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Otsuki H, Yoshida A, Pargaonkar VS, Takahashi K, Honda Y, Fitzgerald PJ, Schnittger I, Tremmel JA. Comparison of Coronary Physiological Indices in Identifying Functionally Significant Myocardial Bridges in ANOCA. Circ Cardiovasc Interv 2025; 18:e014824. [PMID: 40365677 DOI: 10.1161/circinterventions.124.014824] [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: 10/02/2024] [Accepted: 03/26/2025] [Indexed: 05/15/2025]
Abstract
BACKGROUND A functionally significant myocardial bridge (MB) is an important cause of angina with nonobstructive coronary arteries. However, distinguishing a functionally significant versus incidental MB remains challenging. Resting and hyperemic intracoronary functional indices are available, but no studies have compared their diagnostic performance in MBs. METHODS We prospectively studied 64 patients with angina and nonobstructive coronary arteries, all of whom had an MB confirmed by intravascular ultrasound. We evaluated the diagnostic performance of instantaneous wave-free ratio (iFR) and resting full-cycle ratio (RFR) under dobutamine stress, with dobutamine diastolic fractional flow reserve (dFFR) as a reference standard. Dobutamine iFR and dobutamine RFR were assessed in the first 18 patients, while only dobutamine RFR was assessed in the remaining 46. dobutamine dFFR ≤0.76 was considered indicative of a functionally significant MB. RESULTS There was a strong correlation between dobutamine iFR (R2=0.67, P<0.001) and dobutamine RFR (R2=0.80, P<0.001) with dobutamine dFFR. Receiver operating characteristics curve analysis to identify the cutoff for dobutamine dFFR ≤0.76 was 0.81 for dobutamine iFR (area under the curve 0.961) and 0.76 for dobutamine RFR (area under the curve 0.996). The diagnostic accuracy of dobutamine iFR was 94.4%, with a sensitivity of 100% and specificity of 85.7%. For dobutamine RFR, the diagnostic accuracy was 96.9%, with a sensitivity of 95.8% and specificity of 100%. CONCLUSIONS In patients with angina and nonobstructive coronary arteries and an MB confirmed by intravascular ultrasound, dobutamine iFR and dobutamine RFR may serve as alternatives to dobutamine dFFR in identifying a functionally significant MB, with dobutamine RFR having superior diagnostic accuracy.
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Affiliation(s)
- Hisao Otsuki
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA
| | - Akihiro Yoshida
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA
| | | | - Kuniaki Takahashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA
| | - Yasuhiro Honda
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA
| | - Peter J Fitzgerald
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA
| | - Ingela Schnittger
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA
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Demir OM, Sinha A, Rahman H, Ryan M, O'Gallagher K, Ellis H, Li Kam Wa M, Saraf S, Alfakih K, Webb I, Melikian N, De Silva K, Chiribiri A, Plein S, Perera D. Pressure-Derived Indices in the Left Main Coronary Artery: Insights From Comprehensive In Vivo Hemodynamic Studies of Diseased and Unobstructed Vessels. Circ Cardiovasc Interv 2025:e015320. [PMID: 40351192 DOI: 10.1161/circinterventions.125.015320] [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: 03/03/2025] [Accepted: 04/23/2025] [Indexed: 05/14/2025]
Abstract
BACKGROUND Pressure-based physiological evaluation of coronary artery disease is well established, but its application is limited in left main coronary artery (LMCA) disease. Our aim was to investigate whether pressure-based indices are comparable in the left anterior descending (LAD) and left circumflex artery (LCx) branches of the LMCA, and if discordance is due to differences in microvascular function in these territories. METHODS Simultaneous measurements of coronary pressure and flow were made in patients with (1) isolated LMCA disease and (2) unobstructed coronary arteries. Fractional flow reserve, instantaneous wave-free ratio, and microvascular resistance reserve values in the LAD were compared with those of the LCx. RESULTS A total of 80 patients were enrolled (mean age 65±10 years, 56% male). In those with isolated LMCA disease, fractional flow reserve in the LAD was lower than in the LCx (0.74±0.11 versus 0.81±0.11; P<0.0001). Instantaneous wave-free ratio was also lower in the LAD (0.89 [0.76-0.92] versus 0.94 [0.88-0.97]; P<0.0001). The misclassification rates of functionally significant coronary disease, when these indices were measured in the LCx, were 21% for fractional flow reserve and 28% for instantaneous wave-free ratio. Microvascular resistance reserve was higher in the LAD than the LCx, in cohorts with diseased (3.57±1.40 versus 2.50±0.81; P<0.0001) or unobstructed LMCA (3.40±0.78 versus 2.47±0.68; P<0.0001). Microvascular resistance reserve in the LAD territory was similar regardless of whether the LMCA was obstructed or not (P=0.56). Similarly, microvascular resistance reserve in the LCx territory was comparable between cohorts (P=0.88). CONCLUSIONS Microvascular resistance in the LAD is lower than in the LCx territory. Consequently, fractional flow reserve and nonhyperemic pressure-derived indices are lower in the LAD than the LCx. These findings have important implications for how LMCA atheroma should be assessed in clinical practice and also suggest the need for territory-specific thresholds for defining abnormal microvascular function or epicardial conductance.
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Affiliation(s)
- Ozan M Demir
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (O.M.D., A.S., H.R., H.E., M.L.K.W., K.D.S., A.C., D.P.)
| | - Aish Sinha
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (O.M.D., A.S., H.R., H.E., M.L.K.W., K.D.S., A.C., D.P.)
| | - Haseeb Rahman
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (O.M.D., A.S., H.R., H.E., M.L.K.W., K.D.S., A.C., D.P.)
| | - Matthew Ryan
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- King's College Hospital NHS Foundation Trust, London, United Kingdom (M.R., K.O.G., K.A., I.W., N.M.)
| | - Kevin O'Gallagher
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- King's College Hospital NHS Foundation Trust, London, United Kingdom (M.R., K.O.G., K.A., I.W., N.M.)
| | - Howard Ellis
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (O.M.D., A.S., H.R., H.E., M.L.K.W., K.D.S., A.C., D.P.)
| | - Matthew Li Kam Wa
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (O.M.D., A.S., H.R., H.E., M.L.K.W., K.D.S., A.C., D.P.)
| | - Smriti Saraf
- East Kent Hospitals NHS Foundation Trust, United Kingdom (S.S.)
| | - Khaled Alfakih
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- King's College Hospital NHS Foundation Trust, London, United Kingdom (M.R., K.O.G., K.A., I.W., N.M.)
| | - Ian Webb
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- King's College Hospital NHS Foundation Trust, London, United Kingdom (M.R., K.O.G., K.A., I.W., N.M.)
| | - Narbeh Melikian
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- King's College Hospital NHS Foundation Trust, London, United Kingdom (M.R., K.O.G., K.A., I.W., N.M.)
| | - Kalpa De Silva
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (O.M.D., A.S., H.R., H.E., M.L.K.W., K.D.S., A.C., D.P.)
| | - Amedeo Chiribiri
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (O.M.D., A.S., H.R., H.E., M.L.K.W., K.D.S., A.C., D.P.)
| | - Sven Plein
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
| | - Divaka Perera
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom (O.M.D., A.S., H.R., M.R., K.O.G., H.E., M.L.K.W., K.A., I.W., N.M., K.D.S., A.C., S.P., D.P.)
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (O.M.D., A.S., H.R., H.E., M.L.K.W., K.D.S., A.C., D.P.)
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De Filippo O, Mineo R, Millesimo M, Wańha W, Proietto Salanitri F, Greco A, Leone AM, Franchin L, Palazzo S, Quadri G, Tuttolomondo D, Fabris E, Campo G, Giachet AT, Bruno F, Iannaccone M, Boccuzzi G, Gaibazzi N, Varbella F, Wojakowski W, Maremmani M, Gallone G, Sinagra G, Capodanno D, Musumeci G, Boretto P, Pawlus P, Saglietto A, Burzotta F, Aldinucci M, Giordano D, De Ferrari GM, Spampinato C, D'Ascenzo F. Non-invasive physiological assessment of intermediate coronary stenoses from plain angiography through artificial intelligence: the STARFLOW system. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2025; 11:343-352. [PMID: 39382111 DOI: 10.1093/ehjqcco/qcae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 02/10/2024] [Accepted: 03/25/2024] [Indexed: 10/10/2024]
Abstract
BACKGROUND Despite evidence supporting use of fractional flow reserve (FFR) and instantaneous waves-free ratio (iFR) to improve outcome of patients undergoing coronary angiography (CA) and percutaneous coronary intervention, such techniques are still underused in clinical practice due to economic and logistic issues. OBJECTIVES We aimed to develop an artificial intelligence (AI)-based application to compute FFR and iFR from plain CA. METHODS AND RESULTS Consecutive patients performing FFR or iFR or both were enrolled. A specific multi-task deep network exploiting 2 projections of the coronary of interest from standard CA was appraised. Accuracy of prediction of FFR/iFR of the AI model was the primary endpoint, along with sensitivity and specificity. Prediction was tested both for continuous values and for dichotomous classification (positive/negative) for FFR or iFR. Subgroup analyses were performed for FFR and iFR.A total of 389 patients from 5 centers were enrolled. Mean age was 67.9 ± 9.6 and 39.2% of patients were admitted for acute coronary syndrome. Overall, the accuracy was 87.3% (81.2-93.4%), with a sensitivity of 82.4% (71.9-96.4%) and a specificity of 92.2% (90.4-93.9%). For FFR, accuracy was 84.8% (77.8-91.8%), with a sensitivity of 81.9% (69.4-94.4%) and a specificity of 87.7% (85.5-89.9%), while for iFR accuracy was 90.2% (86.0-94.6%), with a sensitivity of 87.2% (76.6-97.8%) and a specificity of 93.2% (91.7-94.7%, all confidence intervals 95%). CONCLUSION The presented machine-learning based tool showed high accuracy in prediction of wire-based FFR and iFR.
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Affiliation(s)
- Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città della Salute e della Scienza" Hospital, Corso Bramante 88, 10126 Turin, Italy
| | - Raffaele Mineo
- Department of Electrical, Electronics and Computer Engineering, University of Catania, Viale Andrea Doria 6, 95125 Catania, Italy
| | - Michele Millesimo
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città della Salute e della Scienza" Hospital, Corso Bramante 88, 10126 Turin, Italy
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 18 Medyków Street 40-752 Katowice, Poland
| | - Federica Proietto Salanitri
- Department of Electrical, Electronics and Computer Engineering, University of Catania, Viale Andrea Doria 6, 95125 Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Via S. Sofia, 78, 95123 Catania, Italy
| | - Antonio Maria Leone
- Ospedale Isola Tiberina - Gemelli Isola, Via di Ponte Quattro capi 39, 00186 Rome, Italy and Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Largo A. Gemelli 1, 00168 Rome, Italy
| | - Luca Franchin
- Cardiology Department, Santa Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale Santa Maria della Misericordia, 15, 33100 Udin, Italy
| | - Simone Palazzo
- Department of Electrical, Electronics and Computer Engineering, University of Catania, Viale Andrea Doria 6, 95125 Catania, Italy
| | - Giorgio Quadri
- Cardiology Department, A. O. Ordine Mauriziano Umberto I, Largo Filippo Turati, 62, 10128 Torino, Italy
| | - Domenico Tuttolomondo
- Department of Cardiology, Parma University Hospital, Viale Gramsci 14, 43126 Parma, Italy
| | - Enrico Fabris
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Via Giacomo Puccini, 50, 34148 Trieste, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro, 8 ȃ 44124 Cona ȃ Ferrara, Italy
| | | | - Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città della Salute e della Scienza" Hospital, Corso Bramante 88, 10126 Turin, Italy
| | - Mario Iannaccone
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Piazza del Donatore di Sangue, 3, 10154 Torino, Italy
| | - Giacomo Boccuzzi
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Piazza del Donatore di Sangue, 3, 10154 Torino, Italy
| | - Nicola Gaibazzi
- Department of Cardiology, Parma University Hospital, Viale Gramsci 14, 43126 Parma, Italy
| | - Ferdinando Varbella
- Interventional Cardiology Unit, "degli infermi Hospital", Via Rivalta, 29, 10098 Rivoli, Torino, Italy
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 18 Medyków Street 40-752 Katowice, Poland
| | - Michele Maremmani
- Department of Cardiology, Policlinico San Marzo - Gruppo San Donato, Corso Europa, 7, 24046, Zingonia, Bergamo, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città della Salute e della Scienza" Hospital, Corso Bramante 88, 10126 Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy, Corso Bramante 88, 10126 Turin, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Via Giacomo Puccini, 50, 34148 Trieste, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Via S. Sofia, 78, 95123 Catania, Italy
| | - Giuseppe Musumeci
- Cardiology Department, A. O. Ordine Mauriziano Umberto I, Largo Filippo Turati, 62, 10128 Torino, Italy
| | - Paolo Boretto
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città della Salute e della Scienza" Hospital, Corso Bramante 88, 10126 Turin, Italy
| | - Pawel Pawlus
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 18 Medyków Street 40-752 Katowice, Poland
| | - Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città della Salute e della Scienza" Hospital, Corso Bramante 88, 10126 Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy, Corso Bramante 88, 10126 Turin, Italy
| | - Francesco Burzotta
- Ospedale Isola Tiberina - Gemelli Isola, Via di Ponte Quattro capi 39, 00186 Rome, Italy and Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Largo A. Gemelli 1, 00168 Rome, Italy
| | - Marco Aldinucci
- Department of Medical Sciences, University of Turin, Turin, Italy, Corso Bramante 88, 10126 Turin, Italy
| | - Daniela Giordano
- Department of Electrical, Electronics and Computer Engineering, University of Catania, Viale Andrea Doria 6, 95125 Catania, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città della Salute e della Scienza" Hospital, Corso Bramante 88, 10126 Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy, Corso Bramante 88, 10126 Turin, Italy
| | - Concetto Spampinato
- Department of Electrical, Electronics and Computer Engineering, University of Catania, Viale Andrea Doria 6, 95125 Catania, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città della Salute e della Scienza" Hospital, Corso Bramante 88, 10126 Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy, Corso Bramante 88, 10126 Turin, Italy
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Zhang M, Keramati H, Gharleghi R, Beier S. Reliability of characterising coronary artery flow with the flow-split outflow strategy: Comparison against the multiscale approach. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2025; 263:108669. [PMID: 39956049 DOI: 10.1016/j.cmpb.2025.108669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2024] [Revised: 12/18/2024] [Accepted: 02/11/2025] [Indexed: 02/18/2025]
Abstract
BACKGROUND In computational modelling of coronary haemodynamics, imposing patient-specific flow conditions is paramount, yet often impractical due to resource and time constraints, limiting the ability to perform a large number of simulations particularly for diseased cases. OBJECTIVE To compare coronary haemodynamics quantified using a simplified flow-split strategy with varying exponents against the clinically verified but computationally intensive multiscale simulations under both resting and hyperaemic conditions in arteries with varying degrees of stenosis. METHODS Six patient-specific left coronary artery trees were segmented and reconstructed, including three with severe (>70 %) and three with mild (<50 %) focal stenoses. Simulations were performed for the entire coronary tree to account for the flow-limiting effects from epicardial artery stenoses. Both a 0D-3D coupled multiscale model and a flow-split approach with four different exponents (2.0, 2.27, 2.33, and 3.0) were used. The resulting prominent haemodynamic metrics were statistically compared between the two methods. RESULTS Flow-split and multiscale simulations did not significantly differ under resting conditions regardless of the stenosis severity. However, under hyperaemic conditions, the flow-split method significantly overestimated the time-averaged wall shear stress by up to 16.8 Pa (p = 0.031) and underestimate the fractional flow reserve by 0.327 (p = 0.043), with larger discrepancies observed in severe stenoses than in mild ones. Varying the exponent from 2.0 to 3.0 within the flow-split methods did not significantly affect the haemodynamic results (p > 0.141). CONCLUSIONS Flow-split strategies with exponents between 2.0 and 3.0 are appropriate for modelling stenosed coronaries under resting conditions. Multiscale simulations are recommended for accurate modelling of hyperaemic conditions, especially in severely stenosed arteries.(247/250 words).
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Affiliation(s)
- Mingzi Zhang
- Sydney Vascular Modelling Group, School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, NSW 2052, Australia.
| | - Hamed Keramati
- Sydney Vascular Modelling Group, School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, NSW 2052, Australia
| | - Ramtin Gharleghi
- Sydney Vascular Modelling Group, School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, NSW 2052, Australia
| | - Susann Beier
- Sydney Vascular Modelling Group, School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, NSW 2052, Australia
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5
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Oshima A, Ninomiya K, Sekiguchi M, Yoshiura D, Gonda Y, Horiuchi Y, Taniwaki M, Yuzawa H, Komiyama K, Tanaka J, Onuma Y, Serruys PW, Tanabe K, Asami M. Diagnostic Performance of Angiography-Based Vessel-Fractional Flow Reserve Compared with Various Wire-Based Physiological Assessments. Catheter Cardiovasc Interv 2025. [PMID: 40230047 DOI: 10.1002/ccd.31534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2025] [Revised: 03/25/2025] [Accepted: 03/28/2025] [Indexed: 04/16/2025]
Abstract
BACKGROUND Although considered the gold standard, pressure wire-derived fractional flow reserve (PW-FFR) and instantaneous wave-free ratio (PW-iFR) are not sufficiently adopted. Vessel fractional flow reserve (vFFR) is a potentially less invasive surrogate. AIMS To validate the diagnostic performance of vFFR against the wire-based physiological assessments in real-world clinical settings. METHODS In this single-center retrospective study, we analyzed 479 patients (586 vessels) who underwent PW-FFR and vFFR in the same vessel, and evaluated the correlation between vFFR and PW-FFR using PW-FFR ≦ 0.80 as the reference. Additionally, we analyzed 378 patients (455 vessels) with vFFR, PW-FFR, and PW-iFR, and 93 patients (119 vessels) with vFFR, PW-FFR, and resting full-cycle ratio (RFR). RESULTS The indications for coronary angiography were stable angina (92%), unstable angina (6.3%), and non-ST-elevation myocardial infarction (1.5%). The target vessels were the left anterior descending artery (61%), left circumflex artery (20%), and right coronary artery (19%). A good correlation was found between vFFR and PW-FFR (R = 0.67; p < 0.001) with a mean bias of 0.0068 ± 0.0786. vFFR demonstrated good accuracy at predicting PW-FFR ≦0.80 (area under the curve [AUC] = 0.86; 95% confidence interval [CI]: 0.83-0.89). At a vFFR cut-off value of ≦0.80, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for predicting PW-FFR ≦0.80 were 78.8%, 82.5%, 77.6%, 83.5%, and 80.9%, respectively, with a Cohen's Kappa coefficient of 0.612. Similar results were observed for vFFR with PW-iFR and RFR. CONCLUSION vFFR demonstrated good correlation and diagnostic performance compared with wire-based physiological assessments.
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Affiliation(s)
- Asahi Oshima
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
- CORRIB Research Center for Advanced Imaging and Core lab, School of Medicine, University of Galway, Galway, Ireland
| | - Kai Ninomiya
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | | | - Daiki Yoshiura
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yuki Gonda
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yu Horiuchi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | | | - Hitomi Yuzawa
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Kota Komiyama
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Jun Tanaka
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yoshinobu Onuma
- CORRIB Research Center for Advanced Imaging and Core lab, School of Medicine, University of Galway, Galway, Ireland
| | - Patrick W Serruys
- CORRIB Research Center for Advanced Imaging and Core lab, School of Medicine, University of Galway, Galway, Ireland
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Masahiko Asami
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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6
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Revaiah PC, Tsai TY, Chinhenzva A, Miyashita K, Tobe A, Oshima A, Ferraz-Costa G, Garg S, Biscaglia S, Patel M, Collet C, Akasaka T, Escaned J, Onuma Y, Serruys PW. Physiological Disease Pattern as Assessed by Pull Back Pressure Gradient Index in Vessels With FFR/iFR Discordance. JACC Cardiovasc Interv 2025; 18:823-834. [PMID: 39985510 DOI: 10.1016/j.jcin.2024.12.017] [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: 06/13/2024] [Revised: 12/11/2024] [Accepted: 12/12/2024] [Indexed: 02/24/2025]
Abstract
BACKGROUND Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are discordant in approximately 20% of cases, and it is unclear whether this is influenced by the physiological pattern of coronary artery disease (CAD). The pull back pressure gradient index (PPGi) can objectively characterize the physiological pattern of CADs. OBJECTIVES The aim of this study was to evaluate whether PPGi differed in discordant groups (FFR+/iFR- vs FFR-/iFR+). METHODS The study enrolled 355 patients (390 vessels) with chronic coronary syndrome who had ≥1 epicardial coronary artery lesion with 40% to 90% diameter stenosis by visual assessment on invasive coronary angiography and had analyzable FFR, iFR, and PPGi derived from quantitative flow ratio. Cutoffs for hemodynamic significance were FFR ≤0.80 and iFR ≤0.89. Vessels were classified as FFR+/iFR+ (n = 103 [26.4%]), FFR-/iFR+ (n = 27 [6.9%]), FFR+/iFR- (n = 38 [9.7%]), and FFR-/iFR- (n = 222 [57%]) groups. RESULTS Median FFR, iFR, and quantitative flow ratio were 0.84 (Q1-Q3: 0.77-0.90), 0.92 (Q1-Q3: 0.88-0.97), and 0.83 (Q1-Q3: 0.73-0.90), respectively. FFR disagreed with iFR in 16.7% of cases (65 of 390). The median PPGi was 0.75 (Q1-Q3: 0.67-0.85). The physiological pattern of CAD was classified according to the PPGi as predominantly physiologically focal (PPGi ≥0.75) in 209 of 390 vessels (53.6%) or diffuse (PPGi < 0.75) in 181 of 390 vessels (46.4%). The median PPGi was significantly lower in FFR-/iFR+ vs FFR+/iFR- vessels (0.65 [Q1-Q3: 0.60-0.69] vs 0.82 [Q1-Q3: 0.75-0.85]; P < 0.001). Predominantly physiologically focal disease was significantly associated with FFR+/iFR- (76.3% [29 of 38]), while predominantly physiologically diffuse disease was significantly associated with FFR-/iFR+ (96.3% [26 of 27] [P < 0.001] for pattern of CAD between FFR+/iFR- and FFR-/iFR+ groups). CONCLUSIONS The physiological pattern of CAD is an important influencing factor in FFR/iFR discordance. (Radiographic Imaging Validation and Evaluation for Angio iFR [REVEAL iFR]; NCT03857503).
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Affiliation(s)
- Pruthvi C Revaiah
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland
| | - Tsung-Ying Tsai
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland
| | - Albert Chinhenzva
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland
| | - Kotaro Miyashita
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland
| | - Akihiro Tobe
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland
| | - Asahi Oshima
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland
| | - Gonçalo Ferraz-Costa
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland; Department of Cardiology, Unidade Local de Saúde de Coimbra, Coimbra, Portugal; Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research, Coimbra, Portugal
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Manesh Patel
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Javier Escaned
- Hospital Clínico San Carlos Instituto de Investigación Sanitaria San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Yoshinobu Onuma
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland
| | - Patrick W Serruys
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland.
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7
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Dai J, Guan C, Xu X, Hou J, Jia H, Yu H, Jin Z, Fu G, Wu X, Wang L, Huang R, Shen Z, Zhao Y, Jin Y, Song L, Tu S, Qiao S, Yu B, Xu B, Stone GW. Angiographic Quantitative Flow Ratio-Guided Treatment of Patients With Physiologically Intermediate Coronary Lesions. J Am Heart Assoc 2025; 14:e035756. [PMID: 40118790 DOI: 10.1161/jaha.124.035756] [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: 03/26/2024] [Accepted: 09/09/2024] [Indexed: 03/23/2025]
Abstract
BACKGROUND The FAVOR III (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients With Coronary Artery Disease) China trial reported improved clinical outcomes with percutaneous coronary intervention guided by quantitative flow ratio (QFR) compared with angiography. Whether these benefits also apply for patients presenting with "uncertainty-zone" lesions of intermediate physiological significance is uncertain. This study aims to examine the impact of QFR guidance versus angiography guidance on the management and outcomes of percutaneous coronary intervention in uncertainty-zone lesions. METHODS AND RESULTS In this prespecified subgroup analysis, offline QFR assessment categorized 873 patients (22.9%) into the uncertainty-zone subgroup, defined as having an offline QFR of 0.75 to 0.85 in all coronary arteries with a lesion causing ≥50% diameter stenosis. At 2 years, the rate of major adverse cardiac events, a composite of all-cause death, myocardial infarction, or ischemia-driven revascularization, occurred in 31 patients (7.0%) in the QFR-guided group and 35 patients (8.3%) in the angiography-guided group (hazard ratio [HR], 0.85 [95% CI, 0.52-1.37]). In landmark analysis, the relative treatment effect of QFR guidance versus angiography guidance on major adverse cardiac events differed before 1 year (4.7% versus 3.8%; HR, 1.25 [95% CI, 0.65-2.40]) and after 1 year (2.3% versus 5.5%; HR, 0.41 [95% CI, 0.20-0.87]) (Pinteraction=0.03), driven by fewer nonprocedural myocardial infarctions and ischemia-driven revascularizations in the QFR-guided group after 1-year follow-up. CONCLUSIONS In the modest-sized subgroup of patients with physiologically intermediate lesions randomized in the FAVOR III China trial, 2-year clinical outcomes were not significantly improved with a QFR-guided revascularization strategy compared with angiography guidance. REGISTRATION URL: https://www.clinicaltrials.gov; Identifier: NCT03656848.
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Affiliation(s)
- Jiannan Dai
- Department of Cardiology The Second Affiliated Hospital of Harbin Medical University Harbin Heilongjiang Province China
| | - Changdong Guan
- The Key Laboratory of Myocardial Ischemia Chinese Ministry of Education Harbin Heilongjiang Province China
- Department of Cardiology National Clinical Research Center for Cardiovascular Diseases Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Xueming Xu
- Department of Cardiology The Second Affiliated Hospital of Harbin Medical University Harbin Heilongjiang Province China
| | - Jingbo Hou
- Department of Cardiology The Second Affiliated Hospital of Harbin Medical University Harbin Heilongjiang Province China
| | - Haibo Jia
- Department of Cardiology The Second Affiliated Hospital of Harbin Medical University Harbin Heilongjiang Province China
| | - Huai Yu
- Department of Cardiology The Second Affiliated Hospital of Harbin Medical University Harbin Heilongjiang Province China
| | - Zening Jin
- Department of Cardiology Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Guosheng Fu
- Department of Cardiology Sir Run Run Shaw Hospital Zhejiang University School of Medicine Hangzhou Zhejiang Province China
| | - Xiaofan Wu
- Department of Cardiology Beijing Anzhen Hospital Capital Medical University Beijing China
| | - Liansheng Wang
- Department of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing China
| | - Rongchong Huang
- Department of Cardiology Beijing Friendship Hospital Capital Medical University Beijing China
| | - Zhujun Shen
- Department of Cardiology Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Yanyan Zhao
- Medical Research and Biometrics Center National Center for Cardiovascular Diseases Beijing China
| | - Yuanzhe Jin
- Department of Cardiology The Fourth Affiliated Hospital of China Medical University Shenyang China
| | - Lei Song
- The Key Laboratory of Myocardial Ischemia Chinese Ministry of Education Harbin Heilongjiang Province China
- Department of Cardiology National Clinical Research Center for Cardiovascular Diseases Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Shengxian Tu
- Biomedical Instrument Institute School of Biomedical Engineering Shanghai Jiao Tong University Shanghai China
| | - Shubin Qiao
- The Key Laboratory of Myocardial Ischemia Chinese Ministry of Education Harbin Heilongjiang Province China
- Department of Cardiology National Clinical Research Center for Cardiovascular Diseases Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Bo Yu
- Department of Cardiology The Second Affiliated Hospital of Harbin Medical University Harbin Heilongjiang Province China
| | - Bo Xu
- The Key Laboratory of Myocardial Ischemia Chinese Ministry of Education Harbin Heilongjiang Province China
- Department of Cardiology National Clinical Research Center for Cardiovascular Diseases Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
- National Clinical Research Center for Cardiovascular Diseases Fuwai Hospital Chinese Academy of Medical Sciences Shenzhen Guangdong Province China
| | - Gregg W Stone
- The Zena and Michael A Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY USA
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8
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Liu W, Shi J, Shan R, Wang Y, Zhao L, Zhou H, Li W, Feng L. Pressure Guidewire Indicated for Coronary Fractional Flow Reserve Assessment: Structural Design, Deficiencies and Potential Solutions. Catheter Cardiovasc Interv 2025. [PMID: 40108763 DOI: 10.1002/ccd.31504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2024] [Revised: 03/04/2025] [Accepted: 03/08/2025] [Indexed: 03/22/2025]
Abstract
Coronary heart disease (CHD) is one of the leading causes of mortality worldwide. It is primarily caused by myocardial ischemia and hypoxia resulting from atherosclerotic plaques in the coronary arteries, leading to symptoms such as angina. The severity of CHD determines the treatment approach, which may include medication or interventional therapy. Therefore, accurately assessing the severity of myocardial ischemia is crucial for effective CHD management. In recent years, fractional flow reserve (FFR), derived from the relationship between flow and pressure, has gained widespread recognition for providing valuable information to guide coronary revascularization. Pressure guidewires equipped with pressure sensors at their tips are the most commonly used tools for clinical FFR assessment. These wires measure vessel pressure to determine the severity of coronary lesions. However, during their use, issues such as signal drift, tip breakage, core wire fractures, and coating detachment may occur. This article reviews the historical development of pressure guidewires, examines the general structure of two commonly used pressure guidewires available in the market, highlights typical issues encountered during clinical use, and proposes corresponding solutions.
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Affiliation(s)
- Wengang Liu
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Jun Shi
- Department of Cardiology, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Rong Shan
- Department of Cardiology, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Yu Wang
- Department of Cardiology, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Liangfeng Zhao
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Honglei Zhou
- Schools of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, China
| | - Wei Li
- Schools of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, China
| | - Liuliu Feng
- Department of Cardiology, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
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9
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Kuramitsu S, Kawase Y, Shinozaki T, Domei T, Yamanaka F, Kaneko U, Kakuta T, Horie K, Terai H, Ando H, Shiono Y, Tagashira T, Nogi K, Kubo T, Asano T, Shiraishi J, Otake H, Sugano A, Anai R, Iwai A, Kikuta Y, Nishina H, Fujita T, Amano T, Iwabuchi M, Yokoi H, Akasaka T, Matsuo H, Tanaka N. Prevalence and Clinical Outcomes of Discordant Lesions Between Fractional Flow Reserve and Nonhyperemic Pressure Ratios in Clinical Practice: The J-PRIDE Registry. Circulation 2025; 151:672-685. [PMID: 39781739 DOI: 10.1161/circulationaha.124.071139] [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: 06/28/2024] [Accepted: 12/09/2024] [Indexed: 01/12/2025]
Abstract
BACKGROUND Limited large-scale, real-world data exist on the prevalence and clinical impact of discordance between fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs). METHODS The J-PRIDE registry (Clinical Outcomes of Japanese Patients With Coronary Artery Disease Assessed by Resting Indices and Fractional Flow Reserve: A Prospective Multicenter Registry) prospectively enrolled 4304 lesions in 3200 patients from 20 Japanese centers. The lesions were classified into FFR+/NHPR-, FFR-/NHPR+, FFR+/NHPR+, or FFR-/NHPR groups according to cutoff values of 0.89 for NHPRs and 0.80 for FFR. The primary study end point was the cumulative 1-year incidence of target vessel failure (a composite of cardiac death, target vessel-related myocardial infarction, and clinically driven target vessel revascularization) on a lesion basis. RESULTS An NHPR cutoff value of 0.89, determined using online software, predicted an FFR of 0.80 across various NHPR types. Discordance between FFR and NHPRs was observed in 20% of lesions (FFR+/NHPR-, 11.2%; FFR-/NHPRs+, 8.8%). Revascularization was deferred in 42.9% and 88.4% of the FFR+/NHPR- and FFR-/NHPR+ groups, respectively. In deferred vessels, the FFR+/NHPR- and FFR-/NHPR+ groups showed a higher 1-year incidence of target vessel failure compared with the FFR-/NHPR- group (7.9% versus 5.5% versus 1.7%; for FFR+/NHPR-, adjusted hazard ratio [aHR], 4.89 [95% CI, 2.68-8.91]; P<0.001; for FFR-/NHPR+, aHR, 2.64 [95% CI, 1.49-4.69]; P<0.001). In revascularized vessels, the 1-year target vessel failure rate was numerically higher in the FFR-/NHPR+ group than in the FFR+/NHPR+ group (9.6% versus 3.4%; aHR, 2.27 [95% CI, 0.70-7.34]; P=0.17), although with similar outcomes between the FFR+/NHPR- and FFR+/NHPR+ groups (2.3% versus 3.4%; aHR, 0.96 [95% CI, 0.37-2.38]; P=0.93). The FFR+/NHPR- group benefited from revascularization compared with medical treatment (aHR, 0.26 [95% CI, 0.08-0.86]; P=0.027); the FFR-/NHPR+ group did not (aHR, 2.39 [95% CI, 0.62-9.21]; P=0.20). CONCLUSIONS Discordance between FFR and NHPRs was noted in 20% of lesions, and discordant deferred lesions resulted in worse outcomes than concordant negative lesions. Although the outcomes after deferring revascularization were comparable between the FFR+/NHPR- and FFR-/NHPR+ lesions, only FFR+/NHPR- lesions showed a benefit from revascularization compared with medical treatment, suggesting that an FFR-guided strategy is superior to an NHPR-guided strategy in discordant lesions. REGISTRATION URL: https://www.umin.ac.jp; Unique identifier: UMIN000038403.
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Affiliation(s)
- Shoichi Kuramitsu
- Department of Cardiovascular Medicine, Sapporo Cardiovascular Clinic, Sapporo Heart Center, Japan (S.K., U.K., T.F.)
| | - Yoshiaki Kawase
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (Y. Kawase, H.M.)
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Japan (T.S.)
| | - Takenori Domei
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan (T.D.)
| | - Futoshi Yamanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kanagawa, Japan (F.Y.)
| | - Umihiko Kaneko
- Department of Cardiovascular Medicine, Sapporo Cardiovascular Clinic, Sapporo Heart Center, Japan (S.K., U.K., T.F.)
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan (T. Kakuta)
| | - Kazunori Horie
- Department of Cardiovascular Medicine, Sendai Kousei Hospital, Japan (K.H.)
| | - Hidenobu Terai
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan (H.T.)
| | - Hirohiko Ando
- Department of Cardiology, Aichi Medical University, Aichi, Japan (H.A., T. Amano)
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan (Y.S.)
| | - Toru Tagashira
- Department of Cardiology, Kita-Harima Medical Center, Ono, Japan (T.T.)
| | - Kazutaka Nogi
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan (K.N.)
| | - Takashi Kubo
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Japan (T. Kubo, N.T.)
| | - Taku Asano
- Department of Cardiovascular Medicine, St Luke's International Hospital, Tokyo, Japan (T. Asano)
| | - Jun Shiraishi
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan (J.S.)
| | - Hiromasa Otake
- Division of Cardiology, Department of Internal Medicine, Kobe University Graduates School of Medicine, Japan (H.O.)
| | - Akinori Sugano
- Department of Cardiology, Ibaraki Prefectural Central Hospital, Tomobe, Japan (A.S.)
| | - Reo Anai
- The Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (R.A.)
| | - Atsushi Iwai
- Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan (A.I.)
| | - Yuetsu Kikuta
- Department of Cardiology, Fukuyama Cardiovascular Hospital, Japan (Y. Kikuta)
| | | | - Tsutomu Fujita
- Department of Cardiovascular Medicine, Sapporo Cardiovascular Clinic, Sapporo Heart Center, Japan (S.K., U.K., T.F.)
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Aichi, Japan (H.A., T. Amano)
| | - Masashi Iwabuchi
- Department of Cardiovascular Medicine, Nephrology and Neurology, Graduate School of Medicine, University of Ryukyus, Okinawa, Japan (M.I.)
| | - Hiroyoshi Yokoi
- Department of Cardiology, Fukuoka Sanno Hospital, Japan (H.Y.)
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Nishinomiya Watanabe Cardiovascular Center, Japan (T. Akasaka)
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (Y. Kawase, H.M.)
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Japan (T. Kubo, N.T.)
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10
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Di Molfetta A, Cusimano V, Cesario M, Mollo P, Di Ruzza G, Menichelli M. Hyperemic vs non-hyperemic indexes discordance: Role of epicardial and microvascular resistance (HyperDisco Study). CARDIOVASCULAR REVASCULARIZATION MEDICINE 2025; 72:44-51. [PMID: 39332933 DOI: 10.1016/j.carrev.2024.09.004] [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: 08/09/2024] [Revised: 08/26/2024] [Accepted: 09/12/2024] [Indexed: 09/29/2024]
Abstract
BACKGROUND Literature reports a 20 % discordance between hyperemic (FFR) and non-hyperemic indexes (NHi) of coronary stenosis lesions. This work aims to develop and test clinically, a formula relating FFR and NHi (including iFR, RFR and Pd/Pa) to study their discordance. METHODS We conducted a prospective, single-center, clinical study enrolling all patients undergoing full coronary physiology assessment with Coroventis CoroFlow Cardiovascular System (Abbott Vascular, St. Paul, Minnesota) to validate the developed formula: [Formula: see text] where IMR(BMR) is the hyperemic (basal) microvascular resistance and HSR(BSR) is the hyperemic (basal) stenosis resistance. RESULTS A total of 51 patients were enrolled, 72 % male, average age 67.4 ± 8.9. Mean hemodynamic data were: FFR 0.87 ± 0.07, iFR 0.93 ± 0.05, RFR 0.91 ± 0.05, Pd/Pa 0.92 ± 0.05, BMR 76.6 ± 51.6 mmHg*s, IMR 28.4 ± 22.8 mmHg*s, BSR 5.5 ± 4.7 mmHg, HSR 3.8 ± 2.9 mmHg*s, coronary flow reserve (CFR) 2.9 ± 1.6, resistive reserve ratio (RRR) 3.3 ± 2.0. Lin's Concordance and Bland Altman analysis showed an optimal correlation between measured and estimated data. Sensitivity analysis showed that: (1) FFR can underestimate epicardial stenosis severity leading to FFR- vs NHi + discordance in case of elevated IMR, (2) NHi can overestimate epicardial stenosis severity leading to FFR- vs NHi + in the case of low BMR, (3) if BSR > HSR, FFR- vs NHi + discordance can occur, while if BSR < HSR, FFR+ vs NHi- discordance can occur. CONCLUSION (1) NHi can be more reliable in case of elevated IMR; (2) FFR-CFR combination can be more reliable for low BMR occurring to compensate an epicardial stenosis; (3) NHi-CFR combination can be more reliable when BSR > HSR, while FFR-CFR combination can be more reliable when BSR < HSR. The combination between pressure and flow indexes (FFR-CFR or NHi-CFR) is more reliable when compensatory mechanisms occur.
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Affiliation(s)
- A Di Molfetta
- Catheterization Laboratory - Ospedale Fabrizio Spaziani, Italy.
| | - V Cusimano
- IASI-Italian National Research Council, Italy
| | - M Cesario
- Catheterization Laboratory - Ospedale Fabrizio Spaziani, Italy
| | - P Mollo
- Catheterization Laboratory - Ospedale Fabrizio Spaziani, Italy
| | - G Di Ruzza
- Catheterization Laboratory - Ospedale Fabrizio Spaziani, Italy
| | - M Menichelli
- Catheterization Laboratory - Ospedale Fabrizio Spaziani, Italy
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11
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Seto AH, Kumar G. Can a SWEDEHEART Win Over the FLAIR Crew and End the iFR/FFR Debate? JACC Cardiovasc Interv 2025; 18:468-470. [PMID: 40010918 DOI: 10.1016/j.jcin.2024.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2024] [Accepted: 12/16/2024] [Indexed: 02/28/2025]
Affiliation(s)
- Arnold H Seto
- Department of Medicine, VA Long Beach Healthcare System, Long Beach, California, USA; Department of Medicine, Charles R. Drew University of Medicine and Science, Willowbrook, California, USA.
| | - Gautam Kumar
- Department of Medicine, Emory University, Atlanta, Georgia, USA; Department of Medicine, Atlanta VA Medical Center, Atlanta, Georgia, USA
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12
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Roh JW, Lee OH, Kim Y, Heo SJ, Im E, Cho DK. Diastolic Hyperemia-Free Ratio in Patients With Coronary Artery Disease: A Prospective Observational Study. Korean Circ J 2025; 55:55.e52. [PMID: 40206008 DOI: 10.4070/kcj.2024.0351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Revised: 01/05/2025] [Accepted: 02/05/2025] [Indexed: 04/11/2025] Open
Abstract
BACKGROUND AND OBJECTIVES Diastolic hyperemia-free ratio (DFR), an alternative to fractional flow reserve (FFR) for the assessment of intermediate coronary artery stenosis, helps reduce patients' time, and inconvenience. However, the validation data for DFR and FFR are lacking. We aimed to evaluate the diagnostic accuracy of DFR and FFR and to assess the effective decision making for revascularization using their values. METHODS Patients subjected to an invasive physiological study for intermediate coronary artery stenosis at a single center in South Korea between August 2022 and January 2024 were prospectively recruited. We evaluated the correlation between DFR and FFR measurements and the diagnostic accuracy of DFR ≤0.89 to predict FFR ≤ 0.80. We also compared the correlation for each coronary artery. RESULTS A total of 324 intermediate coronary stenotic lesions from 300 patients were evaluated using DFR and FFR values simultaneously. There was a strong linear relationship between DFR and FFR (r = 0.80; 95% confidence interval [CI], 0.76-0.84; p < 0.001). The diagnostic accuracy of the DFR was 92.0% in predicting FFR ≤0.80. When compared separately for each coronary artery, all vessels showed a strong linear relationship with no statistical differences between any of the vessels (p=0.641). There was also a strong linear relationship between DFR and distal coronary pressure/aorta pressure (r=0.93; 95% CI, 0.91-0.94; p<0.001). CONCLUSIONS There was a strong correlation between DFR and FFR and a high diagnostic accuracy rate of DFR compared to FFR. Good diagnostic performance of DFR was also observed in each coronary artery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05421169.
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Affiliation(s)
- Ji Woong Roh
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, Korea
| | - Oh-Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, Korea
| | - Yongcheol Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, Korea.
| | - Seok-Jae Heo
- Division of Biostatistics, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Eui Im
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, Korea
| | - Deok-Kyu Cho
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, Korea.
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Molossi S, Sachdeva S. Advice to Young Athletes With Anomalous Aortic Origin of a Coronary Artery With and Without Surgery. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2025; 28:83-93. [PMID: 40382130 DOI: 10.1053/j.pcsu.2025.01.002] [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: 11/03/2024] [Revised: 01/13/2025] [Accepted: 01/18/2025] [Indexed: 05/20/2025]
Abstract
Congenital coronary artery anomalies remain a leading cause of sudden cardiac death in the young. Within these, anomalous aortic origin of a coronary artery represents the largest group, with anomalies of the left coronary artery carrying higher risk for sudden cardiac arrest and clinical manifestations of myocardial ischemia. In contrast, anomalies of origin of the right coronary artery are more common and generally have a more benign clinical course, though rarely also associated with sudden events and myocardial ischemia. Risk stratification to guide management decisions remains to be well defined, though substantial advances have occurred in the last few years, with assessment of myocardial perfusion under provocative stress being an integral part of the evaluation in the young. Discussion and counseling on exercise behavior is essential to foster healthy lifestyle for these patients, acknowledging shared decision-making should be practiced in lieu of many unanswered questions as to outcomes long-term.
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Affiliation(s)
- Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas; The Lillie Frank Abercrombie Division of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Texas Children's Hospital, Houston, Texas; The Lillie Frank Abercrombie Division of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Garcha A, Grande Gutiérrez N. Sensitivity of coronary hemodynamics to vascular structure variations in health and disease. Sci Rep 2025; 15:3325. [PMID: 39865100 PMCID: PMC11770140 DOI: 10.1038/s41598-025-85781-x] [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: 04/05/2024] [Accepted: 01/03/2025] [Indexed: 01/28/2025] Open
Abstract
Local hemodynamics play an essential role in the initiation and progression of coronary artery disease. While vascular geometry alters local hemodynamics, the relationship between vascular structure and hemodynamics is poorly understood. Previous computational fluid dynamics (CFD) studies have explored how anatomy influences plaque-promoting hemodynamics. For example, areas exposed to low wall shear stress (ALWSS) can indicate regions of plaque growth. However, small sample sizes, idealized geometries, and simplified boundary conditions have limited their scope. We generated 230 synthetic models of left coronary arteries and simulated coronary hemodynamics with physiologically realistic boundary conditions. We measured the sensitivity of hemodynamic metrics to changes in bifurcation angles, positions, diameter ratios, tortuosity, and plaque topology. Our results suggest that the diameter ratio between left coronary branches plays a substantial role in generating adverse hemodynamic phenotypes and can amplify the effect of other geometric features such as bifurcation position and angle, and vessel tortuosity. Introducing mild plaque in the models did not change correlations between structure and hemodynamics. However, certain vascular structures can induce ALWSS at the trailing edge of the plaque. Our analysis demonstrates that coronary artery vascular structure can provide key insight into the hemodynamic environments conducive to plaque formation and growth.
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Affiliation(s)
- Arnav Garcha
- Mechanical Engineering, Carnegie Mellon University, Pittsburgh, 15213, USA
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15
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Escaned J, Travieso A, Dehbi HM, Nijjer SS, Sen S, Petraco R, Patel M, Serruys PW, Davies J. Coronary Revascularization Guided With Fractional Flow Reserve or Instantaneous Wave-Free Ratio: A 5-Year Follow-Up of the DEFINE FLAIR Randomized Clinical Trial. JAMA Cardiol 2025; 10:25-31. [PMID: 39412778 PMCID: PMC11581635 DOI: 10.1001/jamacardio.2024.3314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 08/02/2024] [Indexed: 11/24/2024]
Abstract
Importance The differences between the use of fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) in the long term are unknown. Objective To compare long-term outcomes of iFR- and FFR-based strategies to guide revascularization. Design, Setting, and Participants The DEFINE-FLAIR multicenter study randomized patients with coronary artery disease to use either iFR or FFR as a pressure index to guide revascularization. Patients from 5 continents with coronary artery disease and angiographically intermediate severity stenoses who underwent hemodynamic interrogation with pressure wires were included. These data were analyzed from March, 13, 2014, through April, 27, 2021. MAIN OUTCOME MEASURES Five-year major adverse cardiac events (MACE) (a composite of all-cause death, nonfatal myocardial infarction, and unplanned revascularization), as well as the individual components of the combined end point. Results At 5 years of follow-up, no significant differences were found between the iFR (mean age [SD], 65.5 [10.8] years; 962 male [77.5%]) and FFR (mean age [SD], 65.2 [10.6] years; 929 male [74.3%]) groups in terms of MACE (21.1% vs 18.4%, respectively; hazard ratio [HR], 1.18; 95% CI, 0.99-1.42; P = .06). While all-cause death was higher among patients randomized to iFR, it was not driven by myocardial infarction (6.3% vs 6.2% in the FFR study arm; HR, 1.01; 95% CI, 0.74-1.38; P = .94) or unplanned revascularization (11.9% vs 12.2% in the FFR group; HR, 0.98; 95% CI, 0.78-1.23; P = .87). Furthermore, patients in whom revascularization was deferred on the basis of iFR or FFR had similar MACE in both study arms (17.9% in the iFR group vs 17.5% in the FFR group; HR, 1.03; 95% CI, 0.79-1.35; P = .80) with similar rates of the components of MACE, including all-cause death. On the contrary, in patients who underwent revascularization after physiologic interrogation, the incidence of MACE was higher in the iFR group (24.6%) compared with the FFR group (19.2%) (HR, 1.36; 95% CI, 1.07-1.72; P = .01). Conclusions and relevance At 5-year follow up, an iFR based-strategy was not statistically different than an FFR strategy to guide revascularization in terms of MACE, nonfatal myocardial infarction, and unplanned revascularization. Trial Registration ClinicalTrials.gov Identifier: NCT02053038.
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Affiliation(s)
- Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid and CIBERCV, Madrid, Spain
- Comprehensive Clinical Trials Unit at UCL, University College London, London, United Kingdom
| | - Alejandro Travieso
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid and CIBERCV, Madrid, Spain
- Comprehensive Clinical Trials Unit at UCL, University College London, London, United Kingdom
| | - Hakim-Moulay Dehbi
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Sukhjinder S. Nijjer
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sayan Sen
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Ricardo Petraco
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh Patel
- Department of Cardiology, University of Galway, Galway, Ireland
| | - Patrick W. Serruys
- College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
| | - Justin Davies
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Dalmaso C, Fossan FE, Bråten AT, Müller LO. Uncertainty Quantification and Sensitivity Analysis for Non-invasive Model-Based Instantaneous Wave-Free Ratio Prediction. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2025; 41:e3898. [PMID: 39777995 PMCID: PMC11706247 DOI: 10.1002/cnm.3898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/20/2024] [Accepted: 11/29/2024] [Indexed: 01/11/2025]
Abstract
The main objectives of this work are to validate a 1D-0D unsteady solver with a distributed stenosis model for the patient-specific estimation of resting haemodynamic indices and to assess the sensitivity of instantaneous wave-free ratio (iFR) predictions to uncertainties in input parameters. We considered 52 patients with stable coronary artery disease, for which 81 invasive iFR measurements were available. We validated the performance of our solver compared to 3D steady-state and transient results and invasive measurements. Next, we used a polynomial chaos approach to characterise the uncertainty in iFR predictions based on the inputs associated with boundary conditions (coronary flow, compliance and aortic/left ventricular pressures) and vascular geometry (radius). Agreement between iFR and the ratio between cardiac cycle averaged distal and aortic pressure waveforms (restingP d / P a $$ {P}_d/{P}_a $$ ) obtained through 1D-0D and 3D models was satisfactory, with a bias of 0.0-0.005 (±0.016-0.026). The sensitivity analysis showed that iFR estimation is mostly affected by uncertainties in vascular geometry and coronary flow (steady-state parameters). In particular, our 1D-0D method overestimates invasive iFR measurements, with a bias of -0.036 (±0.101), indicating that better flow estimates could significantly improve our modelling pipeline. Conversely, we showed that standard pressure waveforms could be used for simulations, since the impact of uncertainties related to inlet-pressure waveforms on iFR prediction is negligible. Furthermore, while compliance is the most relevant transient parameter, its effect on iFR estimates is negligible compared to that of vascular geometry and flow. Finally, we observed a strong correlation between iFR and restingP d / P a $$ {P}_d/{P}_a $$ , suggesting that steady-state simulations could replace unsteady simulations for iFR prediction.
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Affiliation(s)
| | - Fredrik Eikeland Fossan
- Department of Structural EngineeringNorwegian University of Science and TechnologyTrondheimNorway
| | - Anders Tjellaug Bråten
- Clinic of CardiologySt. Olavs HospitalTrondheimNorway
- Department of Circulation and Medical ImagingNorwegian University of Science and TechnologyTrondheimNorway
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Pintea Bentea G, Berdaoui B, Morissens M, van de Borne P, Castro Rodriguez J. Pathophysiology, Diagnosis, and Management of Coronary Artery Disease in the Setting of Atrial Fibrillation. J Am Heart Assoc 2024; 13:e037552. [PMID: 39575708 DOI: 10.1161/jaha.124.037552] [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] [Indexed: 01/03/2025]
Abstract
Atrial fibrillation (AF) and coronary artery disease are frequently associated and, when so, lead to a grim prognosis. Recent studies suggest the presence of interconnected pathophysiological pathways between the 2 conditions that can promote and aggravate each other, igniting a vicious cycle. Notwithstanding, in contrast with the attention dedicated to the management of antithrombotic treatment, research on other aspects of coronary artery disease in AF is only recently gaining traction. The clinical impact of correct assessment of coronary artery stenosis in AF is especially high, due to the antithrombotic therapy imposed by both AF and coronary stenting. Until recently, an in-depth characterization of coronary microcirculation in AF was lacking. However, contemporary studies indicate that coronary microvascular dysfunction is a frequent encounter in AF, possibly explaining the ischemic symptoms even in the absence of obstructive coronary artery disease and interfering with the use of pressure-based indices to evaluate the hemodynamic significance of coronary artery stenosis. This comprehensive review addresses our current knowledge on coronary physiology in AF and its repercussion on the invasive management of coronary artery disease in this setting.
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18
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Bigler MR, Stark AW, Shiri I, Illi J, Siepe M, Caobelli F, Giannopoulos AA, Buechel RR, Haeberlin A, Obrist D, Räber L, Gräni C. Noninvasive anatomical assessment for ruling out hemodynamically relevant coronary artery anomalies in adults - A comparison of coronary-CT to invasive coronary angiography: The NARCO study design. Contemp Clin Trials Commun 2024; 42:101394. [PMID: 39634517 PMCID: PMC11616572 DOI: 10.1016/j.conctc.2024.101394] [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: 02/19/2024] [Revised: 09/23/2024] [Accepted: 11/17/2024] [Indexed: 12/07/2024] Open
Abstract
Background Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital heart disease, potentially leading to myocardial ischemia and adverse cardiac events. As the sole presence of AAOCA does not always imply a revascularization, a detailed anatomical and functional analysis is crucial for clinical decision-making. Currently, invasive coronary angiography is the gold-standard method for a thorough hemodynamic assessment of AAOCA. However, due to its invasive nature, the development of noninvasive diagnostic alternatives is desired. Methods In the NARCO trial, patients with AAOCA will undergo coronary computed tomography angiography (CCTA) to assess anatomical high-risk features followed by a vessel-based (i.e. invasive measurement with fractional flow reserve and intravascular imaging under a dobutamine-volume challenge) and a myocardium-based (i.e. nuclear imaging) ischemia testing. Comparison of noninvasive and invasive imaging will be performed. Additionally, explorative analysis of post-processing advanced computational fluid dynamics (CFD) and 3D printing will be performed to unravel the pathophysiologic mechanism of myocardial ischemia in AAOCA. Aims Our primary aim is to define characteristics of anatomical high-risk features (using CCTA) to rule out noninvasively hemodynamically relevant anomalous vessels in AAOCA patients. The secondary aim is to investigate the underlying pathophysiology of AAOCA-related hemodynamic relevance using advanced techniques such as CFD and 3D printing. Conclusions The NARCO trial will help to optimize AAOCA patient selection for revascularization by improving risk stratification and ruling out hemodynamic relevance noninvasively and, therefore, preventing unnecessary downstream testing and/or costly interventions in patients with AAOCA.
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Affiliation(s)
- Marius R. Bigler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anselm W. Stark
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Isaac Shiri
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joel Illi
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Siepe
- Centre for Congenital Heart Disease, Department of Cardiovascular Surgery, Inselspital, Bern, Switzerland
| | - Federico Caobelli
- University Clinic of Nuclear Medicine, Inselspital, Bern University Hospital, Switzerland
| | - Andreas A. Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Ronny R. Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominik Obrist
- ARTORG Center for Biomedical Engineering Research, Faculty of Medicine, University of Bern, 3008, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Jong CB, Lu TS, Liao MT, Xu JL, Chen CK, Kuo JC, Wu CC. Comparison of Nitroglycerin-Induced Pressure Ratio Drop and Resting Full-Cycle Ratio in a Pressure Wire Study. J Clin Med 2024; 13:6716. [PMID: 39597860 PMCID: PMC11594636 DOI: 10.3390/jcm13226716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2024] [Revised: 10/25/2024] [Accepted: 11/05/2024] [Indexed: 11/29/2024] Open
Abstract
Background/Objectives: The acute drop in distal coronary pressure (Pd)-to-aortic pressure (Pa) ratio after intracoronary nitroglycerin (NTG-Pd/Pa) administration is an acceptable estimate of fractional flow reserve (FFR). We aimed to compare the diagnostic performance of NTG-Pd/Pa with that of the resting full-cycle ratio (RFR) in predicting the binary results of FFR. Methods: This study included two prospective studies registered under the numbers NCT04700397 and NCT03693157. Altogether, 202 vessels were included. The optimal cutoff of NTG-Pd/Pa for predicting FFR ≤ 0.8 was identified and validated in another prospective registry. We used the McNemar's test and the DeLong method to compare the diagnostic efficiency of NTG-Pd/Pa vs. RFR in predicting FFR ≤ 0.8 in a pooled cohort. Results: NTG-Pd/Pa was strongly correlated with FFR (r = 0.945, p < 0.001). The NTG-Pd/Pa cutoff for predicting FFR ≤ 0.8 was 0.85 in both the derivation and validation cohorts. The area under the receiver-operating characteristic curve (AUC) and accuracy in predicting FFR ≤ 0.8 were higher for NTG-Pd/Pa than for RFR in the pooled cohort (AUC 0.97 vs. 0.91, p < 0.001; accuracy 91% vs. 84%, p < 0.001). The sensitivity and negative predictive values were also higher for NTG-Pd/Pa than for RFR (all p < 0.05). The specificity and positive predictive value were numerically higher for NTG-Pd/Pa than for RFR (all p > 0.05). Conclusions: The diagnostic performance of NTG-Pd/Pa may surpass that of the RFR in predicting the binary results of the FFR.
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Affiliation(s)
- Chien-Boon Jong
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu 300195, Taiwan; (M.-T.L.); (C.-K.C.); (C.-C.W.)
- College of Medicine, National Taiwan University, Taipei 100233, Taiwan
| | - Tsui-Shan Lu
- Department of Mathematics, National Taiwan Normal University, Taipei 116059, Taiwan;
| | - Min-Tsun Liao
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu 300195, Taiwan; (M.-T.L.); (C.-K.C.); (C.-C.W.)
- College of Medicine, National Taiwan University, Taipei 100233, Taiwan
| | - Jia-Lang Xu
- Big Data Center, National Chung Hsing University, Taichung 402202, Taiwan;
- Department of Computer Science & Information Engineering, Chaoyang University of Technology, Taichung 413310, Taiwan
| | - Chun-Kai Chen
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu 300195, Taiwan; (M.-T.L.); (C.-K.C.); (C.-C.W.)
- College of Medicine, National Taiwan University, Taipei 100233, Taiwan
| | - Jui-Cheng Kuo
- Department of Radiology, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu 300195, Taiwan;
| | - Chih-Cheng Wu
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu 300195, Taiwan; (M.-T.L.); (C.-K.C.); (C.-C.W.)
- College of Medicine, National Taiwan University, Taipei 100233, Taiwan
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20
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Nakamura R, Shiono Y, Honda K, Kunimoto H, Wada T, Fujimoto T, Ikuchi M, Ideguchi Y, Taruya A, Takahata M, Ozaki Y, Agematsu K, Tanaka A, Nishimura Y. Risk factors for unsuccessful restoration of coronary flow reserve after coronary bypass surgery. Int J Cardiol 2024; 414:132419. [PMID: 39098607 DOI: 10.1016/j.ijcard.2024.132419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 08/01/2024] [Indexed: 08/06/2024]
Abstract
OBJECTIVES Coronary flow reserve (CFR) is a strong predictor of cardiovascular events and prognosis in patients with coronary artery disease. This study aimed to evaluate preoperative factors associated with the unsuccessful restoration of CFR after coronary artery bypass grafting (CABG). METHODS Included in this study were the 65 patients who presented with functionally significant left anterior descending artery (LAD) lesions confirmed by both fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), and who underwent successful CABG at our hospital within the study period. After CABG, graft patency was confirmed by coronary computed tomography angiography, and CFR in the LAD artery was measured by echocardiography. We defined postoperative CFR <2.5 as impaired CFR, and CFR ≥2.5 as preserved CFR. RESULTS Of the 65 patients, 14 patients (22%) showed impaired CFR, while 51 patients had preserved CFR. Patients with impaired CFR had significantly higher HbA1c (6.7% vs. 6.0%, P < 0.01), greater use of insulin (43% vs. 4%, P < 0.01), longer lesion length (33 mm vs. 25 mm, P = 0.044), and lower iFR (0.69 vs 0.81, P = 0.01) than those with preserved CFR, although both groups had comparable FFR (0.65 vs 0.64, P = 0.46). In receiver operating characteristic curve analysis, iFR had a significantly larger area under the curve than FFR in terms of the prediction of impaired CFR (0.74 vs 0.42, P = 0.01). CONCLUSIONS Poorly-controlled preoperative diabetes, greater reliance on insulin, longer lesion length and lower iFR were associated with postoperative impaired CFR, suggesting the involvement of microvascular dysfunction.
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Affiliation(s)
- Ryo Nakamura
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Yasutsugu Shiono
- Department of Cardiology, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Kentaro Honda
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan.
| | - Hideki Kunimoto
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Teruaki Wada
- Department of Cardiology, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Takahiro Fujimoto
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Mizuho Ikuchi
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Yuya Ideguchi
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Akira Taruya
- Department of Cardiology, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Masahiro Takahata
- Department of Cardiology, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Yuichi Ozaki
- Department of Cardiology, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Kota Agematsu
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Atsushi Tanaka
- Department of Cardiology, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Yoshiharu Nishimura
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
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Bennett J, Chandrasekhar S, Woods E, McLean P, Newman N, Montelaro B, Hassan Virk HU, Alam M, Sharma SK, Jned H, Khawaja M, Krittanawong C. Contemporary Functional Coronary Angiography: An Update. Future Cardiol 2024; 20:755-778. [PMID: 39445463 PMCID: PMC11622791 DOI: 10.1080/14796678.2024.2416817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 10/11/2024] [Indexed: 10/25/2024] Open
Abstract
Functional coronary angiography (FCA) is a novel modality for assessing the physiology of coronary lesions, going beyond anatomical visualization by traditional coronary angiography. FCA incorporates indices like fractional flow reserve (FFR) and instantaneous wave-free ratio (IFR), which utilize pressure measurements across coronary stenoses to evaluate hemodynamic impacts and to guide revascularization strategies. In this review, we present traditional and evolving modalities and uses of FCA. We will also evaluate the existing evidence and discuss the applicability of FCA in various clinical scenarios. Finally, we provide insight into emerging evidence, current challenges, and future directions in FCA.
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Affiliation(s)
- Josiah Bennett
- Department of Internal Medicine, Emory University, Atlanta, GA30322, USA
| | | | - Edward Woods
- Department of Internal Medicine, Emory University, Atlanta, GA30322, USA
| | - Patrick McLean
- Department of Internal Medicine, Emory University, Atlanta, GA30322, USA
| | - Noah Newman
- Department of Internal Medicine, Emory University, Atlanta, GA30322, USA
| | - Brett Montelaro
- Department of Internal Medicine, Emory University, Atlanta, GA30322, USA
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH44106, USA
| | - Mahboob Alam
- Department of Cardiology, The Texas Heart Institute, Baylor College of Medicine, Houston, TX77030, USA
| | - Samin K Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY10029, USA
| | - Hani Jned
- John Sealy Distinguished Centennial Chair in Cardiology, Chief, Division of Cardiology, University of Texas Medical Branch, Galveston, TX77555, USA
| | - Muzamil Khawaja
- Division of Cardiology, Emory University, Atlanta, GA30322, USA
| | - Chayakrit Krittanawong
- Cardiology Division, NYU Langone Health & NYU School of Medicine, New York, NY10016, USA
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Zhang XC, Zhang Q, Wu GF, Hu HT, Lin L, Tian S, Hao LL, Wang T. Evaluation of enhanced external counterpulsation for diabetic foot based on a patient-specific 0D-1D cardiovascular system model. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 255:108333. [PMID: 39047576 DOI: 10.1016/j.cmpb.2024.108333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 07/07/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND AND OBJECTIVE Diabetic foot (DF) complications often lead to severe vascular issues. This study investigated the effectiveness of enhanced external counterpulsation (EECP) and its derived innovative compression strategies in addressing poor perfusion in DF. Although developing non-invasive and efficient treatment methods for DF is critical, the hemodynamic alterations during EECP remain underexplored despite promising outcomes in microcirculation. This research sought to address this gap by developing a patient-specific 0D-1D model based on clinical ultrasound data to identify potentially superior compression strategies that could substantially enhance blood flow in patients with DF complications. METHODS Data were gathered from 10 patients with DF utilizing ultrasound for blood flow rate and computed tomography angiography (CTA) to identify lower limb conditions. Clinical measurements during standard EECP, with varying cuff pressures, facilitated the creation of a patient-specific 0D-1D model through a two-step parameter estimation process. The accuracy of this model was verified via comparison with the clinical measurements. Four compression strategies were proposed and rigorously evaluated using this model: EECP-Simp-I (removing hip cuffs), EECP-Simp-II (further removing the cuffs around the lower leg), EECP-Impr-I (removing all cuffs around the affected side), and EECP-Impr-II (building a loop circulation from the healthy side to the affected side). RESULTS The predicted results under the rest and standard EECP states were generally closely aligned with clinical measurements. The patient-specific 0D-1D model demonstrated that EECP-Simp-I and EECP-Impr-I contributed similar enhancement to perfusion in the dorsal artery (DA) and were comparable to standard EECP, while EECP-Simp-II had the least effect and EECP-Impr-II displayed the most significant enhancement. Pressure at the aortic root (AO) remained consistent across strategies. CONCLUSIONS EECP-Simp-I is recommended for patients with DF, emphasizing device simplification. However, EECP-Simp-II is discouraged as it significantly diminished blood perfusion in this study, except in cases of limb fragility. EECP-Impr-II showed superior enhancement of blood perfusion in DA to all other strategies but required a more complex EECP device. Despite increased AO pressure in all the proposed compression strategies, safety could be guaranteed as the pressue remained within a safe range.
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Affiliation(s)
- Xiao-Cong Zhang
- Department of Emergency, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong 518033, China; Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong 518033, China; Department of Cardiology, Foshan Fosun Chancheng Hospital, Foshan, Guangdong 528000, China
| | - Qi Zhang
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong 518033, China; College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, Liaoning 110167, China
| | - Gui-Fu Wu
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong 518033, China
| | - Hai-Tao Hu
- Department of Wound Repairment, Foshan Fosun Chancheng Hospital, Foshan, Guangdong 528000, China
| | - Ling Lin
- Department of Radiology, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong 518033, China
| | - Shuai Tian
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong 518033, China.
| | - Li-Ling Hao
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, Liaoning 110167, China.
| | - Tong Wang
- Department of Emergency, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong 518033, China.
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Liu Z, Liu Y, Liu J, Sun H, Liu J, Hou C, Wang L, Li B. Noninvasive and fast method of calculation for instantaneous wave-free ratio based on haemodynamics and deep learning. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 255:108355. [PMID: 39067137 DOI: 10.1016/j.cmpb.2024.108355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 07/21/2024] [Accepted: 07/23/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND AND OBJECTIVES Instantaneous wave-free ratio (iFR) is a new invasive indicator of myocardial ischaemia, and its diagnostic performance is as good as the "gold standard" of myocardial ischaemia diagnosis: fractional flow reserve (FFR). iFR can be approximated by iFRCT, which is calculated based on noninvasive coronary CT angiography (CTA) images and computational fluid dynamics (CFD). However, the existing methods for calculating iFRCT fail to accurately simulate the resting state of the coronary artery, resulting in low computational accuracy. Furthermore, the use of CFD technology limits its computational efficiency, making it difficult to meet clinical application needs. The role of coronary microcirculatory resistance compensation suggests that microcirculatory resistance can be adaptively reduced to compensate for increases in coronary stenotic resistance, thereby maintaining stable myocardial perfusion in the resting state. It is therefore necessary to consider this compensation mechanism to establish a high-fidelity microcirculation resistance model in the resting state in line with human physiology, and so to achieve accurate calculation of iFRCT. METHODS In this study we successfully collected clinical data, such as FFR, in 205 stenotic vessels from 186 patients with coronary heart disease. A neural network model was established to predict coronary artery stenosis resistance. Based on the compensation mechanism of coronary microcirculation resistance, an iterative solution algorithm for microcirculation resistance in the resting state was developed. Combining the two methods, a simplified single-branch model combining coronary stenosis and microcirculation resistance was established, and the noninvasive and rapid numerical calculation of iFRCT was performed. RESULTS The results showed that the mean squared error (MSE) between the pressure drop predicted by the neural network value for the coronary artery stenosis model and the ground truth in the test set was 0.053 %, and correlation analysis proved that there was a good correlation between them (r = 0.99, p < 0.001). With reference to clinical diagnosis of myocardial ischaemia (using FFR as the gold standard), the diagnostic accuracy of the iFRCT calculation model for the 205 cases was 88.29 % (r = 0.71, p < 0.001), and the total calculation time was < 8 s. CONCLUSIONS The results of this study demonstrate the utility of a simplified single-branch model in an iFRCT calculation method based on haemodynamics and deep learning, which is important for noninvasive and rapid diagnosis of myocardial ischaemia.
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Affiliation(s)
- Zining Liu
- Department of Biomedical Engineering, College of Chemistry and Life Science, Beijing University of Technology, Beijing, China
| | - Youjun Liu
- Department of Biomedical Engineering, College of Chemistry and Life Science, Beijing University of Technology, Beijing, China
| | - Jincheng Liu
- Department of Biomedical Engineering, College of Chemistry and Life Science, Beijing University of Technology, Beijing, China
| | - Hao Sun
- Department of Biomedical Engineering, College of Chemistry and Life Science, Beijing University of Technology, Beijing, China
| | - Jian Liu
- Cardiovascular department, Peking University People's Hospital, Beijing, China
| | - Chang Hou
- Cardiovascular department, Peking University People's Hospital, Beijing, China
| | - Lihua Wang
- Radiology department, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Bao Li
- Department of Biomedical Engineering, College of Chemistry and Life Science, Beijing University of Technology, Beijing, China.
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Henry TD, Widmer RJ. Letter by Henry and Widmer Regarding Article, "Visual Estimates of Coronary Slow Flow Are Not Associated With Invasive Wire-Based Diagnoses of Coronary Microvascular Dysfunction". Circ Cardiovasc Interv 2024; 17:e014588. [PMID: 39324265 DOI: 10.1161/circinterventions.124.014588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Affiliation(s)
- Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH (T.D.H.)
| | - R Jay Widmer
- Division of Cardiology, Department of Internal Medicine, Baylor Scott and White Medical Center, Temple, TX (R.J.W.)
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Ganzorig N, Pompei G, Jenkins K, Wang W, Rubino F, Gill K, Kunadian V. Role of physiology in the management of multivessel disease among patients with acute coronary syndrome. ASIAINTERVENTION 2024; 10:157-168. [PMID: 39347110 PMCID: PMC11413640 DOI: 10.4244/aij-d-24-00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 08/02/2024] [Indexed: 10/01/2024]
Abstract
Multivessel coronary artery disease (CAD), defined as ≥50% stenosis in 2 or more epicardial arteries, is associated with a high burden of morbidity and mortality in acute coronary syndrome (ACS) patients. A salient challenge for managing this cohort is selecting the optimal revascularisation strategy, for which the use of coronary physiology has been increasingly recognised. Fractional flow reserve (FFR) is an invasive, pressure wire-based, physiological index measuring the functional significance of coronary lesions. Understanding this can help practitioners evaluate which lesions could induce myocardial ischaemia and, thus, decide which vessels require urgent revascularisation. Non-hyperaemic physiology-based indices, such as instantaneous wave-free ratio (iFR), provide valid alternatives to FFR. While FFR and iFR are recommended by international guidelines in stable CAD, there is ongoing discussion regarding the role of physiology in patients with ACS and multivessel disease (MVD); growing evidence supports FFR use in the latter. Compelling findings show FFR-guided complete percutaneous coronary intervention (PCI) can reduce adverse cardiovascular events, mortality, and repeat revascularisations in ACS and MVD patients compared to angiography-based PCI. However, FFR is limited in identifying non-flow-limiting vulnerable plaques, which can disadvantage high-risk patients. Here, integrating coronary physiology assessment with intracoronary imaging in decision-making can improve outcomes and quality of life. Further research into novel physiology-based tools in ACS and MVD is needed. This review aims to highlight the key evidence surrounding the role of FFR and other functional indices in guiding PCI strategy in ACS and MVD patients.
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Affiliation(s)
- Nandine Ganzorig
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Graziella Pompei
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Kenny Jenkins
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Wanqi Wang
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Francesca Rubino
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Cardiology, HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Kieran Gill
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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Mukheja Y, Sarkar A, Arora R, Pal K, Ahuja A, Vashishth A, Kuhad A, Chopra K, Jain M. Unravelling the progress and potential of drug-eluting stents and drug-coated balloons in cardiological insurgencies. Life Sci 2024; 352:122908. [PMID: 39004270 DOI: 10.1016/j.lfs.2024.122908] [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: 02/24/2024] [Revised: 07/01/2024] [Accepted: 07/08/2024] [Indexed: 07/16/2024]
Abstract
AIM Coronary artery disease (CAD) is the leading cause of mortality. Though percutaneous transluminal angioplasty followed by stenting is still the default treatment of choice for revascularization of obstructive CAD, the high rate of restenosis compromises the outcomes of endovascular procedures. To overcome restenosis, drug-eluting stents (DES) and drug-coated balloons (DCB) are designed that release antiproliferative drugs like sirolimus, paclitaxel, everolimus, etc., over time to inhibit cell growth and proliferation. Our review aims to summarize the challenges and progress of DES/DCBs in clinical settings. MATERIAL AND METHODS The comprehensive review, search and selection encompasses in relevant articles through Google Scholar, Springer online, Cochrane library and PubMed that includes research articles, reviews, letters and communications, various viewpoints, meta-analyses, randomized trials and quasi-randomized trials. Several preclinical and clinical data have been included from National Institutes of Health and clinicaltrials.gov websites. KEY FINDINGS Challenges like delayed endothelialization, stent thrombosis (ST), and inflammation was prominent in first-generation DES. Second-generation DES with improved designs and drug coatings enhanced biocompatibility with fewer complications. Gradual absorption of bioresorbable DES over time mitigated long-term issues associated with permanent implants. Polymer-free DES addressed the inflammation concerns but still, they leave behind metallic stents in the vasculature. As an alternative therapeutic strategy, DCB were developed to minimize inflammation in the vessel. Although both DES and DCBs have shown considerable progress, challenges persist. SIGNIFICANCE This review illustrates the advancements in the designs, preparation technologies, biodegradable materials, and drugs used as well as challenges associated with DES and DCBs in clinical settings.
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Affiliation(s)
- Yashdeep Mukheja
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Ankan Sarkar
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Rubal Arora
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Kashish Pal
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Akanksha Ahuja
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Anushka Vashishth
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Anurag Kuhad
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Kanwaljit Chopra
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Manish Jain
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India.
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Thielmann M, Bonaros N, Barbato E, Barili F, Folliguet T, Friedrich G, Gottardi R, Legutko J, Parolari A, Punjabi P, Sandner S, Suwalski P, Shehada SE, Wendt D, Czerny M, Muneretto C. Hybrid coronary revascularization: position paper of the European Society of Cardiology Working Group on Cardiovascular Surgery and European Association of Percutaneous Cardiovascular Interventions. Eur J Cardiothorac Surg 2024; 66:ezae271. [PMID: 39142801 DOI: 10.1093/ejcts/ezae271] [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: 03/07/2024] [Revised: 05/17/2024] [Accepted: 07/10/2024] [Indexed: 08/16/2024] Open
Abstract
Myocardial revascularization in coronary artery disease via percutaneous coronary intervention or coronary artery bypass graft (CABG) surgery effectively relieves symptoms, significantly improves prognosis and quality of life when combined with guideline-directed medical therapy. Hybrid coronary revascularization is a promising alternative to percutaneous coronary intervention or CABG in selected patients and is defined as a planned and/or intended combination of consecutive CABG surgery using at least 1 internal mammary artery to the left anterior descending (LAD), and catheter-based coronary intervention to the non-LAD vessels for the treatment of multivessel disease. The main indications for hybrid coronary revascularization are (i) to achieve complete revascularization in patients who cannot undergo conventional CABG, (ii) to treat patients with acute coronary syndromes and multivessel disease with a non-LAD vessel as the culprit lesion that needs revascularization and (iii) in highly select patients with multivessel disease with complex LAD lesions and simple percutaneous coronary intervention targets for all other vessels. Hybrid coronary revascularization patients receive a left internal mammary artery graft to the LAD artery through a minimal incision along with percutaneous coronary intervention to the remaining diseased coronary vessels using latest generation drug-eluting stents. A collaborative environment with a dedicated heart team is the optimal platform to perform such interventions, which aim to improve the quality and outcome of myocardial revascularization. This position paper analyses the rationale of hybrid coronary revascularization and the currently available evidence on the various techniques and delves into the sequence of the interventions and pharmacological management during and after the procedure.
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Affiliation(s)
- Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
- Cardiovascular Research Center Aalst OLV Hospital, Aalst, Belgium
| | - Fabio Barili
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Thierry Folliguet
- Chirurgie Cardiaque et Transplantation, Assistance Publique Hôpital Henri Mondor, Université Paris UPEC, Paris, France
| | - Guy Friedrich
- Department of Cardiology, Innsbruck Medical University, Innsbruck, Austria
| | - Roman Gottardi
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
| | - Jacek Legutko
- Department of Interventional Cardiology, Jagiellonian University Medical College, Institute of Cardiology, The John Paul II Hospital, Krakow, Poland
| | - Alessandro Parolari
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Prakash Punjabi
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Piotr Suwalski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre for Postgraduate Medical Education, Warsaw, Poland
| | - Sharaf-Eldin Shehada
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Daniel Wendt
- Faculty of Medicine, University Hospital Essen, Essen, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Claudio Muneretto
- Department and School of Cardiovascular Surgery, University of Brescia Medical School, Spedali Civili di Brescia, Brescia, Italy
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Hidalgo F, Gonzalez-Manzanares R, Suárez de Lezo J, Gallo I, Alvarado M, Perea J, Maestre-Luque LC, Resúa A, Romero M, López-Benito M, Pérez de Prado A, Ojeda S, Pan M. The Usefulness of Coregistration with iFR in Tandem or Long Diffuse Coronary Lesions: The iLARDI Randomized Clinical Trial. J Clin Med 2024; 13:4342. [PMID: 39124613 PMCID: PMC11313554 DOI: 10.3390/jcm13154342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 07/23/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024] Open
Abstract
Background. Despite technical advancements, patients with sequential or diffuse coronary lesions undergoing percutaneous coronary intervention (PCI) have an increased risk of cardiovascular events at follow-up. We aimed to analyze the utility of a SyncVision/iFR (S-iFR)-guided PCI strategy versus an angiography-guided strategy in patients with this type of lesions. Methods. Randomized, multicenter, controlled, and open-label trial to compare S-iFR versus angiography-guided PCI in patients with sequential or diffuse angiographic coronary stenosis (ClinicalTrials.gov identifier: NCT04283734). The primary endpoint was the implanted stent length. The main secondary endpoint was targeting vessel failure (TVF) at one year. Results. A total of 100 patients underwent randomization, with 49 patients assigned to the S-iFR group and 51 to the angiography-guided PCI group. There were no differences between groups regarding clinical and anatomical characteristics. The baseline iFR was 0.71 ± 0.16 vs. 0.67 ± 0.19 (p = 0.279) in the S-iFR and angiography group, respectively. The mean lesion length was 42.3 ± 12 mm and 39.8 ± 12 (p = 0.297). The implanted stent length was 32.7 ± 17.2 mm in the S-iFR group and 43.1 ± 14.9 mm in the angiography group (mean difference, -10.4 mm; 95% confidence interval [CI], -16.9 to -4.0; p = 0.002). At one year, target vessel failure (TVF) occurred in four patients: three (6.1%) in the S-iFR group vs. one (1.9%) in the angiography group (p = 0.319). Conclusions. Among patients with sequential or long diffuse coronary lesions, a S-iFR-guided PCI strategy resulted in a reduction of the total stent length compared to an angiography-guided PCI strategy. A nonsignificant increase in TVF was observed in the S-iFR group.
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Affiliation(s)
- Francisco Hidalgo
- Department of Cardiology, Reina Sofia University Hospital, 14004 Cordoba, Spain; (R.G.-M.); (J.S.d.L.); (I.G.); (J.P.); (L.C.M.-L.); (A.R.); (M.R.); (S.O.); (M.P.)
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Rafael Gonzalez-Manzanares
- Department of Cardiology, Reina Sofia University Hospital, 14004 Cordoba, Spain; (R.G.-M.); (J.S.d.L.); (I.G.); (J.P.); (L.C.M.-L.); (A.R.); (M.R.); (S.O.); (M.P.)
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Javier Suárez de Lezo
- Department of Cardiology, Reina Sofia University Hospital, 14004 Cordoba, Spain; (R.G.-M.); (J.S.d.L.); (I.G.); (J.P.); (L.C.M.-L.); (A.R.); (M.R.); (S.O.); (M.P.)
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Ignacio Gallo
- Department of Cardiology, Reina Sofia University Hospital, 14004 Cordoba, Spain; (R.G.-M.); (J.S.d.L.); (I.G.); (J.P.); (L.C.M.-L.); (A.R.); (M.R.); (S.O.); (M.P.)
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
| | - Marco Alvarado
- Department of Cardiology, Reina Sofia University Hospital, 14004 Cordoba, Spain; (R.G.-M.); (J.S.d.L.); (I.G.); (J.P.); (L.C.M.-L.); (A.R.); (M.R.); (S.O.); (M.P.)
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
| | - Jorge Perea
- Department of Cardiology, Reina Sofia University Hospital, 14004 Cordoba, Spain; (R.G.-M.); (J.S.d.L.); (I.G.); (J.P.); (L.C.M.-L.); (A.R.); (M.R.); (S.O.); (M.P.)
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
| | - Luis Carlos Maestre-Luque
- Department of Cardiology, Reina Sofia University Hospital, 14004 Cordoba, Spain; (R.G.-M.); (J.S.d.L.); (I.G.); (J.P.); (L.C.M.-L.); (A.R.); (M.R.); (S.O.); (M.P.)
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
| | - Adriana Resúa
- Department of Cardiology, Reina Sofia University Hospital, 14004 Cordoba, Spain; (R.G.-M.); (J.S.d.L.); (I.G.); (J.P.); (L.C.M.-L.); (A.R.); (M.R.); (S.O.); (M.P.)
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
| | - Miguel Romero
- Department of Cardiology, Reina Sofia University Hospital, 14004 Cordoba, Spain; (R.G.-M.); (J.S.d.L.); (I.G.); (J.P.); (L.C.M.-L.); (A.R.); (M.R.); (S.O.); (M.P.)
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Department of Medicine, University of Cordoba, 14004 Cordoba, Spain
| | - María López-Benito
- Department of Cardiology, University Hospital of Leon, 24008 Leon, Spain (A.P.d.P.)
| | | | - Soledad Ojeda
- Department of Cardiology, Reina Sofia University Hospital, 14004 Cordoba, Spain; (R.G.-M.); (J.S.d.L.); (I.G.); (J.P.); (L.C.M.-L.); (A.R.); (M.R.); (S.O.); (M.P.)
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Department of Medicine, University of Cordoba, 14004 Cordoba, Spain
| | - Manuel Pan
- Department of Cardiology, Reina Sofia University Hospital, 14004 Cordoba, Spain; (R.G.-M.); (J.S.d.L.); (I.G.); (J.P.); (L.C.M.-L.); (A.R.); (M.R.); (S.O.); (M.P.)
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), 14004 Cordoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Department of Medicine, University of Cordoba, 14004 Cordoba, Spain
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Vergni F, Fiore G, Pellone F, Luzi M. [Functional assessment of coronary stenosis: alternative hyperemic, nonhyperemic, and angiographic indexes]. REC: INTERVENTIONAL CARDIOLOGY 2024; 6:224-234. [PMID: 40415782 PMCID: PMC12097319 DOI: 10.24875/recic.m24000446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/12/2024] [Indexed: 05/27/2025] Open
Abstract
Assessment of the functional significance of coronary artery stenoses to guide percutaneous coronary intervention is widely performed using pressure wire fractional flow reserve during adenosine- or adenosine triphosphate-induced hyperemia. However, the use of fractional flow reserve may be limited by the contraindications and adverse effects of this hyperemic stimulus, as well as the potential risk of vessel damage from the pressure wire. This review will discuss alternative evaluation methods, including various hyperemic agents, nonhyperemic pressure ratios, and angiography-based indices.
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Affiliation(s)
- Federico Vergni
- Department of Interventional Cardiology, Ospedale Generale Provinciale - Macerata, ItaliaDepartment of Interventional CardiologyOspedale Generale ProvincialeMacerataItalia
| | - Giuliano Fiore
- Department of Cardiology, Ospedale Generale Provinciale - Macerata, ItaliaDepartment of CardiologyOspedale Generale ProvincialeMacerataItalia
| | - Francesco Pellone
- Department of Interventional Cardiology, Ospedale Generale Provinciale - Macerata, ItaliaDepartment of Interventional CardiologyOspedale Generale ProvincialeMacerataItalia
| | - Mario Luzi
- Department of Cardiology, Ospedale Generale Provinciale - Macerata, ItaliaDepartment of CardiologyOspedale Generale ProvincialeMacerataItalia
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Doan TT, Puelz C, Rusin C, Molossi S. Anomalous Aortic Origin of a Coronary Artery in Pediatric Patients. CURRENT PEDIATRICS REPORTS 2024; 12:69-80. [PMID: 39816672 PMCID: PMC11729077 DOI: 10.1007/s40124-024-00317-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 01/18/2025]
Abstract
Purpose of Review We present a contemporary approach to risk assessment and management of patients with anomalous aortic origin of a coronary artery (AAOCA). Recent Findings Anomalous left coronary artery from the right aortic sinus (L-AAOCA) with interarterial course carries a high risk of sudden cardiac death (SCD); therefore, current guidelines recommend exercise restriction and surgical intervention. Recent data in intraseptal and juxtacommissural L-AAOCA showed inducible perfusion abnormalities, leading to consideration of surgical intervention. Anomalous right coronary artery from the left aortic sinus (R-AAOCA) carries a much lower risk and stress perfusion imaging is helpful in identifying patients with inducible ischemia. Perfusion abnormalities resolve following successful surgical intervention of AAOCA. Computational modeling techniques identifying risk features shows promise in the evaluation of AAOCA. Summary Stress perfusion imaging is helpful in assessing AAOCA upon presentation and following surgical intervention. Computational modeling has potential in bridging knowledge gaps in AAOCA. Supplementary Information The online version contains supplementary material available at 10.1007/s40124-024-00317-7.
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Affiliation(s)
- Tam T. Doan
- Coronary Artery Anomalies Program, Division of Cardiology, Texas Children’s Hospital, 6651 Main Street MC-E1920, Houston, TX 77030 USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030 USA
| | - Charles Puelz
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030 USA
| | - Craig Rusin
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030 USA
| | - Silvana Molossi
- Coronary Artery Anomalies Program, Division of Cardiology, Texas Children’s Hospital, 6651 Main Street MC-E1920, Houston, TX 77030 USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030 USA
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31
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Cai L, Zhong Q, Xu J, Huang Y, Gao H. A lumped parameter model for evaluating coronary artery blood supply capacity. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2024; 21:5838-5862. [PMID: 38872561 DOI: 10.3934/mbe.2024258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
The coronary artery constitutes a vital vascular system that sustains cardiac function, with its primary role being the conveyance of indispensable nutrients to the myocardial tissue. When coronary artery disease occurs, it will affect the blood supply of the heart and induce myocardial ischemia. Therefore, it is of great significance to numerically simulate the coronary artery and evaluate its blood supply capacity. In this article, the coronary artery lumped parameter model was derived based on the relationship between circuit system parameters and cardiovascular system parameters, and the blood supply capacity of the coronary artery in healthy and stenosis states was studied. The aortic root pressure calculated by the aortic valve fluid-structure interaction (AV FSI) simulator was employed as the inlet boundary condition. To emulate the physiological phenomenon of sudden pressure drops resulting from an abrupt reduction in blood vessel radius, a head loss model was connected at the coronary artery's entrance. For each coronary artery outlet, the symmetric structured tree model was appended to simulate the terminal impedance of the missing downstream coronary arteries. The particle swarm optimization (PSO) algorithm was used to optimize the blood flow viscous resistance, blood flow inertia, and vascular compliance of the coronary artery model. In the stenosis states, the relative flow and fractional flow reserve (FFR) calculated by numerical simulation corresponded to the published literature data. It was anticipated that the proposed model can be readily adapted for clinical application, serving as a valuable reference for diagnosing and treating patients.
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Affiliation(s)
- Li Cai
- School of Mathematics and Statistics, Northwestern Polytechnical University, Xi'an 710129, China
- NPU-UoG International Cooperative Lab for Computation and Application in Cardiology, Xi'an 710129, China
- Xi'an Key Laboratory of Scientific Computation and Applied Statistics, Xi'an 710129, China
| | - Qian Zhong
- School of Mathematics and Statistics, Northwestern Polytechnical University, Xi'an 710129, China
- NPU-UoG International Cooperative Lab for Computation and Application in Cardiology, Xi'an 710129, China
- Xi'an Key Laboratory of Scientific Computation and Applied Statistics, Xi'an 710129, China
| | - Juan Xu
- School of Mathematics and Statistics, Northwestern Polytechnical University, Xi'an 710129, China
- NPU-UoG International Cooperative Lab for Computation and Application in Cardiology, Xi'an 710129, China
- Xi'an Key Laboratory of Scientific Computation and Applied Statistics, Xi'an 710129, China
| | - Yuan Huang
- Department of Mathematics, University of Cambridge, Cambridge CB2 1TN, UK
| | - Hao Gao
- School of Mathematics and Statistics, University of Glasgow, Glasgow G12 8QQ, UK
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Rawal H, Nguyen TD, Igbinomwanhia E, Klein LW. Clinical effects of physiologic lesion testing in influencing treatment strategy for multi-vessel coronary artery disease. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 40:100378. [PMID: 38510505 PMCID: PMC10945951 DOI: 10.1016/j.ahjo.2024.100378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 03/22/2024]
Abstract
Background The application of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in multivessel coronary artery disease (CAD) patients has not been definitively explored. We herein assessed how treatment strategies were decided based on FFR/iFR values in vessels selected clinically. Specifically, we sought to determine whether treatment selection was based on whether the vessel tested was the clinical target stenosis. Methods 270 consecutive patients with angiographically determined multivessel disease who underwent FFR/iFR testing were included. Patients were classified initially based on their angiographic findings, then re-evaluated from FFR/iFR results (normal or abnormal). Tested lesions were classified into target or non-target lesions based on clinical and non-invasive evaluations. Results Abnormal FFR/iFR values were demonstrated in 51.9 % of patients, in whom 51.4 % received coronary stenting (PCI) and 44.3 % had bypass surgery (CABG). With two-vessel CAD patients, medical therapy was preferred when the target lesion was normal (72.6 %), while PCI was preferred when it was abnormal (78.4 %). In non-target lesions, PCI was preferred regardless of FFR/iFR results (78.0 %). With three-vessel CAD patients, CABG was preferred when the target lesion was abnormal (68.5 %), and there was no difference in the selected modality when it was normal. Furthermore, the incidence of tested lesions was higher in the left anterior descending (LAD) compared to other coronary arteries, and two-vessel CAD patients with LAD stenoses were more frequently treated by PCI. Conclusion The use of invasive physiologic testing in multivessel CAD patients may alter the preferred treatment strategy, leading to an overall increase in PCI selection.
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Affiliation(s)
- Harsh Rawal
- University of Connecticut, St Francis Hospital, Hartford, CT, United States of America
| | - Tung D. Nguyen
- Department of Physiology & Biophysics, University of Illinois at Chicago – College of Medicine, Chicago, IL, United States of America
| | - Efehi Igbinomwanhia
- Department of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States of America
| | - Lloyd W. Klein
- Department of Cardiology, University of California – San Francisco, San Francisco, CA, United States of America
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Abbasciano RG, Layton GR, Torre S, Abbaker N, Copperwheat A, Lucarelli C, Bhandari S, Nijjer S, Mikhail G, Casula R, Zakkar M, Viviano A. Fractional flow reserve and instantaneous wave-free ratio in coronary artery bypass grafting: a meta-analysis and practice review. Front Cardiovasc Med 2024; 11:1348341. [PMID: 38516003 PMCID: PMC10955066 DOI: 10.3389/fcvm.2024.1348341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/20/2024] [Indexed: 03/23/2024] Open
Abstract
Objective Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are invasive methods to assess the functional significance of intermediate severity coronary lesions. Both indexes have been extensively validated in clinical trials in guiding revascularisation in patients with stable ischaemic heart disease undergoing percutaneous coronary intervention (PCI) with improved clinical outcomes. However, the role of these tools in coronary artery bypass grafting (CABG) is less clear. Methods A meta-analysis of randomised trials and observational studies was carried out to help in determining the optimal strategy for assessing lesion severity and selecting graft targets in patients undergoing CABG. Electronic searches were carried out on Embase, MEDLINE, and Web of Science. A group of four authors independently screened and then assessed the retrieved records. Cochrane's Risk of Bias and Robins-I tools were used for bias assessment. A survey was conducted among surgeons and cardiologists to describe current attitudes towards the preoperative use of functional coronary investigations in practice. Results Clinical outcomes including mortality at 30 days, perioperative myocardial infarction, number of grafts, incidence of stroke, rate of further need for revascularisation, and patient-reported quality of life did not differ in CABG guided by functional testing from those guided by traditional angiography.The survey revealed that in half of the surgical and cardiology units functional assessment is performed in CABG patients; there is a general perception that functional testing has improved patient care and its use would clarify the role of moderate coronary lesions that often need multidisciplinary rediscussions; moderate stenosis are felt to be clinically relevant; and anatomical considerations need to be taken into account together with functional assessment. Conclusions At present, the evidence to support the routine use of functional testing in intermediate lesions for planning CABG is currently insufficient. The pooled data currently available do not show an increased risk in mortality, myocardial injury, and stroke in the FFR/iFR-guided group. Further trials with highly selected populations are needed to clarify the best strategy. Systematic Review Registration ClinicalTrials.gov, identifier (CRD42023414604).
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Affiliation(s)
- R. G. Abbasciano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - G. R. Layton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - S. Torre
- Cardiac Surgery Unit, Giaccone Hospital, Palermo, Italy
| | - N. Abbaker
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - A. Copperwheat
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - C. Lucarelli
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - S. Bhandari
- Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - S. Nijjer
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - G. Mikhail
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - R. Casula
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - M. Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - A. Viviano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
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Molossi S, Doan T, Sachdeva S. Anomalous Coronary Arteries: A State-of-the-Art Approach. Card Electrophysiol Clin 2024; 16:51-69. [PMID: 38280814 DOI: 10.1016/j.ccep.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Congenital coronary anomalies are not an infrequent occurrence and their clinical presentation typically occurs during early years, though may be manifested only in adulthood. In the setting of anomalous aortic origin of a coronary artery, this is particularly concerning as it inflicts sudden loss of healthy young lives. Risk stratification remains a challenge and so does the best management decision-making in these patients, particularly if asymptomatic. Standardized approach to evaluation and management, with careful data collection and collaboration among centers, will likely impact future outcomes in this patient population, thus allowing for exercise participation and healthier lives.
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Affiliation(s)
- Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA.
| | - Tam Doan
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
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35
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Sehatbakhsh S, Li W, Takahashi T, Takahashi K, Parikh MA, Kobayashi Y. Nonhyperemic Pressure Ratios-All the Same or Nuanced Differences? Cardiol Clin 2024; 42:13-19. [PMID: 37949534 DOI: 10.1016/j.ccl.2023.07.011] [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] [Indexed: 11/12/2023]
Abstract
Fractional flow reserve (FFR) has become the gold standard for invasively assessing the functional significance of coronary artery disease (CAD) to guide revascularization. The amount of evidence supporting the role of FFR in the cardiac catheterization laboratory is large and still growing. However, FFR uptake in the daily practice is limited by a variety of factors such as invasive instrumentation of the coronary artery that requires extra time and need for vasodilator medications for hyperemia. In this review, we describe the details of wire-based alternatives to FFR, providing insights as to their development, clinical evidence, and limitations.
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Affiliation(s)
- Samineh Sehatbakhsh
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 210th Street, Bronx, NY 10467, USA
| | - Weijia Li
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, The Bronx, NY 10461, USA
| | - Tatsunori Takahashi
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, The Bronx, NY 10461, USA
| | - Kayo Takahashi
- Department of Cardiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Manish A Parikh
- Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, 506 6th Street, Brooklyn, NY 11215, USA
| | - Yuhei Kobayashi
- Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, 506 6th Street, Brooklyn, NY 11215, USA.
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36
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Nijjer SS. Using Physiology Pullback for Percutaneous Coronary Intervention Guidance: Is this the Future? Cardiol Clin 2024; 42:41-53. [PMID: 37949539 DOI: 10.1016/j.ccl.2023.07.008] [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] [Indexed: 11/12/2023]
Abstract
Modern coronary intervention requires integration of angiographic, physiologic, and intravascular imaging. This article describes the use and techniques needed to understand coronary physiology pullback data and how use it to make revascularization decisions. The article describes instantaneous wave-free ratio, fractional flow reserve, and the data that support their use and how they differ when used in tandem disease. Common practical mistakes and errors are discussed together with a brief review of the limited published research data.
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Affiliation(s)
- Sukhjinder Singh Nijjer
- Department of Cardiology, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, United Kingdom. https://twitter.com/SukhNijjer
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37
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Fawaz S, Cook CM. Understanding the Basis for Hyperemic and Nonhyperemic Coronary Pressure Assessment. Cardiol Clin 2024; 42:1-11. [PMID: 37949531 DOI: 10.1016/j.ccl.2023.07.012] [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] [Indexed: 11/12/2023]
Abstract
Despite the now routine integration of invasive physiologic systems into coronary catheter laboratories worldwide, it remains critical that all operators maintain a sound understanding of the fundamental physiologic basis for coronary pressure assessment. More specifically, performing operators should be well informed regarding the basis for hyperemic (ie, fractional flow reserve) and nonhyperemic (ie, instantaneous wave-free ratio and other nonhyperemic pressure ratio) coronary pressure assessment. In this article, we provide readers a comprehensive history charting the inception, development, and validation of hyperemic and nonhyperemic coronary pressure assessment.
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Affiliation(s)
- Samer Fawaz
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom
| | - Christopher M Cook
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom.
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38
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Joseph T, Foley M, Al-Lamee R. Physiology and Intravascular Imaging Coregistration-Best of all Worlds? Cardiol Clin 2024; 42:77-87. [PMID: 37949541 DOI: 10.1016/j.ccl.2023.07.006] [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] [Indexed: 11/12/2023]
Abstract
Percutaneous coronary intervention is increasingly guided by coronary physiology and optimized using intravascular imaging. Pressure-based measurements determine the significance of a stenosis using hyperemic or nonhyperemic pressure ratios (eg, the instantaneous wave-free ratio). Intravascular ultrasound and optical coherence tomography provide cross-sectional and longitudinal detail regarding plaque composition and vessel characteristics. These facilitate lesion preparation and optimization of stent sizing and positioning. This review explores the evidence-base and practical aspects of coregistering pressure gradient assessment and intravascular imaging with angiography. We then discuss gaps in the evidence and what is needed to help integrate these techniques into clinical practice.
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Affiliation(s)
- Tobin Joseph
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W120HS, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London, W120HS, UK
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W120HS, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London, W120HS, UK.
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W120HS, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London, W120HS, UK; Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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39
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Foley M, Rajkumar CA, Ahmed-Jushuf F, Nour D, Fung CH, Seligman H, Pathimagaraj RH, Petraco R, Sen S, Nijjer S, Howard JP, Ahmad Y, Allahwala U, Bhindi R, Chamie D, Doi S, Kuwata S, Kaihara T, Koga M, Ishibashi Y, Higuma T, Tanabe Y, Nakayama M, Kawase Y, Watanabe A, Funayama N, Horinaka R, Hijikata N, Takahashi T, Matsuo H, Hansen PS, Manica A, Weaver J, Alzuhairi K, Yong TH, Warisawa T, Francis DP, Shun-Shin MJ, Al-Lamee RK. The ability of contemporary cardiologists to judge the ischemic impact of a coronary lesion visually. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 59:60-66. [PMID: 37612169 DOI: 10.1016/j.carrev.2023.08.003] [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: 03/22/2023] [Revised: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Landmark trials showed that invasive pressure measurement (Fractional Flow Reserve, FFR) was a better guide to coronary stenting than visual assessment. However, present-day interventionists have benefited from extensive research and personal experience of mapping anatomy to hemodynamics. AIMS To determine if visual assessment of the angiogram performs as well as invasive measurement of coronary physiology. METHODS 25 interventional cardiologists independently visually assessed the single vessel coronary disease of 200 randomized participants in The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial (ORBITA). They gave a visual prediction of the FFR and Instantaneous Wave-free Ratio (iFR), denoted vFFR and viFR respectively. Each judged each lesion on 2 occasions, so that every lesion had 50 vFFR, and 50 viFR assessments. The group consensus visual estimates (vFFR-group and viFR-group) and individual cardiologists' visual estimates (vFFR-individual and viFR-individual) were tested alongside invasively measured FFR and iFR for their ability to predict the placebo-controlled reduction in stress echo ischemia with stenting. RESULTS Placebo-controlled ischemia improvement with stenting was predicted by vFFR-group (p < 0.0001) and viFR-group (p < 0.0001), vFFR-individual (p < 0.0001) and viFR-individual (p < 0.0001). There were no significant differences between the predictive performance of the group visual estimates and their invasive counterparts: p = 0.53 for vFFR vs FFR and p = 0.56 for viFR vs iFR. CONCLUSION Visual assessment of the angiogram by contemporary experts, provides significant additional information on the amount of ischaemia which can be relieved by placebo-controlled stenting in single vessel coronary artery disease.
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Affiliation(s)
- Michael Foley
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Fiyyaz Ahmed-Jushuf
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Daniel Nour
- James Cook University, Queensland, Australia
| | - Chi Ho Fung
- Imperial College Healthcare NHS Trust, London, England, UK
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | | | - Ricardo Petraco
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Sukhjinder Nijjer
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | | | | | - Daniel Chamie
- Yale School of Medicine, Yale University, New Haven, CT, USA; Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Shunich Doi
- St Marianna University School of Medicine, Kawasaki, Japan
| | - Shingo Kuwata
- St Marianna University School of Medicine, Kawasaki, Japan
| | | | - Masashi Koga
- St Marianna University School of Medicine, Kawasaki, Japan
| | - Yuki Ishibashi
- St Marianna University School of Medicine, Kawasaki, Japan
| | - Takumi Higuma
- St Marianna University School of Medicine, Kawasaki, Japan
| | | | - Masafumi Nakayama
- Gifu Heart Center, Gifu, Japan; Toda Chuo General Hospital, Toda, Japan
| | | | | | | | | | | | | | | | | | - Andre Manica
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, Brazil
| | - James Weaver
- Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, Australia
| | | | - Thon-Hon Yong
- Imperial College Healthcare NHS Trust, London, England, UK
| | - Takayuki Warisawa
- National Heart and Lung Institute, Imperial College London, UK; St Marianna University School of Medicine, Kawasaki, Japan; Gifu Heart Center, Gifu, Japan
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK
| | - Rasha K Al-Lamee
- National Heart and Lung Institute, Imperial College London, UK; Imperial College Healthcare NHS Trust, London, England, UK.
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40
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de Winter RW, van Diemen PA, Schumacher SP, Jukema RA, Somsen YBO, Hoek R, van Rossum AC, Twisk JWR, de Waard GA, Nap A, Raijmakers PG, Driessen RS, Knaapen P, Danad I. Hemodynamic Insights into Combined Fractional Flow Reserve and Instantaneous Wave-Free Ratio Assessment Through Quantitative [ 15O]H 2O PET Myocardial Perfusion Imaging. J Nucl Med 2024; 65:279-286. [PMID: 38176722 DOI: 10.2967/jnumed.123.265973] [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: 05/03/2023] [Revised: 11/01/2023] [Indexed: 01/06/2024] Open
Abstract
In patients evaluated for obstructive coronary artery disease (CAD), guidelines recommend using either fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) to guide coronary revascularization decision-making. The hemodynamic significance of lesions with discordant FFR and iFR measurements is debated. This study compared [15O]H2O PET-derived absolute myocardial perfusion between vessels with concordant and discordant FFR and iFR measurements. Methods: We included 197 patients suspected of obstructive CAD who had undergone [15O]H2O PET perfusion imaging and combined FFR/iFR interrogation in 468 vessels. Resting myocardial blood flow (MBF), hyperemic MBF, and coronary flow reserve (CFR) were compared among 4 groups: FFR low/iFR low (n = 79), FFR high/iFR low (n = 22), FFR low/iFR high (n = 22), and FFR high/iFR high (n = 345). Predefined [15O]H2O PET thresholds for ischemia were 2.3 mL·min-1·g-1 or less for hyperemic MBF and 2.5 or less for CFR. Results: Hyperemic MBF was lower in the concordant low (2.09 ± 0.67 mL·min-1·g-1), FFR high/iFR low (2.41 ± 0.80 mL·min-1·g-1), and FFR low/iFR high (2.40 ± 0.69 mL·min-1·g-1) groups compared with the concordant high group (2.91 ± 0.84 mL·min-1·g-1) (P < 0.001, P = 0.004, and P < 0.001, respectively). A lower CFR was observed in the concordant low (2.37 ± 0.76) and FFR high/iFR low (2.64 ± 0.84) groups compared with the concordant high group (3.35 ± 1.07, P < 0.01 for both). However, for vessels with either low FFR or low iFR, quantitative hyperemic MBF and CFR values exceeded the ischemic threshold in 38% and 49%, respectively. In addition, resting MBF exhibited a negative correlation with iFR (P < 0.001) and was associated with FFR low/iFR high discordance compared with concordant low FFR/low iFR measurements, independent of clinical and angiographic characteristics, as well as hyperemic MBF (odds ratio [OR], 0.41; 95% CI, 0.26-0.65; P < 0.001). Conclusion: We found reduced myocardial perfusion in vessels with concordant low and discordant FFR/iFR measurements. However, FFR/iFR combinations often inaccurately classified vessels as either ischemic or nonischemic when compared with hyperemic MBF and CFR. Furthermore, a lower resting MBF was associated with a higher iFR and the occurrence of FFR low/iFR high discordance. Our study showed that although combined FFR/iFR assessment can be useful to estimate the hemodynamic significance of coronary lesions, these pressure-derived indices provide a limited approximation of [15O]H2O PET-derived quantitative myocardial perfusion as the physiologic standard of CAD severity.
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Affiliation(s)
- Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yvemarie B O Somsen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roel Hoek
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and
| | - Guus A de Waard
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology, Nuclear Medicine, and PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands;
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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41
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Molossi S, Doan T, Sachdeva S. Anomalous Coronary Arteries: A State-of-the-Art Approach. Interv Cardiol Clin 2024; 13:51-70. [PMID: 37980067 DOI: 10.1016/j.iccl.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Congenital coronary anomalies are not an infrequent occurrence and their clinical presentation typically occurs during early years, though may be manifested only in adulthood. In the setting of anomalous aortic origin of a coronary artery, this is particularly concerning as it inflicts sudden loss of healthy young lives. Risk stratification remains a challenge and so does the best management decision-making in these patients, particularly if asymptomatic. Standardized approach to evaluation and management, with careful data collection and collaboration among centers, will likely impact future outcomes in this patient population, thus allowing for exercise participation and healthier lives.
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Affiliation(s)
- Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA.
| | - Tam Doan
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
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42
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Shi Y, Zheng J, Zhang Y, Sun Q, Shen J, Gao Y, Sun J, Yang N, Zhou X, Li S, Weir-McCall JR, Xia P, Teng Z. The influence of flow distribution strategy for the quantification of pressure- and wall shear stress-derived parameters in the coronary artery: A CTA-based computational fluid dynamics analysis. J Biomech 2023; 161:111857. [PMID: 37939424 DOI: 10.1016/j.jbiomech.2023.111857] [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: 04/13/2023] [Revised: 10/15/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
For image-based computational fluid dynamics (CFD) analysis to characterize the local coronary hemodynamic environment, the accuracy depends on the flow rate which is in turn associated with outlet branches' morphology. A good flow distribution strategy is important to mitigate the effect when certain branches cannot be considered. In this study, stenotic coronary arteries from 13 patients were used to analyze the effect of missing branches and different flow distribution strategies. Pressure- and wall shear stress (WSS)-derived parameters around the stenotic region (ROI) were compared, including fractional flow reserve (CT-FFR), instantaneous wave-free ratio (CT-iFR), resting distal to aortic coronary pressure (CT-Pd/Pa), time-averaged WSS, oscillatory shear index (OSI) and relative residence time (RRT). Three flow distribution strategies were the Huo-Kassab model at distal outlets (Type I), flow distribution based on outlet resistances (Type II), and a developed algorithm distributing flow at each bifurcation until the final outlets (Type III). Results showed that Type III strategy for models with truncated branch(es) had a good agreement in both pressure- and WSS-related results (interquatile range less than 0.12% and 4.02%, respectively) with the baseline model around the ROI. The relative difference of pressure- and WSS-related results were correlated with the flow differences in the ROI to the baseline mode. Type III strategy had the best performance in maintaining the flow in intermediate branches. It is recommended for CFD analysis. Removal of branches distal to a stenosis can be undertaken with an improved performance and maintained accuracy, while those proximal to the ROI should be kept.
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Affiliation(s)
- Yibing Shi
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Jin Zheng
- Department of Radiology, University of Cambridge, UK
| | - Ying Zhang
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Quanlin Sun
- Department of Radiology, University of Cambridge, UK; Nanjing Jingsan Medical Science and Technology, Ltd., Jiangsu, China
| | - Jinhua Shen
- Nanjing Jingsan Medical Science and Technology, Ltd., Jiangsu, China
| | - Yongguang Gao
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Jingxi Sun
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Ning Yang
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Xuanxuan Zhou
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Suqing Li
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China
| | - Jonathan R Weir-McCall
- Department of Radiology, University of Cambridge, UK; Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | - Ping Xia
- Department of Radiology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Jiangsu, China.
| | - Zhongzhao Teng
- Department of Radiology, University of Cambridge, UK; Nanjing Jingsan Medical Science and Technology, Ltd., Jiangsu, China.
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43
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Luo Y, Mao M, Wu F, Ma K, Chang J, Xiang R. Diagnostic performance of resting full-cycle ratio in identifying coronary lesions causing myocardial ischaemia: a meta-analysis. Acta Cardiol 2023; 78:1103-1109. [PMID: 37811658 DOI: 10.1080/00015385.2023.2250944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/17/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND The resting full-cycle ratio (RFR), a new non-congestive resting index, is commonly used for physiological evaluations of coronary arteries. AIMS This study aims to evaluate the accuracy of RFR in detecting coronary artery stenosis with hemodynamic significance using fractional flow reserve (FFR) as the reference standard. METHODS Using 'RFR, resting full-cycle ratio' as the search term, we searched PubMed, Embase, Cochrane Library, and Web of Science databases, screening the literature according to the inclusion and exclusion criteria. By applying FFR ≤ 0.80 and RFR ≤ 0.89 as the diagnostic criteria for ischaemia, we analysed the synthetic sensitivity, specificity, and corresponding 95% confidence intervals, then synthesised the summary receiver operating characteristic curve (SROC). RESULTS Three studies were included in this meta-analysis, comprising 1,084 patients with 1,312 lesions. When we used FFR ≤ 0.80 as the reference standard, the synthesised sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) of RFR in the diagnosis of coronary ischaemia were 73%, 81%, 67%, 85%, 3.95, and 0.33, respectively. Besides, the area under the curve (AUC) was 0.8276. CONCLUSION Using FFR as the reference standard, RFR has good diagnostic accuracy in detecting coronary ischaemic lesions and may be an effective alternative to FFR in the future, to some extent.
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Affiliation(s)
- Yue Luo
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Min Mao
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fan Wu
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kanghua Ma
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Chang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Xiang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Kubota M, Oguri A. Diagnostic accuracy of diastolic pressure ratio using a pressure microcatheter for intracoronary physiological assessment. Heart Vessels 2023; 38:1395-1403. [PMID: 37626238 DOI: 10.1007/s00380-023-02301-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/02/2023] [Indexed: 08/27/2023]
Abstract
Recently, instantaneous wave-free ratio (iFR) has emerged as an alternative to the fractional flow reserve (FFR) for intracoronary physiological assessment. Although all diastolic resting indices are reportedly identical to the iFR, limited data exist on diastolic pressure ratio (dPR) measured using a microcatheter (dPRmicro). This study aimed to evaluate the diagnostic accuracy of dPRmicro compared to FFR measured using a microcatheter (FFRmicro) in real-world practice for intracoronary physiological assessment. This was a single-center, retrospective, observational study. We identified 103 consecutive suspected angina pectoris patients (107 lesions) who underwent dPRmicro and FFRmicro measurement using the Navvus® catheter at Takasaki Heart Hospital from March 2019 to June 2019. A total of 103 lesions in 103 patients were finally included in the study. The mean FFRmicro and dPRmicro values were 0.80 and 0.88, respectively. With an FFRmicro ≤ 0.80, the dPRmicro showed a diagnostic accuracy of 79.6%, sensitivity of 74.6%, specificity of 87.5%, positive predictive value of 90.4%, and negative predictive value of 68.6%. The area under the receiver operating characteristic (ROC) curve was 0.894 (95% confidence interval, 0.833-0.956), and the optimal cut-off value for dPRmicro derived from the ROC analysis was 0.90. dPRmicro and FFRmicro values were discordant in 21/103 cases (20.4%). As a multivariable logistic regression analysis was performed, the male sex (vs. female) had a statistically significant association with a dPRmicro-FFRmicro discordance (OR 4.91; 95% CI, 1.04-23.0; P = 0.044). No other factors were found to be significantly associated with the discordance. In conclusion, dPRmicro measured using a microcatheter had good diagnostic accuracy and correlation with FFRmicro, hence, it can be useful for making revascularization decisions. However, re-studies in larger populations will be needed to better understand the properties of diastolic resting index measured using a microcatheter in clinical settings.
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Affiliation(s)
- Masayuki Kubota
- Department of Cardiology, Takasaki Heart Hospital, Gumma, Japan
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsushi Oguri
- Department of Cardiology, Takasaki Heart Hospital, Gumma, Japan.
- Department of Cardiovascular Medicine, Don-Don Mamorou Clinic, Tochigi, Japan.
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Eftekhari A, Holck EN, Westra J, Olsen NT, Bruun NH, Jensen LO, Engstrøm T, Christiansen EH. Instantaneous wave free ratio vs. fractional flow reserve and 5-year mortality: iFR SWEDEHEART and DEFINE FLAIR. Eur Heart J 2023; 44:4376-4384. [PMID: 37634144 DOI: 10.1093/eurheartj/ehad582] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS Guidelines recommend revascularization of intermediate epicardial artery stenosis to be guided by evidence of ischaemia. Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are equally recommended. Individual 5-year results of two major randomized trials comparing FFR with iFR-guided revascularization suggested increased all-cause mortality following iFR-guided revascularization. The aim of this study was a study-level meta-analysis of the 5-year outcome data in iFR-SWEDEHEART (NCT02166736) and DEFINE-FLAIR (NCT02053038). METHODS Composite of major adverse cardiovascular events (MACE) and its individual components [all-cause death, myocardial infarction (MI), and unplanned revascularisation] were analysed. Raw Kaplan-Meier estimates, numbers at risk, and number of events were extracted at 5-year follow-up and analysed using the ipdfc package (Stata version 18, StataCorp, College Station, TX, USA). RESULTS In total, iFR and FFR-guided revascularization was performed in 2254 and 2257 patients, respectively. Revascularization was more often deferred in the iFR group [n = 1128 (50.0%)] vs. the FFR group [n = 1021 (45.2%); P = .001]. In the iFR-guided group, the number of deaths, MACE, unplanned revascularization, and MI was 188 (8.3%), 484 (21.5%), 235 (10.4%), and 123 (5.5%) vs. 143 (6.3%), 420 (18.6%), 241 (10.7%), and 123 (5.4%) in the FFR group. Hazard ratio [95% confidence interval (CI)] estimates for MACE were 1.18 [1.04; 1.34], all-cause mortality 1.34 [1.08; 1.67], unplanned revascularization 0.99 [0.83; 1.19], and MI 1.02 [0.80; 1.32]. CONCLUSIONS Five-year all-cause mortality and MACE rates were increased with revascularization guided by iFR compared to FFR. Rates of unplanned revascularization and MI were equal in the two groups.
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Affiliation(s)
- Ashkan Eftekhari
- Department Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Emil Nielsen Holck
- Department Cardiology, Aarhus University Hospital, Denmark
- Department Clinical Medicine, Health, Aarhus University, Denmark
| | - Jelmer Westra
- Department Cardiology, Aarhus University Hospital, Denmark
- Department Cardiology, Linköping University Hospital, Sweden
| | | | | | | | | | - Evald Høj Christiansen
- Department Cardiology, Aarhus University Hospital, Denmark
- Department Clinical Medicine, Health, Aarhus University, Denmark
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46
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Alasnag M. Instantaneous wave-free ratio compared with fractional flow reserve: time for rethinking current recommendations. Eur Heart J 2023; 44:4385-4387. [PMID: 37634167 DOI: 10.1093/eurheartj/ehad574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023] Open
Affiliation(s)
- Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, PO Box 126418, Jeddah 21372, Saudi Arabia
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47
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Boutaleb AM, Scalia A, Ghafari C, Carlier S. Microcatheter-versus wire-based measurement of the fractional flow reserve. Acta Cardiol 2023; 78:1024-1032. [PMID: 37581347 DOI: 10.1080/00015385.2023.2246009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/29/2023] [Accepted: 08/03/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR) guided-percutaneous interventions is nowadays the gold standard for optimal coronary artery revascularization. While multiple pressure guidewires have been validated, the use of microcatheter for FFR measurements is still a matter of debate. OBJECTIVE The aim of this study was to investigate the crossing profile characteristics of the NAVVUS® microcatheter as compared with the COMETTM pressure wire. At the same time, we compared non-hyperaemic pressure ratio (NHPR) and FFR measurements of both systems. METHOD/MATERIALS In this retrospective study, all angiographically intermediate coronary artery stenoses each month were assessed, using either the NAVVUS® or the COMETTM pressure system, to receive coronary artery physiology assessment with NHPR and FFR measurements. The crossing profile of both systems was compared regarding objective coronary artery lesion characteristics using quantitative coronary analysis evaluation. RESULTS Over a period of 4.5 years, we evaluated 213 coronary artery stenoses using one of the two coronary tools. We found a 9.2% crossing profile failure rate using the microcatheter, compared to 0.7% in the pressure wire group (p < .001). The crossing failure was significantly correlated with the presence of coronary artery calcifications and angulation (p = .042, p = .049, respectively). FFR values were comparable be- tween the two groups and were significantly lower in the presence of coronary calcifications and proportional to the degree of stenosis (p = .036, p = .010). Pressure drift was comparable. CONCLUSION Our observations are in line with other studies reporting the poor crossing profile of the NAVVUS® microcatheter. NHPR and FFR measures of both systems were well correlated.
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Affiliation(s)
| | | | - Chadi Ghafari
- Department of Cardiology, University of Mons, UMONS, Mons, Belgium
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48
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Faurie B, Acheampong A, Abdellaoui M, Dessus I, Monsegu J, Wintzer-Wehekind J. Direct wire pacing during measurement of fractional flow reserve: A randomized proof-of-concept noninferiority crossover trial. Front Cardiovasc Med 2023; 10:1137309. [PMID: 37937287 PMCID: PMC10625906 DOI: 10.3389/fcvm.2023.1137309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/30/2023] [Indexed: 11/09/2023] Open
Abstract
Background Adenosine administration for fractional flow reserve (FFR) measurement may induce heart pauses. Aims To assess the accuracy and tolerability of direct wire pacing (DWP) during measurement of FFR. Methods Adults with at least one intermediate coronary artery stenosis (40%-80%) were consecutively enrolled between June 2021 and February 2022 in this randomized, noninferiority, crossover trial (NCT04970082) carried out in France. DWP was applied (DWP) or not (standard method) through the pressure guidewire used for FFR measurement during adenosine-induced maximal hyperaemia. Subjects were randomly assigned to the allocation sequence (DWP first or standard first). A 2-minute washout period was observed between the two FFR measurements performed for each stenosis. The primary endpoint was the reproducibility of FFR measurements between methods. Results A total of 150 focal lesions, presented by 94 subjects, were randomized (ratio: 1:1). The FFR values obtained with each method were nearly identical (R = 0.98, p = 0.005). The mean FFR difference of 0.00054 (95% confidence interval: 0.004 to 0.003) showed the noninferiority of FFR measurement with DWP vs. that with the standard method. Higher levels of chest discomfort were reported with DWP than with the standard method (0.61 ± 0.84 vs. 1.05 ± 0.89, p < 0.001), and a correlation was observed between the electrical sensations reported with DWP and chest discomfort (p < 0.001). Pauses (n = 20/148 lesions) were observed with the standard method, but did not correlate with chest discomfort (p = 0.21). No pauses were observed with DWP. Conclusions DWP during FFR measurement resulted in accurate and reproducible FFR values, and eliminated the pauses induced by adenosine.
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Affiliation(s)
| | - Angela Acheampong
- Institut Cardiovasculaire de Grenoble, Grenoble, France
- Université Libre de Bruxelles, Bruxelles, Belgium
| | | | - Ilona Dessus
- Institut Cardiovasculaire de Grenoble, Grenoble, France
- Université Grenoble-Alpes, CHU Grenoble-Alpes, Grenoble, France
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Koo BK, Lee JM, Hwang D, Park S, Shiono Y, Yonetsu T, Lee SH, Kawase Y, Ahn JM, Matsuo H, Shin ES, Hu X, Ding D, Fezzi S, Tu S, Low AF, Kubo T, Nam CW, Yong AS, Harding SA, Xu B, Hur SH, Choo GH, Tan HC, Mullasari A, Hsieh IC, Kakuta T, Akasaka T, Wang J, Tahk SJ, Fearon WF, Escaned J, Park SJ. Practical Application of Coronary Physiologic Assessment: Asia-Pacific Expert Consensus Document: Part 1. JACC. ASIA 2023; 3:689-706. [PMID: 38095005 PMCID: PMC10715899 DOI: 10.1016/j.jacasi.2023.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/13/2023] [Accepted: 07/08/2023] [Indexed: 12/30/2023]
Abstract
Coronary physiologic assessment is performed to measure coronary pressure, flow, and resistance or their surrogates to enable the selection of appropriate management strategy and its optimization for patients with coronary artery disease. The value of physiologic assessment is supported by a large body of evidence that has led to major recommendations in clinical practice guidelines. This expert consensus document aims to convey practical and balanced recommendations and future perspectives for coronary physiologic assessment for physicians and patients in the Asia-Pacific region based on updated information in the field that including both wire- and image-based physiologic assessment. This is Part 1 of the whole consensus document, which describes the general concept of coronary physiology, as well as practical information on the clinical application of physiologic indices and novel image-based physiologic assessment.
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Affiliation(s)
- Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sungjoon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Seung Hun Lee
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yoshiaki Kawase
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Daixin Ding
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
| | - Simone Fezzi
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Adrian F. Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Takashi Kubo
- Department of Cardiology, Tokyo Medical University, Hachioji Medical Center, Tokyo, Japan
| | - Chang-Wook Nam
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Andy S.C. Yong
- Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia
| | - Scott A. Harding
- Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Bo Xu
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Seung-Ho Hur
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Gim Hooi Choo
- Department of Cardiology, Cardiac Vascular Sentral KL (CVSKL), Kuala Lumpur, Malaysia
| | - Huay Cheem Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Ajit Mullasari
- Department of Cardiology, Madras Medical Mission, Chennai, India
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Seung-Jea Tahk
- Department of Cardiology, Ajou University Medical Center, Suwon, Korea
| | - William F. Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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50
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Giannopoulos AA, Keller L, Sepulcri D, Boehm R, Garefa C, Venugopal P, Mitra J, Ghose S, Deak P, Pack JD, Davis CL, Stähli BE, Stehli J, Pazhenkottil AP, Kaufmann PA, Buechel RR. High-Speed On-Site Deep Learning-Based FFR-CT Algorithm: Evaluation Using Invasive Angiography as the Reference Standard. AJR Am J Roentgenol 2023; 221:460-470. [PMID: 37132550 DOI: 10.2214/ajr.23.29156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND. Estimation of fractional flow reserve from coronary CTA (FFR-CT) is an established method of assessing the hemodynamic significance of coronary lesions. However, clinical implementation has progressed slowly, partly because of off-site data transfer with long turnaround times for results. OBJECTIVE. The purpose of this study was to evaluate the diagnostic performance of FFR-CT computed on-site with a high-speed deep learning-based algorithm with invasive hemodynamic indexes as the reference standard. METHODS. This retrospective study included 59 patients (46 men, 13 women; mean age, 66.5 ± 10.2 years) who underwent coronary CTA (including calcium scoring) followed within 90 days by invasive angiography with invasive fractional flow reserve (FFR) and/or instantaneous wave-free ratio measurements from December 2014 to October 2021. Coronary artery lesions were considered to have hemodynamically significant stenosis in the presence of invasive FFR of 0.80 or less and/or instantaneous wave-free ratio of 0.89 or less. A single cardiologist evaluated the CTA images using an on-site deep learning-based semiautomated algorithm entailing a 3D computational flow dynamics model to determine FFR-CT for coronary artery lesions detected with invasive angiography. Time for FFR-CT analysis was recorded. FFR-CT analysis was repeated by the same cardiologist in 26 randomly selected examinations and by a different cardiologist in 45 randomly selected examinations. Diagnostic performance and agreement were assessed. RESULTS. A total of 74 lesions were identified with invasive angiography. FFR-CT and invasive FFR had strong correlation (r = 0.81) and, in Bland-Altman analysis, bias of 0.01 and 95% limits of agreement of -0.13 to 0.15. FFR-CT had AUC for hemodynamically significant stenosis of 0.975. At a cutoff of 0.80 or less, FFR-CT had 95.9% accuracy, 93.5% sensitivity, and 97.7% specificity. In 39 lesions with severe calcifications (≥ 400 Agatston units), FFR-CT had AUC of 0.991 and at a cutoff of 0.80, 94.7% sensitivity, 95.0% specificity, and 94.9% accuracy. Mean analysis time per patient was 7 minutes 54 seconds. Intraobserver agreement (intraclass correlation coefficient, 0.85; bias, -0.01; 95% limits of agreement, -0.12 and 0.10) and interobserver agreement (intraclass correlation coefficient, 0.94; bias, -0.01; 95% limits of agreement, -0.08 and 0.07) were good to excellent. CONCLUSION. A high-speed on-site deep learning-based FFR-CT algorithm had excellent diagnostic performance for hemodynamically significant stenosis with high reproducibility. CLINICAL IMPACT. The algorithm should facilitate implementation of FFR-CT technology into routine clinical practice.
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Affiliation(s)
- Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Lukas Keller
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Daniel Sepulcri
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Reto Boehm
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Chrysoula Garefa
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | | | | | | | | | | | | | - Barbara E Stähli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Julia Stehli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
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