indexed: 12/31/2022] Open
Abstract
Background Stress cardiovascular magnetic resonance (CMR) to screen for silent myocardial ischaemia in asymptomatic high risk patients with type 2 diabetes mellitus (DM) has never been performed, and its effectiveness is unknown. Our aim was to determine the feasibility of a screening programme using stress CMR by obtaining preliminary data on the prevalence of silent ischaemia caused by obstructive coronary artery disease (CAD) and quantify myocardial perfusion in asymptomatic high risk patients with type 2 diabetes. Methods In this prospective cohort study, we recruited 63 asymptomatic DM patients (mean age 66 years ± 4.4 years; 77.8% male); with Framingham risk score ≥ 20% from 3 sites from June 2017 to August 2018. Normal volunteers were recruited to determine normal global myocardial perfusion reserve index (MPRI). Adenosine stress CMR and global MPRI was performed and measured in all subjects. Positive stress CMR cases were referred for catheter coronary angiography (CCA) with/without fractional flow reserve (FFR) measurements. Positive CCA was defined as an FFR ≤ 0.8 or coronary narrowing ≥ 70%. Patients were followed up for major adverse cardiovascular events. Prevalence is presented as patient numbers and percentage. Mann–Whitney U test was used to compare global MPRI between patients and normal volunteers. Results 13 patients had positive stress CMR with positive CCA (20.6% of patient population), while 9 patients with positive stress CMR examinations had a negative CCA. 5 patients (7.9%) had infarcts detected of which 2 patients had no stress perfusion defects. 12 patients had coronary artery stents inserted, whilst 1 patient declined stent placement. DM patients had lower global MPRI than normal volunteers (n = 7) (1.43 ± 0.27 vs 1.83 ± 0.31 respectively; p < 0.01). After a median follow-up of 653 days, there was no death, heart failure, acute coronary syndrome hospitalisation or stroke. Conclusion 20.6% of asymptomatic DM patients (with Framingham risk ≥ 20%) had silent obstructive CAD. Furthermore, asymptomatic patients have reduced global MPRI than normal volunteers. Trial Registration: ClinicalTrials.gov Registration Number: NCT03263728 on 28th August 2017; https://clinicaltrials.gov/ct2/show/NCT03263728.
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Affiliation(s)
- Ming-Yen Ng
- Department of Diagnostic Radiology, The University of Hong Kong, Room 406, Block K, 102 Pokfulam Road, Hong Kong SAR, China. .,Department of Medical Imaging, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
| | - Wenli Zhou
- Department of Diagnostic Radiology, The University of Hong Kong, Room 406, Block K, 102 Pokfulam Road, Hong Kong SAR, China
| | - Varut Vardhanabhuti
- Department of Diagnostic Radiology, The University of Hong Kong, Room 406, Block K, 102 Pokfulam Road, Hong Kong SAR, China
| | - Chi-Ho Lee
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | - Kit Chan
- Department of Cardiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Andrew T Yan
- Departments of Medicine and Medical Imaging, St. Michael's Hospital, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Tai-Pang Ip
- Department of Medicine, Tung Wah Hospital, Hong Kong, China
| | - Kai-Hang Yiu
- Department of Medicine, The University of Hong Kong, Hong Kong, China.,Department of Cardiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Bernd J Wintersperger
- Department of Medical Imaging, University of Toronto, Toronto, Canada.,Department of Medical Imaging, University Health Network, Toronto, Canada
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Ely Pizzato P, Samdani AJ, Vergara-Martel A, Palma Dallan LA, Tensol Rodrigues Pereira G, Zago E, Zimin V, Grando Bezerra H. Feasibility of coronary angiogram-derived vessel fractional flow reserve in the setting of standard of care percutaneous coronary intervention and its correlation with invasive FFR. Int J Cardiol 2019; 301:45-49. [PMID: 31757646 DOI: 10.1016/j.ijcard.2019.10.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/27/2019] [Accepted: 10/31/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Vessel Fractional Flow Reserve (vFFR), a new angiography-derived method for the functional assessment of coronaries, was recently shown to have good correlation with invasive wire-derived FFR, when vFFR-specific image acquisition requirements were followed. We sought to investigate the feasibility of vFFR analysis and its correlation with FFR in the situation where angiography is completed in routine fashion, without intention for virtual analysis. METHODS Utilizing an anonymized database maintained at our Cardiovascular Imaging Core Laboratory, we included angiographic images from patients that underwent pre- and post-PCI FFR. CAAS Workstation 8.1 software (Pie Medical Imaging) was used for vFFR evaluation. RESULTS Out of 624 angiograms (312 pre-PCI and 312 post-PCI), vFFR was successfully analyzed in 219 (35.1%) (115 pre-PCI and 104 post-PCI). Reasons for vFFR analysis failure were: <2 angiographic projections (42.5%), table movement while acquisition (25.7%) and resolution incompatibility (15%). From 115 patients with analyzable pre-PCI vFFR, 74 (64.3%) showed agreement with the respective FFR results in terms of positive (≤0.80) vs negative (>0.80) FFR. Pearson's correlation coefficient between them was 0.449 (p < 0.0001). From 104 lesions with analyzable post-PCI vFFR, 94 had availability of FFR, 74 (78.7%) of which showed agreement between the vFFR and FFR. Pearson's correlation between the values was 0.115 (p = 0.2703). CONCLUSION vFFR could be analyzed in about one-third of previously completed angiographies and a weak correlation was seen between vFFR and FFR. Our results show the importance of following the pre-specified requirements for vFFR analysis. Further studies are needed to validate the software in different settings.
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Affiliation(s)
- Patricia Ely Pizzato
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, United States of America.
| | - Abdul Jawwad Samdani
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, United States of America
| | - Armando Vergara-Martel
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, United States of America
| | - Luis Augusto Palma Dallan
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, United States of America
| | | | - Elder Zago
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, United States of America
| | - Vladislav Zimin
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, United States of America
| | - Hiram Grando Bezerra
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, United States of America
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Zhou F, Wang YN, Schoepf UJ, Tesche C, Tang CX, Zhou CS, Xu L, Hou Y, Zheng MW, Yan J, Lu MJ, Lu GM, Zhang DM, Zhang B, Zhang JY, Zhang LJ. Diagnostic Performance of Machine Learning Based CT-FFR in Detecting Ischemia in Myocardial Bridging and Concomitant Proximal Atherosclerotic Disease. Can J Cardiol 2019; 35:1523-1533. [PMID: 31679622 DOI: 10.1016/j.cjca.2019.08.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The diagnostic performance of coronary computed tomography angiography-derived fractional flow reserve (CT-FFR) in detecting ischemia in myocardial bridging (MB) has not been investigated to date. METHODS This retrospective multicentre study included 104 patients with left anterior descending MBs. MB was classified as either superficial or deep, short, or long, whereas all MB vessels were further divided into <50%, 50% to 69%, and ≥70% groups, according to proximal lumen stenosis on invasive coronary angiography. Diagnostic performance and receiver operating characteristics (ROC) of CT-FFR to detect lesion-specific ischemia was assessed on a per-vessel level, using invasive FFR as reference standard. Intraclass correlation coefficient (ICC) and Bland-Altman plots were used for agreement measurement. RESULTS Forty-eight MB vessels (46.2%) showed ischemia by invasive FFR (≤0.80). Sensitivity, specificity, and accuracy of CT-FFR to detect functional ischemia were 0.96 (0.85 to 0.99), 0.84 (0.71 to 0.92), and 0.89 (0.81 to 0.94), respectively, in all MB vessels. There were no differences in diagnostic performance between superficial and deep MB or between short and long MB (all P > 0.05). The accuracy of CT-FFR was 0.96 (0.85 to 0.99) in ≥70% stenosis, 0.82 (0.67 to 0.91) in 50% to 69% stenosis, and 0.89 (0.51 to 0.99) in <50% stenosis (P = 0.081). Bland-Altman analysis showed a slight mean difference between CT-FFR and invasive FFR of 0.014 (95% limit of agreement, -0.117 to 0.145). The ICC was 0.775 (95% confidence interval, 0.685-0.842, P < 0.001). CONCLUSIONS CT-FFR demonstrated high diagnostic performance for identifying functional ischemia in vessels with MB and concomitant proximal atherosclerotic disease when compared with invasive FFR. However, the clinical use of CT-FFR in patients with MB needs further study for stronger and more robust results.
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Affiliation(s)
- Fan Zhou
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Yi Ning Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - U Joseph Schoepf
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China; Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christian Tesche
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina, USA; Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany
| | - Chun Xiang Tang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Chang Sheng Zhou
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Lei Xu
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Hou
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Min Wen Zheng
- Department of Radiology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Jing Yan
- Siemens Healthcare Ltd., Shanghai, China
| | - Meng Jie Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Guang Ming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Dai Min Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Bo Zhang
- Department of Radiology, Taizhou People's Hospital, Taizhou, Jiangsu, China
| | - Jia Yin Zhang
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Long Jiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
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Abstract
Background: Calculation of fractional flow reserve (FFR) using computed tomography (CT)-based 3D anatomical models and computational fluid dynamics (CFD) has become a common method to non-invasively assess the functional severity of atherosclerotic narrowing in coronary arteries. We examined the impact of various inflow boundary conditions on computation of FFR to shed light on the requirements for inflow boundary conditions to ensure model representation. Methods: Three-dimensional anatomical models of coronary arteries for four patients with mild to severe stenosis were reconstructed from CT images. FFR and its commonly-used alternatives were derived using the models and CFD. A combination of four types of inflow boundary conditions (BC) was employed: pulsatile, steady, patient-specific and population average. Results: The maximum difference of FFR between pulsatile and steady inflow conditions was 0.02 (2.4%), approximately at a level similar to a reported uncertainty level of clinical FFR measurement (3–4%). The flow with steady BC appeared to represent well the diastolic phase of pulsatile flow, where FFR is measured. Though the difference between patient-specific and population average BCs affected the flow more, the maximum discrepancy of FFR was 0.07 (8.3%), despite the patient-specific inflow of one patient being nearly twice as the population average. Conclusions: In the patients investigated, the type of inflow boundary condition, especially flow pulsatility, does not have a significant impact on computed FFRs in narrowed coronary arteries.
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