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Zahidin AM, Alkatiri AA, Mangkuanom AS, Iryuza N, Firman D. Invasive Coronary Physiology Study in Multivessel Coronary Artery Disease. Int J Angiol 2025; 34:126-129. [PMID: 40365151 PMCID: PMC12068909 DOI: 10.1055/s-0042-1759620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Assessment of relationship between the angiographic stenosis severity and the coronary blood flow is complex. Coronary angiography has many limitations that may impair the judgment of stenosis severity and then affect decision-making regarding intervention. Myocardial perfusion imaging by single-photon emission tomography (MPI-SPECT) is used for a long time to help clinical decisions of interventions, but has limitations, such as issues with identification of extensive coronary artery disease (CAD). Fractional flow reserve (FFR) is a gold standard index for investigating the physiological significance of a coronary stenosis. The instantaneous wave-free ratio (iFR) is a hyperemia-free measurement and easier method to achieve physiological assessment to measure the severity of coronary stenosis. We present a case of multivessel coronary artery disease (MVCAD) patient who was treated with iFR-guided percutaneous coronary intervention (PCI) and emphasize the importance of physiological assessment in PCI. A 63-year-old male with multiple cardiovascular risk factors came to our center with chief complaint of stable angina since 1 year. He underwent MPI-SPECT and the result showed 2.5% of ischemia burden. Coronary angiography showed MVCAD. Surgical conference decided to do PCI. iFR-guided PCI was performed in this case. Our case highlights the importance of iFR as an important cardiology-physiology-based tool as a guide in management decisions for MVCAD. iFR as an alternative approach to physiological study is noninferior compared with FFR-guided PCI.
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Affiliation(s)
- Agita Maryalda Zahidin
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Amir Aziz Alkatiri
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Arwin Saleh Mangkuanom
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Nanda Iryuza
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Doni Firman
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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Freidoonimehr N, Atkins T, Marathe JA, Psaltis PJ, Arjomandi M. Evaluating the severity of tandem coronary stenoses: Insights from simulated FFR and iFR techniques. J Biomech 2025; 185:112707. [PMID: 40252338 DOI: 10.1016/j.jbiomech.2025.112707] [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: 09/24/2024] [Revised: 04/11/2025] [Accepted: 04/15/2025] [Indexed: 04/21/2025]
Abstract
The presence of coronary tandem lesions poses a significant challenge for the accurate diagnosis and management of coronary artery diseases. This study set out to provide a deeper understanding of the haemodynamic interactions between tandem obstructive coronary lesions and their impact on different haemodynamic diagnostic parameters. Using a computational fluid dynamic model, validated against in vitro laboratory experiments, we investigated the various combinations of moderate and severe stenoses interchangeably located in the proximal and distal segments of the artery. The investigation was conducted using two diagnostic parameters: one hyperaemic-based, i.e., FFR, and one rest-based, i.e., iFR, technique, both of which are commonly used to assess the physiological significance of coronary stenoses. The three main findings of this work are: (a) the recovery distance (the immediate local distance affected by the presence of stenosis) is much shorter for the rest-measured diagnostic parameter compared with the hyperaemic-measured diagnostic parameter; (b) pressure drop measurements immediately downstream of the stenotic sections overestimate the significance of stenoses, and (c) the presence of a moderate stenosis downstream of a severe stenosis increases FFR value (faster FFR recovery). These findings enhance our understanding of the diagnostic accuracy of hyperaemic-based and rest-based physiological diagnostic coronary assessments and the nuances of using these different techniques when assessing tandem coronary stenoses. This understanding can help inform tailored therapeutic approaches for the management of coronary artery disease.
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Affiliation(s)
- Navid Freidoonimehr
- School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Queensland 4000, Australia; Centre for Biomedical Technologies, Queensland University of Technology, Brisbane, QLD 4000, Australia; School of Electrical and Mechanical Engineering, The University of Adelaide, South Australia 5005, Australia.
| | - Tam Atkins
- School of Electrical and Mechanical Engineering, The University of Adelaide, South Australia 5005, Australia.
| | - Jessica A Marathe
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia 5000, Australia; Adelaide Medical School, University of Adelaide, Adelaide, South Australia 5005, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia 5000, Australia.
| | - Peter J Psaltis
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia 5000, Australia; Adelaide Medical School, University of Adelaide, Adelaide, South Australia 5005, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia 5000, Australia.
| | - Maziar Arjomandi
- School of Electrical and Mechanical Engineering, The University of Adelaide, South Australia 5005, Australia.
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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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Wang X, Bian Y, Zhang R, Zhu H, Yang J, Wang R, Liu X, Lv B, Cao X, Dai W, Sun Z, Jing J, Du Z, Yu S, Wang J. Hemodynamic assessment of intracranial atherosclerotic stenosis: comparison between invasive non-hyperemic pressure ratio and angiography-derived quantitative flow ratio. Front Neurol 2024; 15:1466864. [PMID: 39606702 PMCID: PMC11598932 DOI: 10.3389/fneur.2024.1466864] [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: 07/18/2024] [Accepted: 11/01/2024] [Indexed: 11/29/2024] Open
Abstract
Objectives To evaluate the diagnostic accuracy of the quantitative flow ratio (QFR) for hemodynamic exploration of intracranial atherosclerotic stenosis, using the invasive cerebrovascular pressure ratio (CVPR) and resting full-cycle ratio (RFR) as reference standards. Materials and methods Patients with symptomatic unifocal intracranial atherosclerotic stenosis were included. The CVPR was defined as the ratio of the proximal and distal pressures. All patients underwent angioplasty under general anesthesia. The QFR was calculated based on digital subtraction angiography. Using the CVPR as a reference, we compared its correlation with the QFR across different degrees and locations of stenosis. Results The CVPR and QFR were measured in 34 vessels of 32 patients. The QFR demonstrated a high correlation and excellent agreement(r = 0.8227, p < 0.001) with the CVPR in distal stenosis before intervention. In the subgroup with diameter stenosis >80%, the QFR showed a high correlation (r = 0.8812, p < 0.001) with the CVPR. In the anterior circulation subgroup, the QFR showed an excellent correlation (r = 0.9066, p < 0.001) with the CVPR. In the posterior circulation subgroup, the QFR showed a high correlation with the CVPR (r = 0.7706, p < 0.001). Diameter stenosis rates showed a moderate negative correlation with the CVPR. Conclusion There was a strong correlation between the QFR and wire-based CVPR, especially for anterior circulation lesions before intervention. The QFR may serve as a predictive factor for evaluating hemodynamic changes in intracranial atherosclerotic stenosis.
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Affiliation(s)
- Xiaohui Wang
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yang Bian
- Health One Departments, The Second Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Rongju Zhang
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Haojing Zhu
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Junjie Yang
- Department of Cardiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ruiling Wang
- Department of Clinical Laboratory, The Third Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xinfeng Liu
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Bin Lv
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiangyu Cao
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Wei Dai
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhibin Sun
- Department of Mathematics, College of Science, Hebei Agricultural University, Baoding, China
| | - Jing Jing
- Department of Cardiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhihua Du
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Shengyuan Yu
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jun Wang
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, 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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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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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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Råmunddal T, Dworeck C, Torild P, Andréen S, Gan LM, Hirlekar G, Ioanes D, Myredal A, Odenstedt J, Petursson P, Pylova T, Töpel F, Völz S, Hilmersson M, Redfors B, Angerås O. Safety and Feasibility Using a Fluid-Filled Wire to Avoid Hydrostatic Errors in Physiological Intracoronary Measurements. Cardiol Res Pract 2024; 2024:6664482. [PMID: 38204600 PMCID: PMC10776192 DOI: 10.1155/2024/6664482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Background Using a fluid-filled wire with a pressure sensor outside the patient compared to a conventional pressure wire may avoid the systematic error introduced by the hydrostatic pressure within the coronary circulation. Aims To assess the safety and effectiveness of the novel fluid-filled wire, Wirecath (Cavis Technologies, Uppsala, Sweden), as well as its ability to avoid the hydrostatic pressure error. Methods and Results The Wirecath pressure wire was used in 45 eligible patients who underwent invasive coronary angiography and had a clinical indication for invasive coronary pressure measurement at Sahlgrenska University Hospital, Gothenburg, Sweden. In 29 patients, a simultaneous measurement was performed with a conventional coronary pressure wire (PressureWire X, Abbott Medical, Plymouth, MN, USA), and in 19 patients, the vertical height difference between the tip of the guide catheter and the wire measure point was measured in a 90-degree lateral angiographic projection. No adverse events caused by the pressure wires were reported. The mean Pd/Pa and mean FFR using the fluid-filled wire and the sensor-tipped wire differed significantly; however, after correcting for the hydrostatic effect, the sensor-tipped wire pressure correlated well with the fluid-filled wire pressure (R = 0.74 vs. R = 0.89 at rest and R = 0.89 vs. R = 0.98 at hyperemia). Conclusion Hydrostatic errors in physiologic measurements can be avoided by using the fluid-filled Wirecath wire, which was safe to use in the present study. This trial is registered with NCT04776577 and NCT04802681.
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Affiliation(s)
- Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Christian Dworeck
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Petronella Torild
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sofie Andréen
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Li-Ming Gan
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Geir Hirlekar
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Myredal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Petur Petursson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Tetiana Pylova
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Fanny Töpel
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sebastian Völz
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | | | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
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10
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Pintea Bentea G, Berdaoui B, Samyn S, Morissens M, van de Borne P, Castro Rodriguez J. Particularities of coronary physiology in patients with atrial fibrillation: insights from combined pressure and flow indices measurements. Front Cardiovasc Med 2023; 10:1206743. [PMID: 37645524 PMCID: PMC10461314 DOI: 10.3389/fcvm.2023.1206743] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023] Open
Abstract
Background Symptoms suggestive of myocardial ischemia are frequently encountered in patients with atrial fibrillation (AF) even in the absence of obstructive coronary artery disease. Nevertheless, an in-depth characterisation of coronary physiology in patients with AF is currently lacking. Objectives We aim to provide an insight into the characteristics of coronary physiology in AF, by performing simultaneous invasive measurements of coronary flow- and pressure- indices in a real-life population of patients with AF and indication of coronary angiography. Methods This is a prospective open label study including patients with permanent or persistent AF and indication of coronary angiography showing intermediate coronary stenosis requiring routine physiological assessment (n = 18 vessels from 14 patients). We measured FFR (fractional flow reserve), and Doppler-derived coronary flow indices, including CFR (coronary flow reserve) and HMR (hyperaemic microvascular resistance). Results From the analysed vessels, 18/18 vessels (100%) presented a pathological CFR (<2.5), indicative of coronary microvascular dysfunction (CMD), and 3/18 (17%) demonstrated obstructive epicardial coronary disease (FFR ≤ 0.8). A large proportion of vessels (15/18; 83%) showed discordant FFR/CFR with preserved FFR and low CFR. 47% of the coronary arteries in patients with AF and non-obstructive epicardial coronary disease presented structural CMD (HMR ≥ 2.5 mmHg/cm/s), and were associated with high BMR and an impaired response to adenosine. Conversely, vessels from patients with AF and non-obstructive epicardial coronary disease with functional CMD (HMR < 2.5 mmHg/cm/s) showed higher bAPV. The permanent AF subpopulation presented increased values of HMR and BMR compared to persistent AF, while structural CMD was more often associated with persistent symptoms at 3 months, taking into account the limited sample size of our study. Conclusion Our findings highlight a systematically impaired CFR in patients with AF even in the absence of obstructive epicardial coronary disease, indicative of CMD. In addition, patients with AF presented more prevalent structural CMD (HMR ≥ 2.5 mmHg/cm/s), characterized by reduced hyperaemic responses to adenosine, possibly interfering with the FFR assessment.
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Affiliation(s)
| | | | - Sophie Samyn
- Department of Cardiology, CHU Brugmann, Brussels, Belgium
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11
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Liu J, Li B, Zhang Y, Zhang L, Huang S, Sun H, Liu J, Zhao X, Zhang M, Wang W, Liu Y. A high-fidelity geometric multiscale hemodynamic model for predicting myocardial ischemia. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 233:107476. [PMID: 36933317 DOI: 10.1016/j.cmpb.2023.107476] [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: 10/16/2022] [Revised: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Coronary computed tomography angiography (CCTA) derived fractional flow reserve (CT-FFR) requires a maximal hyperemic state to be modeled by assuming the total coronary resistance decreased to a constant 0.24 of that under the resting state. However, this assumption neglects the vasodilator capacity of individual patients. Herein, we proposed a high-fidelity geometric multiscale model (HFMM) to characterize coronary pressure and flow under the resting state, seeking to better predict myocardial ischemia by using CCTA-derived instantaneous wave-free ratio (CT-iFR). METHODS Fifty-seven patients (62 lesions) who had undergone CCTA and were then referred to invasive FFR were prospectively enrolled. The coronary microcirculation resistance hemodynamic model (RHM) under the resting condition was established on a patient-specific basis. Coupled with a closed-loop geometric multiscale model (CGM) of their individual coronary circulations, the HFMM model was established to non-invasively derive the CT-iFR from CCTA images. RESULTS With the invasive FFR being the reference standard, accuracy of the obtained CT-iFR in identifying myocardial ischemia was greater than those of the CCTA and non-invasively derived CT-FFR (90.32% vs. 79.03% vs. 84.3%). The overall computational time of CT-iFR was 61 ± 6 min, faster than that of the CT-FFR (8 h). The sensitivity, specificity, positive predictive value, and negative predictive value of the CT-iFR in discriminating an invasive FFR > 0.8 were 78% (95% CI: 40-97%), 92% (95% CI: 82-98%), 64% (95% CI: 39-83%), and 96% (95% CI:88-99%), respectively. CONCLUSIONS A high-fidelity geometric multiscale hemodynamic model was developed for rapid and accurate estimation of CT-iFR. Compared with CT-FFR, CT-iFR is of less computational cost and enables assessment of tandem lesions.
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Affiliation(s)
- Jincheng Liu
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Bao Li
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Yanping Zhang
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Liyuan Zhang
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Suqin Huang
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Hao Sun
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Jian Liu
- Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Xi Zhao
- Central Research Institute, United Imaging Healthcare, Shanghai, China
| | - Mingzi Zhang
- Macquarie Medical School, Faculty of Medicine, Health, and Human Sciences, Macquarie University, Sydney, Australia
| | | | - Youjun Liu
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China.
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12
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Boutaleb AM, Ghafari C, Ungureanu C, Carlier S. Fractional flow reserve and non-hyperemic indices: Essential tools for percutaneous coronary interventions. World J Clin Cases 2023; 11:2123-2139. [PMID: 37122527 PMCID: PMC10131021 DOI: 10.12998/wjcc.v11.i10.2123] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/22/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Hemodynamical evaluation of a coronary artery lesion is an important diagnostic step to assess its functional impact. Fractional flow reserve (FFR) received a class IA recommendation from the European Society of Cardiology for the assessment of angiographically moderate stenosis. FFR evaluation of coronary artery disease offers improvement of the therapeutic strategy, deferring unnecessary procedures for lesions with a FFR > 0.8, improving patients' management and clinical outcome. Post intervention, an optimal FFR > 0.9 post stenting should be reached and > 0.8 post drug eluting balloons. Non-hyperemic pressure ratio measurements have been validated in previous studies with a common threshold of 0.89. They might overestimate the hemodynamic significance of some lesions but remain useful whenever hyperemic agents are contraindicated. FFR remains the gold standard reference for invasive assessment of ischemia. We illustrate this review with two cases introducing the possibility to estimate also non-invasively FFR from reconstructed 3-D angiograms by quantitative flow ratio. We conclude introducing a hybrid approach to intermediate lesions (DFR 0.85-0.95) potentially maximizing clinical decision from all measurements.
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Affiliation(s)
- Amine Mamoun Boutaleb
- Department of Cardiology, Ibn Rochd University Hospital, Casablanca 20230, Casablanca, Morocco
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
| | - Chadi Ghafari
- Department of Cardiology, University of Mons, Mons 7000, Belgium
| | - Claudiu Ungureanu
- Department of Cardiology, University of Mons, Mons 7000, Belgium
- Catheterization Unit, Jolimont Hospital, La Louvière 7100, Belgium, Belgium
| | - Stéphane Carlier
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
- Department of Cardiology, University of Mons, Mons 7000, Belgium
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de Oliveira Laterza Ribeiro M, Correia VM, Herling de Oliveira LL, Soares PR, Scudeler TL. Evolving Diagnostic and Management Advances in Coronary Heart Disease. Life (Basel) 2023; 13:951. [PMID: 37109480 PMCID: PMC10143565 DOI: 10.3390/life13040951] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Despite considerable improvement in diagnostic modalities and therapeutic options over the last few decades, the global burden of ischemic heart disease is steadily rising, remaining a major cause of death worldwide. Thus, new strategies are needed to lessen cardiovascular events. Researchers in different areas such as biotechnology and tissue engineering have developed novel therapeutic strategies such as stem cells, nanotechnology, and robotic surgery, among others (3D printing and drugs). In addition, advances in bioengineering have led to the emergence of new diagnostic and prognostic techniques, such as quantitative flow ratio (QFR), and biomarkers for atherosclerosis. In this review, we explore novel diagnostic invasive and noninvasive modalities that allow a more detailed characterization of coronary disease. We delve into new technological revascularization procedures and pharmacological agents that target several residual cardiovascular risks, including inflammatory, thrombotic, and metabolic pathways.
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Affiliation(s)
| | | | | | | | - Thiago Luis Scudeler
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
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14
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Berntorp K, Rylance R, Yndigegn T, Koul S, Fröbert O, Christiansen EH, Erlinge D, Götberg M. Clinical Outcome of Revascularization Deferral With Instantaneous Wave-Free Ratio and Fractional Flow Reserve: A 5-Year Follow-Up Substudy From the iFR-SWEDEHEART Trial. J Am Heart Assoc 2023; 12:e028423. [PMID: 36734349 PMCID: PMC9973641 DOI: 10.1161/jaha.122.028423] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Although physiology-based assessment of coronary artery stenosis using instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) are established methods of guiding coronary revascularization, its clinical outcome in long-term deferral needs further evaluation, especially with acute coronary syndrome as a clinical presentation. The aim was to evaluate the long-term clinical outcome of deferral of revascularization based on iFR or FFR. Methods and Results This is a substudy of the iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trial, where patients deferred from revascularization from each study arm were selected. Nine hundred eight patients deferred from coronary revascularization with iFR (n=473) and FFR (n=435) were followed for 5 years. The national quality registry, SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies), was used for patient data collection and clinical follow-up. The end point was major adverse cardiac events and their individual components all-cause death, cardiovascular death, noncardiovascular death, nonfatal myocardial infarction, and unplanned revascularization. No significant difference was found in major adverse cardiac events (iFR 18.6% versus FFR 16.8%; adjusted hazard ratio, 1.08 [95% CI, 0.79-1.48]; P=0.63) or their individual components. Conclusions No differences in clinical outcomes after 5-year follow-up were noted when comparing iFR versus FFR as methods for deferral of coronary revascularization in patients presenting with stable angina pectoris and acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02166736.
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Affiliation(s)
- Karolina Berntorp
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Rebecca Rylance
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Troels Yndigegn
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Sasha Koul
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Ole Fröbert
- Faculty of Health, Department of CardiologyÖrebro University HospitalÖrebroSweden
| | | | - David Erlinge
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Matthias Götberg
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
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15
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Yamanaka F, Shishido K, Yokota S, Moriyama N, Ochiai T, Yamada T, Hayashi T, Miyashita H, Yokoyama H, Yamanaga K, Tabata N, Yamaguchi M, Yamagishi T, Matsumoto T, Tobita K, Mizuno S, Tanaka Y, Murakami M, Takahashi S, Saito S, Tsujita K. Discordance between fractional flow reserve and instantaneous wave-free ratio in patients with severe aortic stenosis: A retrospective cohort study. J Cardiol 2023; 81:138-143. [PMID: 36057484 DOI: 10.1016/j.jjcc.2022.08.005] [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: 05/05/2022] [Revised: 07/31/2022] [Accepted: 08/03/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Discordance between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) occurs in approximately 20 % of cases. However, no studies have reported the discordance in patients with severe aortic stenosis (AS). We aimed to evaluate the diagnostic discordance between FFR and iFR in patients with severe AS. METHODS We examined 140 consecutive patients with severe AS (164 intermediate coronary artery stenosis vessels). FFR and iFR were calculated in four quadrants based on threshold FFR and iFR values of ≤0.8 and ≤0.89, respectively (Group 1: iFR >0.89, FFR >0.80; Group 2: iFR ≤0.89, FFR >0.80; Group 3: iFR >0.89, FFR ≤0.80; and Group 4: iFR ≤0.89, FFR ≤0.80). Concordant groups were Groups 1 and 4, and discordant groups were Groups 2 and 3. Positive and negative discordant groups were Groups 3 and 2, respectively. RESULTS The median (Q1, Q3) FFR and iFR were 0.84 (0.76, 0.88) and 0.85 (0.76, 0.91), respectively. Discordance was observed in 48 vessels (29.3 %). In the discordant group, negative discordance (Group 2: iFR ≤0.89 and FFR >0.80) was predominant (45 cases, 93.6 %). Multivariate analysis showed that the left anterior descending artery [odds ratio (OR), 3.88; 95 % confidence interval (CI): 1.54-9.79, p = 0.004] and peak velocity ≥5.0 m/s (OR, 3.21; 95%CI: 1.36-7.57, p = 0.008) were independently associated with negative discordance (FFR >0.8 and iFR ≤0.89). CONCLUSIONS In patients with severe AS, discordance between FFR and iFR was predominantly negative and observed in 29.3 % of vessels. The left anterior descending artery and peak velocity ≥5.0 m/s were independently associated with negative discordance.
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Affiliation(s)
- Futoshi Yamanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan; Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Koki Shishido
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shohei Yokota
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Noriaki Moriyama
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Tomoki Ochiai
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takashi Yamada
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takahiro Hayashi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Hirokazu Miyashita
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Hiroaki Yokoyama
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kenshi Yamanaga
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Noriaki Tabata
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masashi Yamaguchi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Tamiharu Yamagishi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takashi Matsumoto
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kazuki Tobita
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shingo Mizuno
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yutaka Tanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Masato Murakami
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Saeko Takahashi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shigeru Saito
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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16
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Fawaz S, Cook CM. Understanding the Basis for Hyperemic and Nonhyperemic Coronary Pressure Assessment. Interv Cardiol Clin 2023; 12:1-12. [PMID: 36372454 DOI: 10.1016/j.iccl.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Despite the now routine integration of invasive physiologic systems into coronary catheter laboratories worldwide, it remains critical that all operators maintain a sound understanding of the fundamental physiologic basis for coronary pressure assessment. More specifically, performing operators should be well informed regarding the basis for hyperemic (ie, fractional flow reserve) and nonhyperemic (ie, instantaneous wave-free ratio and other nonhyperemic pressure ratio) coronary pressure assessment. In this article, we provide readers a comprehensive history charting the inception, development, and validation of hyperemic and nonhyperemic coronary pressure assessment.
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Affiliation(s)
- Samer Fawaz
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom
| | - Christopher M Cook
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom.
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Di Serafino L, Barbato E, Serino F, Svanerud J, Scalamogna M, Cirillo P, Petitto M, Esposito M, Silvestri T, Franzone A, Piccolo R, Esposito G. Myocardial mass affects diagnostic performance of non-hyperemic pressure-derived indexes in the assessment of coronary stenosis. Int J Cardiol 2023; 370:84-89. [PMID: 36265648 DOI: 10.1016/j.ijcard.2022.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/09/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022]
Abstract
UNLABELLED Background Several non-hyperemic pressure-derived Indexes (NHPI) have been introduced for the assessment of coronary stenosis, showing a good correlation with fractional flow reserve (FFR). Notably, either the assessment of NHPI during adenosine administration (NHPIADO) or the Hybrid Approach (NHPIHA), combining NHPI with FFR, have been showed to increase the accuracy of such indexes. It remains unclear whether diagnostic performance might be affected by the extent of the subtended myocardial mass. METHODS We enrolled consecutive patients with an intermediate coronary stenosis assessed with NHPI and FFR. NHPI were also measured during adenosine (ADO) administration (NHPIADO). The amount of jeopardized myocardium was assessed using the Duke Jeopardy Score (DJS). With FFR as reference, we assessed the accuracy of NHPI, NHPIADO and NHPIHA according to the extent of the subtended myocardium. RESULTS One-hundred-seventy stenoses from 151 patients were grouped according to the DJS as follows: A) Small Extent (SE, n = 82); B) Moderate Extent (ME, n = 53); C) Large Extent (LE, n = 35). As compared with FFR, NHPI showed a significantly different accuracy, as assessed by the Youden's index, according to the extent of the jeopardized myocardium (SE: 0.39 ± 0.05, ME: 0.68 ± 0.06, LE: 0.28 ± 0.06, p < 0.001). Conversely, both the NHPIADO (SE: 0.76 ± 0.02, ME: 0.88 ± 0.02, LE: 0.82 ± 0.02, p = 0.72) and NHPIHA (SE: 0.82 ± 0.07, ME: 0.84 ± 0.02, LE: 0.88 ± 0.02, p = 0.70) allowed for a better diagnostic accuracy regardless of the amount of myocardium subtended. CONCLUSIONS Diagnostic performance of NHPI might be affected by the extent of myocardial territory subtended by the coronary stenosis. A hybrid approach might be useful to overcome this limitation.
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Affiliation(s)
- Luigi Di Serafino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy; Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Federica Serino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Maria Scalamogna
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Marta Petitto
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Mafalda Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Tania Silvestri
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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18
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Liang L, Zhu Y, Li F, Guo K, Chang S, Li Q, Zhang Y, Li D. Comparative analysis of instantaneous wave-free ratio and quantitative real-time myocardial contrast echocardiography for the assessment of myocardial perfusion. Front Cardiovasc Med 2022; 9:893647. [DOI: 10.3389/fcvm.2022.893647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 10/06/2022] [Indexed: 01/10/2023] Open
Abstract
Background and hypothesisThe field of coronary artery physiology is developing rapidly and changing the practice of interventional cardiology. A new functional evaluation technique using the instantaneous wave-free ratio (iFR) has become an alternative to fractional flow reserve. Future research studies need to determine whether physiological indicators play a role in evaluating myocardial perfusion in the catheter room.Materials and methodsThirty-eight patients scheduled for coronary angiography and iFR evaluation underwent a real-time myocardial contrast echocardiography (RT-MCE) examination at rest. The myocardial perfusion parameters (A, β, and A × β) on the myocardial perfusion curve were quantitatively analyzed using Q-Lab software. Coronary angiography and iFR assessment were completed within 1 week after the RT-MCE examination in all patients. Correlation analysis was used to identify iFR- and MCE-related indicators. The sensitivity and specificity of iFR in the quantitative detection of coronary microcirculation were obtained.ResultsThe correlation coefficients between iFR and A, β, and A × β were 0.81, 0.66, and 0.82, respectively. The cut-off value for iFR was 0.85 for microvascular ischemia detection, while the sensitivity and specificity for the diagnosis of myocardial perfusion were 90.7 and 89.9%, respectively. The receiver operating characteristic (ROC) curve area for iFR was 0.946 in the segments related to myocardial blood flow.ConclusionThe iFR is an effective tool for detecting myocardial microcirculation perfusion, with satisfactory diagnostic performance and a demonstrated role in physiological indices used for the perfusion assessment.
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Jeremias A, Nijjer S, Davies J, DiMario C. Physiologic Assessment and Guidance in the Cardiac Catheterization Laboratory. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Aleem S, Parikh P, Bhasin V, Pyo RT. Interventional Approach in Small Vessel, Diffuse, and Tortuous Coronary Artery Disease. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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21
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Kovarnik T, Hitoshi M, Kral A, Jerabek S, Zemanek D, Kawase Y, Omori H, Tanigaki T, Pudil J, Vodzinska A, Branny M, Stipal R, Kala P, Mrozek J, Porzer M, Grezl T, Novobilsky K, Mendiz O, Kopriva K, Mates M, Chval M, Chen Z, Martasek P, Linhart A. Fractional Flow Reserve Versus Instantaneous Wave-Free Ratio in Assessment of Lesion Hemodynamic Significance and Explanation of their Discrepancies. International, Multicenter and Prospective Trial: The FiGARO Study. J Am Heart Assoc 2022; 11:e021490. [PMID: 35502771 PMCID: PMC9238629 DOI: 10.1161/jaha.121.021490] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The FiGARO (FFR versus iFR in Assessment of Hemodynamic Lesion Significance, and an Explanation of Their Discrepancies) trial is a prospective registry searching for predictors of fractional flow reserve/instantaneous wave‐free ratio (FFR/iFR) discrepancy. Methods and Results FFR/iFR were analyzed using a Verrata wire, and coronary flow reserve was analyzed using a Combomap machine (both Philips‐Volcano). The risk polymorphisms for endothelial nitric oxide synthase and for heme oxygenase‐1 were analyzed. In total, 1884 FFR/iFR measurements from 1564 patients were included. The FFR/iFR discrepancy occurred in 393 measurements (20.9%): FFRp (positive)/iFRn (negative) type (264 lesions, 14.0%) and FFRn/iFRp (129 lesions, 6.8%) type. Coronary flow reserve was measured in 343 lesions, correlating better with iFR (R=0.56, P<0.0001) than FFR (R=0.36, P<0.0001). The coronary flow reserve value in FFRp/iFRn lesions (2.24±0.7) was significantly higher compared with both FFRp/iFRp (1.39±0.36), and FFRn/iFRn lesions (1.8±0.64, P<0.0001). Multivariable logistic regression analysis confirmed (1) sex, age, and lesion location in the right coronary artery as predictors for FFRp/iFRn discrepancy; and (2) hemoglobin level, smoking, and renal insufficiency as predictors for FFRn/iFRp discrepancy. The FFRn/iFRp type of discrepancy was significantly more frequent in patients with both risk types of polymorphisms (endothelial nitric oxide synthaser+heme oxygenase‐1r): 8 patients (24.2%) compared with FFRp/iFRn type of discrepancy: 2 patients (5.9%), P=0.03. Conclusions Predictors for FFRp/iFRn discrepancy were sex, age, and location in the right coronary artery. Predictors for FFRn/iFRp were hemoglobin level, smoking, and renal insufficiency. The risk type of polymorphism in endothelial nitric oxide synthase and heme oxygenase‐1 genes was more frequently found in patients with FFRn/iFRp type of discrepancy. Registration URL: https://clinicaltrials.gov; Unique identifier: NCT03033810.
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Affiliation(s)
- Tomas Kovarnik
- 2nd Department of Medicine Department of Cardiovascular Medicine First Faculty of Medicine Charles University and General University Hospital in Prague Prague Czech Republic
| | | | - Ales Kral
- 2nd Department of Medicine Department of Cardiovascular Medicine First Faculty of Medicine Charles University and General University Hospital in Prague Prague Czech Republic
| | - Stepan Jerabek
- 2nd Department of Medicine Department of Cardiovascular Medicine First Faculty of Medicine Charles University and General University Hospital in Prague Prague Czech Republic
| | - David Zemanek
- 2nd Department of Medicine Department of Cardiovascular Medicine First Faculty of Medicine Charles University and General University Hospital in Prague Prague Czech Republic
| | | | | | | | - Jan Pudil
- 2nd Department of Medicine Department of Cardiovascular Medicine First Faculty of Medicine Charles University and General University Hospital in Prague Prague Czech Republic
| | | | - Marian Branny
- Cardiovascular Department University Hospital Ostrava Ostrava Czech Republic
| | - Roman Stipal
- Department of Internal Medicine and Cardiology University HospitalFaculty of MedicineMasaryk University Brno Brno Czech Republic
| | - Petr Kala
- Department of Internal Medicine and Cardiology University HospitalFaculty of MedicineMasaryk University Brno Brno Czech Republic
| | - Jan Mrozek
- Cardiovascular Department University Hospital Ostrava Ostrava Czech Republic
| | - Martin Porzer
- Cardiovascular Department University Hospital Ostrava Ostrava Czech Republic
| | - Tomas Grezl
- Cardiovascular Department University Hospital Ostrava Ostrava Czech Republic
| | - Kamil Novobilsky
- Cardiology Department Municipal Hospital Ostrava Ostrava Czech Republic
| | | | - Karel Kopriva
- Cardiology Department Homolka Hospital Prague Czech Republic
| | - Martin Mates
- Cardiology Department Homolka Hospital Prague Czech Republic
| | - Martin Chval
- Institute for Research and Development of Education Faculty of Education Charles University Prague Czech Republic
| | - Zhi Chen
- Department of Electrical & Computer Engineering Iowa Institute for Biomedical ImagingThe University of Iowa IA
| | - Pavel Martasek
- Department of Paediatrics and Inherited Metabolic Disorders First Faculty of Medicine Charles UniversityGeneral University Hospital Prague Czech Republic
| | - Ales Linhart
- 2nd Department of Medicine Department of Cardiovascular Medicine First Faculty of Medicine Charles University and General University Hospital in Prague Prague Czech Republic
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Darabont RO, Vișoiu IS, Magda ȘL, Stoicescu C, Vintilă VD, Udroiu C, Vinereanu D. Implications of Myocardial Bridge on Coronary Atherosclerosis and Survival. Diagnostics (Basel) 2022; 12:diagnostics12040948. [PMID: 35453995 PMCID: PMC9026775 DOI: 10.3390/diagnostics12040948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/03/2022] [Accepted: 04/07/2022] [Indexed: 12/04/2022] Open
Abstract
Background: In this study, we aimed to describe the impact of MBs on atherosclerosis and survival, in patients with coronary artery disease (CAD). Methods: We retrospectively studied 1920 consecutive patients who underwent conventional coronary angiography for suspected CAD. Atherosclerotic load (AL), defined as the sum of degrees of stenosis, and general atherosclerotic load (GAL), representing the sum of AL, were compared between patients with MB and a control group without MB; patients in these groups were similar in age and sex. We assessed survival at 10 years after the last enrolled patient. Results: Prevalence of MB was 3.96%, predominantly in the mid-segment of left anterior descendent artery (LAD). In the presence of MB, GAL was lower (158.1 ± 93.7 vs. 205.3 ± 117.9, p = 0.004) with a lesser AL in the proximal (30.3 ± 39.9 vs. 42.9 ± 41.1, p = 0.038) and mid-segments (8.1 ± 20.0 vs. 25.3 ± 35.9, p < 0.001) of LAD. Based on a Multinominal Logistic Regression, we found that the presence of MB on LAD (regardless of its location on this artery) is a protective factor against atherosclerotic lesions, decreasing the probability of significant stenosis, especially of those ≥70%, on the entire artery (B −1.539, OR 4660; 95% CI = 1.873−11.595, p = 0.001) and on each of its segments as well: proximal LAD (B −1.275, OR 0.280; 95% CI = 0.015−5.073; p = 0.038), mid-LAD (B −1.879, OR 6.545; 95% CI = 1.492−28.712; p = 0.013) and distal LAD (B −0.900, OR 2.459, 95% CI = 2.459−2.459, p = 0.032). However, 10-year survival was similar between groups (76.70% vs. 74.30%, p = 0.740). Conclusion: The presence of MB on LAD proved to be a protective factor against atherosclerosis for the entire artery and for each of its segments, but it does not influence long-term survival in patients with CAD.
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Affiliation(s)
- Roxana Oana Darabont
- Department of Cardiology and Cardiovascular Surgery, University of Medicine and Pharmacy “Carol Davila”, 37 Dionisie Lupu, 030167 Bucharest, Romania; (Ș.L.M.); (C.S.); (V.D.V.); (D.V.)
- Department of Cardiology, University Emergency Hospital of Bucharest, 169 Splaiul Independenței, 050098 Bucharest, Romania; (I.S.V.); (C.U.)
- Correspondence: ; Tel.: +40-723-441-315
| | - Ionela Simona Vișoiu
- Department of Cardiology, University Emergency Hospital of Bucharest, 169 Splaiul Independenței, 050098 Bucharest, Romania; (I.S.V.); (C.U.)
| | - Ștefania Lucia Magda
- Department of Cardiology and Cardiovascular Surgery, University of Medicine and Pharmacy “Carol Davila”, 37 Dionisie Lupu, 030167 Bucharest, Romania; (Ș.L.M.); (C.S.); (V.D.V.); (D.V.)
- Department of Cardiology, University Emergency Hospital of Bucharest, 169 Splaiul Independenței, 050098 Bucharest, Romania; (I.S.V.); (C.U.)
| | - Claudiu Stoicescu
- Department of Cardiology and Cardiovascular Surgery, University of Medicine and Pharmacy “Carol Davila”, 37 Dionisie Lupu, 030167 Bucharest, Romania; (Ș.L.M.); (C.S.); (V.D.V.); (D.V.)
- Department of Cardiology, University Emergency Hospital of Bucharest, 169 Splaiul Independenței, 050098 Bucharest, Romania; (I.S.V.); (C.U.)
| | - Vlad Damian Vintilă
- Department of Cardiology and Cardiovascular Surgery, University of Medicine and Pharmacy “Carol Davila”, 37 Dionisie Lupu, 030167 Bucharest, Romania; (Ș.L.M.); (C.S.); (V.D.V.); (D.V.)
- Department of Cardiology, University Emergency Hospital of Bucharest, 169 Splaiul Independenței, 050098 Bucharest, Romania; (I.S.V.); (C.U.)
| | - Cristian Udroiu
- Department of Cardiology, University Emergency Hospital of Bucharest, 169 Splaiul Independenței, 050098 Bucharest, Romania; (I.S.V.); (C.U.)
| | - Dragoș Vinereanu
- Department of Cardiology and Cardiovascular Surgery, University of Medicine and Pharmacy “Carol Davila”, 37 Dionisie Lupu, 030167 Bucharest, Romania; (Ș.L.M.); (C.S.); (V.D.V.); (D.V.)
- Department of Cardiology, University Emergency Hospital of Bucharest, 169 Splaiul Independenței, 050098 Bucharest, Romania; (I.S.V.); (C.U.)
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Calculation of Intracoronary Pressure-Based Indexes with JLabChart. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12073448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The Fractional Flow Reserve (FFR) and instantaneous wave-Free Ratio (iFR) have been proposed and clinically validated to measure the pressure gradient across coronary stenoses. They provide quantitative information on stenosis severity. Both are used in coronary revascularization procedures to measure intracoronary pressure giving quantitative information to evaluate coronary diseases during angiographic procedures. We designed and implemented a tool able to acquire and measure iFR and FFR supporting the physicians studying and treating patients in interventional cardiology laboratories. We designed an extensive case study to assess the performance of the tool in (i) acquiring pressure signals from blood pressure measurement systems; (ii) calculating FFR and iFR; and (iii) filtering out extra-beats signals during realtime signal analysis phases. The tool, named JLabChart, is available online. We tested it on two sets of data for a total of 600 cycles from 201 pressure measurements performed on 65 patients, from the Interventional Cardiology Unit of Magna Graecia University. The recognition of cardiac cycles and keypoint of the pressure curve was effective in 100% of cases for proximal (aortic) pressure and in 99.2% for distal pressure. The FFR calculated by JLabChart had an excellent correlation (Rp=0.960; p<0.001) with the FFR values obtained through the commercial systems. Similar results were obtained with iFR (Rp=0.998; p<0.001). Finally, the tool measurement results were compared with a commercial tool proving JLabChart’s efficiency with real cases. It was also compared with measurements performed on synthetic vessels and stenosis designed using the Comsol commercial tool. JLabChart is able to provide reliable measurements of FFR and iFR indexes used to support decisions on interventional procedures. It represents a valuable open source support system that can be used in an interventional cardiology laboratory.
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5-Year Outcomes of PCI Guided by Measurement of Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve. J Am Coll Cardiol 2022; 79:965-974. [PMID: 35272801 DOI: 10.1016/j.jacc.2021.12.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Instantaneous wave-free ratio (iFR) is a coronary physiology index used to assess the severity of coronary artery stenosis to guide revascularization. iFR has previously demonstrated noninferior short-term outcome compared to fractional flow reserve (FFR), but data on longer-term outcome have been lacking. OBJECTIVES The purpose of this study was to investigate the prespecified 5-year follow-up of the primary composite outcome of all-cause mortality, myocardial infarction, and unplanned revascularization of the iFR-SWEDEHEART trial comparing iFR vs FFR in patients with chronic and acute coronary syndromes. METHODS iFR-SWEDEHEART was a multicenter, controlled, open-label, registry-based randomized clinical trial using the Swedish Coronary Angiography and Angioplasty Registry for enrollment. A total of 2,037 patients were randomized to undergo revascularization guided by iFR or FFR. RESULTS No patients were lost to follow-up. At 5 years, the rate of the primary composite endpoint was 21.5% in the iFR group and 19.9% in the FFR group (HR: 1.09; 95% CI: 0.90-1.33). The rates of all-cause death (9.4% vs 7.9%; HR: 1.20; 95% CI: 0.89-1.62), nonfatal myocardial infarction (5.7% vs 5.8%; HR: 1.00; 95% CI: 0.70-1.44), and unplanned revascularization (11.6% vs 11.3%; HR: 1.02; 95% CI: 0.79-1.32) were also not different between the 2 groups. The outcomes were consistent across prespecified subgroups. CONCLUSIONS In patients with chronic or acute coronary syndromes, an iFR-guided revascularization strategy was associated with no difference in the 5-year composite outcome of death, myocardial infarction, and unplanned revascularization compared with an FFR-guided revascularization strategy. (Evaluation of iFR vs FFR in Stable Angina or Acute Coronary Syndrome [iFR SWEDEHEART]; NCT02166736).
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Functional CAD-RADS using FFR CT on therapeutic management and prognosis in patients with coronary artery disease. Eur Radiol 2022; 32:5210-5221. [PMID: 35258672 DOI: 10.1007/s00330-022-08618-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 01/05/2022] [Accepted: 01/28/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To propose a novel functional Coronary Artery Disease-Reporting and Data System (CAD-RADS) category system integrated with coronary CT angiography (CCTA)-derived fractional flow reserve (FFRCT) and to validate its effect on therapeutic decision and prognosis in patients with coronary artery disease (CAD). METHODS Firstly, we proposed a novel functional CAD-RADS and evaluated the performance of functional CAD-RADS for guiding treatment strategies with actual clinical treatment as a reference standard in a retrospective multicenter cohort with CCTA and invasive FFR performed in all patients (n = 466). Net reclassification improvement (NRI) of functional CAD-RADS over anatomical CAD-RADS was calculated. Secondly, the prognostic value of functional CAD-RADS in a prospective two-arm cohort (566 [FFRCT arm] vs. 567 [CCTA arm]) was calculated, after a 1-year follow-up, functional CAD-RADS in FFRCT arm (n = 513) and anatomical CAD-RADS in CCTA arm (n = 511) to determine patients at risk of adverse outcomes were compared with a Cox hazard proportional model. RESULTS Functional CAD-RADS demonstrated superior value over anatomical CAD-RADS (AUC: 0.828 vs. 0.681, p < 0.001) and comparable performance to FFR (AUC: 0.828 vs. 0.848, p = 0.253) in guiding therapeutic decisions. Functional CAD-RADS resulted in the revision of management plan as determined by anatomical CAD-RADS in 30.0% of patients (n = 140) (NRI = 0.369, p < 0.001). Functional CAD-RADS was an independent predictor for 1-year outcomes with indexes of concordance of 0.795 and the corresponding value was 0.751 in anatomical CAD-RADS. CONCLUSION The novel functional CAD-RADS gained incremental value in guiding therapeutic decision-making compared with anatomical CAD-RADS and comparable power in 1-year prognosis with anatomical CAD-RADS in a real-world scenario. KEY POINTS • The novel functional CAD-RADS category system with FFRCT integrated into the anatomical CAD-RADS categories was originally proposed. • The novel functional CAD-RADS category system was validated superior value over anatomical CAD-RADS (AUC: 0.828 vs. 0.681, p < 0.001) in guiding therapeutic decisions and revised management plan in 30.0% of patients as determined by anatomical CAD-RADS (net reclassification improvement index = 0.369, p < 0.001). • Functional CAD-RADS was an independent predictor with an index of concordance of 0.795 and 0.751 in anatomical CAD-RADS for 1-year prognosis of adverse outcomes.
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Zhang J, Xu K, Hu Y, Yang L, Leng X, Jin H, Tang Y, Liu X, Ye C, Guo Y, Wang L, Zhang J, Feng Y, Mou C, Tang L, Xiang J, Du C. Diagnostic performance of deep learning and computational fluid dynamics-based instantaneous wave-free ratio derived from computed tomography angiography. BMC Cardiovasc Disord 2022; 22:33. [PMID: 35120463 PMCID: PMC8817609 DOI: 10.1186/s12872-022-02469-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/13/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Both fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are widely used to evaluate ischemia-causing coronary lesions. A new method of CT-iFR, namely AccuiFRct, for calculating iFR based on deep learning and computational fluid dynamics (CFD) using coronary computed tomography angiography (CCTA) has been proposed. In this study, the diagnostic performance of AccuiFRct was thoroughly assessed using iFR as the reference standard. METHODS Data of a total of 36 consecutive patients with 36 vessels from a single-center who underwent CCTA, invasive FFR, and iFR were retrospectively analyzed. The CT-derived iFR values were computed using a novel deep learning and CFD-based model. RESULTS Mean values of FFR and iFR were 0.80 ± 0.10 and 0.91 ± 0.06, respectively. AccuiFRct was well correlated with FFR and iFR (correlation coefficients, 0.67 and 0.68, respectively). The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of AccuiFRct ≤ 0.89 for predicting FFR ≤ 0.80 were 78%, 73%, 81%, 73%, and 81%, respectively. Those of AccuiFRct ≤ 0.89 for predicting iFR ≤ 0.89 were 81%, 73%, 86%, 79%, and 82%, respectively. AccuiFRct showed a similar discriminant function when FFR or iFR were used as reference standards. CONCLUSION AccuiFRct could be a promising noninvasive tool for detection of ischemia-causing coronary stenosis, as well as facilitating in making reliable clinical decisions.
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Affiliation(s)
- Jingyuan Zhang
- Department of Medicine, The Second College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Kun Xu
- Department of Medicine, The Second College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yumeng Hu
- ArteryFlow Technology Co., Ltd., 459 Qianmo Road, Hangzhou, 310051, China
| | - Lin Yang
- Department of Geriatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaochang Leng
- ArteryFlow Technology Co., Ltd., 459 Qianmo Road, Hangzhou, 310051, China
| | - Hongfeng Jin
- Department of Cardiology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Yiming Tang
- Department of Cardiology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Xiaowei Liu
- Department of Cardiology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Chen Ye
- Department of Cardiology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Yitao Guo
- Department of Cardiology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Lei Wang
- Department of Cardiology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Jianjun Zhang
- Department of Radiology, Zhejiang Hospital, Hangzhou, China
| | - Yue Feng
- Department of Radiology, Zhejiang Hospital, Hangzhou, China
| | - Caiyun Mou
- Department of Radiology, Zhejiang Hospital, Hangzhou, China
| | - Lijiang Tang
- Department of Medicine, The Second College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China.
- Department of Cardiology, Zhejiang Hospital, Hangzhou, 310013, China.
| | - Jianping Xiang
- ArteryFlow Technology Co., Ltd., 459 Qianmo Road, Hangzhou, 310051, China.
| | - Changqing Du
- Department of Medicine, The Second College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China.
- Department of Cardiology, Zhejiang Hospital, Hangzhou, 310013, China.
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Jain P, Udelson JE, Kimmelstiel C. Physiologic Guidance for Percutaneous Coronary Intervention: State of the Evidence. Trends Cardiovasc Med 2022:S1050-1738(22)00014-7. [DOI: 10.1016/j.tcm.2022.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/10/2022] [Accepted: 01/25/2022] [Indexed: 01/10/2023]
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Berntorp K, Persson J, Koul SM, Patel MR, Christiansen EH, Gudmundsdottir I, Yndigegn T, Omerovic E, Erlinge D, Fröbert O, Götberg M. Instantaneous wave-free ratio compared with fractional flow reserve in PCI: A cost-minimization analysis. Int J Cardiol 2021; 344:54-59. [PMID: 34600977 DOI: 10.1016/j.ijcard.2021.09.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Coronary physiology is a routine diagnostic tool when assessing whether coronary revascularization is indicated. The iFR-SWEDEHEART trial demonstrated similar clinical outcomes when using instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) to guide revascularization. The objective of this analysis was to assess a cost-minimization analysis of iFR-guided compared with FFR-guided revascularization. METHODS In this cost-minimization analysis we used a decision-tree model from a healthcare perspective with a time-horizon of one year to estimate the cost difference between iFR and FFR in a Nordic setting and a United States (US) setting. Treatment pathways and health care utilizations were constructed from the iFR-SWEDEHEART trial. Unit cost for revascularization and myocardial infarction in the Nordic setting and US setting were derived from the Nordic diagnosis-related group versus Medicare cost data. Unit cost of intravenous adenosine administration and cost per stent placed were based on the average costs from the enrolled centers in the iFR-SWEDEHEART trial. Deterministic and probabilistic sensitivity analyses were carried out to test the robustness of the result. RESULTS The cost-minimization analysis demonstrated a cost saving per patient of $681 (95% CI: $641 - $723) in the Nordic setting and $1024 (95% CI: $934 - $1114) in the US setting, when using iFR-guided compared with FFR-guided revascularization. The results were not sensitive to changes in uncertain parameters or assumptions. CONCLUSIONS IFR-guided revascularization is associated with significant savings in cost compared with FFR-guided revascularization.
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Affiliation(s)
- Karolina Berntorp
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Josefine Persson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
| | - Sasha M Koul
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | | | | | - Ingibjörg Gudmundsdottir
- Department of Cardiology, Reykjavik University Hospital and University of Iceland, Reykjavik, Iceland.
| | - Troels Yndigegn
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - David Erlinge
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Ole Fröbert
- Örebro University, Faculty of Health, Department of Cardiology, Örebro, Sweden.
| | - Matthias Götberg
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
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Yu Y, Yu L, Dai X, Zhang J. CT Fractional Flow Reserve for the Diagnosis of Myocardial Bridging-Related Ischemia: A Study Using Dynamic CT Myocardial Perfusion Imaging as a Reference Standard. Korean J Radiol 2021; 22:1964-1973. [PMID: 34668350 PMCID: PMC8628161 DOI: 10.3348/kjr.2021.0043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/27/2021] [Accepted: 07/26/2021] [Indexed: 01/02/2023] Open
Abstract
Objective To investigate the diagnostic performance of CT fractional flow reserve (CT-FFR) for myocardial bridging-related ischemia using dynamic CT myocardial perfusion imaging (CT-MPI) as a reference standard. Materials and Methods Dynamic CT-MPI and coronary CT angiography (CCTA) data obtained from 498 symptomatic patients were retrospectively reviewed. Seventy-five patients (mean age ± standard deviation, 62.7 ± 13.2 years; 48 males) who showed myocardial bridging in the left anterior descending artery without concomitant obstructive stenosis on the imaging were included. The change in CT-FFR across myocardial bridging (ΔCT-FFR, defined as the difference in CT-FFR values between the proximal and distal ends of the myocardial bridging) in different cardiac phases, as well as other anatomical parameters, were measured to evaluate their performance for diagnosing myocardial bridging-related myocardial ischemia using dynamic CT-MPI as the reference standard (myocardial blood flow < 100 mL/100 mL/min or myocardial blood flow ratio ≤ 0.8). Results ΔCT-FFRsystolic (ΔCT-FFR calculated in the best systolic phase) was higher in patients with vs. without myocardial bridging-related myocardial ischemia (median [interquartile range], 0.12 [0.08–0.17] vs. 0.04 [0.01–0.07], p < 0.001), while CT-FFRsystolic (CT-FFR distal to the myocardial bridging calculated in the best systolic phase) was lower (0.85 [0.81–0.89] vs. 0.91 [0.88–0.96], p = 0.043). In contrast, ΔCT-FFRdiastolic (ΔCT-FFR calculated in the best diastolic phase) and CT-FFRdiastolic (CT-FFR distal to the myocardial bridging calculated in the best diastolic phase) did not differ significantly. Receiver operating characteristic curve analysis showed that ΔCT-FFRsystolic had largest area under the curve (0.822; 95% confidence interval, 0.717–0.901) for identifying myocardial bridging-related ischemia. ΔCT-FFRsystolic had the highest sensitivity (91.7%) and negative predictive value (NPV) (97.8%). ΔCT-FFRdiastolic had the highest specificity (85.7%) for diagnosing myocardial bridging-related ischemia. The positive predictive values of all CT-related parameters were low. Conclusion ΔCT-FFRsystolic reliably excluded myocardial bridging-related ischemia with high sensitivity and NPV. Myocardial bridging showing positive CT-FFR results requires further evaluation.
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Affiliation(s)
- Yarong Yu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Lihua Yu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xu Dai
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiayin Zhang
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Demir OM, Rahman H, van de Hoef TP, Escaned J, Piek JJ, Plein S, Perera D. Invasive and non-invasive assessment of ischaemia in chronic coronary syndromes: translating pathophysiology to clinical practice. Eur Heart J 2021; 43:105-117. [PMID: 34516621 PMCID: PMC8757583 DOI: 10.1093/eurheartj/ehab548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/22/2021] [Accepted: 08/05/2021] [Indexed: 01/10/2023] Open
Abstract
Intracoronary physiology testing has emerged as a valuable diagnostic approach in the management of patients with chronic coronary syndrome, circumventing limitations like inferring coronary function from anatomical assessment and low spatial resolution associated with angiography or non-invasive tests. The value of hyperaemic translesional pressure ratios to estimate the functional relevance of coronary stenoses is supported by a wealth of prognostic data. The continuing drive to further simplify this approach led to the development of non-hyperaemic pressure-based indices. Recent attention has focussed on estimating physiology without even measuring coronary pressure. However, the reduction in procedural time and ease of accessibility afforded by these simplifications needs to be counterbalanced against the increasing burden of physiological assumptions, which may impact on the ability to reliably identify an ischaemic substrate, the ultimate goal during catheter laboratory assessment. In that regard, measurement of both coronary pressure and flow enables comprehensive physiological evaluation of both epicardial and microcirculatory components of the vasculature, although widespread adoption has been hampered by perceived technical complexity and, in general, an underappreciation of the role of the microvasculature. In parallel, entirely non-invasive tools have matured, with the utilization of various techniques including computational fluid dynamic and quantitative perfusion analysis. This review article appraises the strengths and limitations for each test in investigating myocardial ischaemia and discusses a comprehensive algorithm that could be used to obtain a diagnosis in all patients with angina scheduled for coronary angiography, including those who are not found to have obstructive epicardial coronary disease.
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Affiliation(s)
- Ozan M Demir
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, Westminster Bridge Road, London SE1 7EH, UK
| | - Haseeb Rahman
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, Westminster Bridge Road, London SE1 7EH, UK
| | - Tim P van de Hoef
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, Netherlands
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, SpainCalle del Prof Martín Lagos, Madrid 28040, Spain
| | - Jan J Piek
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, Netherlands
| | - Sven Plein
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, Westminster Bridge Road, London SE1 7EH, UK
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Shiono Y, Matsuo H, Fujita H, Tanaka N, Ogasawara Y, Kawamura I, Katayama Y, Matsuo A, Kawase Y, Kakuta T, Takashima H, Yokoi H, Ohira H, Suwa S, Oguri M, Yamamoto F, Kubo T, Akasaka T. Diagnostic Accuracy of Diastolic Fractional Flow Reserve for Functional Evaluation of Coronary Stenosis: DIASTOLE Study. JACC. ASIA 2021; 1:230-241. [PMID: 36338166 PMCID: PMC9627917 DOI: 10.1016/j.jacasi.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/28/2021] [Accepted: 07/08/2021] [Indexed: 01/10/2023]
Abstract
Background In the resting conditions, narrowing the window of coronary pressure measurements from the whole cardiac cycle to diastole improves diagnostic performance of coronary pressure-derived physiological index. However, whether this also applies to the hyperemic conditions has not yet been thoroughly evaluated. Objectives The purpose of this study was to assess whether diastolic fractional flow reserve (diastolic FFR) has better diagnostic performance in identifying ischemia-causing coronary lesions than conventional FFR in a prospective, multicenter, and independent core laboratory-based environment. Methods In this prospective multicenter registry at 29 Japanese centers, we compared the diagnostic performance of FFR, diastolic FFR, resting distal to aortic coronary pressure (Pd/Pa), and diastolic pressure ratio (dPR) using myocardial perfusion scintigraphy (MPS) as the reference standard in 378 patients with single-vessel coronary disease. Results Inducible myocardial ischemia was found on MPS in the relevant myocardial territory of the target vessel in 85 patients (22%). In the receiver-operating curve analyses, diastolic FFR had comparable area under the curve (AUC) compared with FFR (AUCdiastolic FFR: 0.66; 95% confidence interval [CI]: 0.58-0.73, vs AUCFFR: 0.66; 95% CI: 0.58-0.74, P = 0.624). FFR and diastolic FFR showed significantly larger AUCs than resting Pd/Pa (0.62; 95% CI: 0.54-0.70; P = 0.033 and P = 0.046) but did not show significantly larger AUCs than dPR (0.62; 95% CI: 0.55-0.70; P = 0.102 and P = 0.113). Conclusions Diastolic FFR showed a similar diagnostic performance to FFR as compared with MPS. This result reaffirms the use of FFR as the most accurate invasive physiological lesion assessment. (Diagnostic accuracy of diastolic fractional flow reserve (d-FFR) for functional evaluation of coronary stenosis; UMIN000015906).
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Key Words
- FFR, fractional flow reserve
- IQR, interquartile range
- LAD, left anterior descending artery
- LCX, left circumflex artery
- MPS, myocardial perfusion scintigraphy
- RCA, right coronary artery
- ROC, receiver-operating characteristic
- SDS, summed difference score
- SRS, summed rest score
- SSS, summed stress score
- dPR, diastolic pressure ratio
- fractional flow reserve
- iFR, instantaneous wave-free ratio
- myocardial ischemia
- myocardial perfusion scintigraphy
- stable coronary artery disease
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Affiliation(s)
- Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hitoshi Matsuo
- Department of Cardiology, Gifu Heart Center, Gifu, Japan
| | - Hiroshi Fujita
- Department of Cardiology, North Medical Center Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Care Center, Tokyo, Japan
| | - Yasuo Ogasawara
- Department of Medical Engineering, Kawasaki University of Medical Welfare, Okayama, Japan
| | - Itta Kawamura
- Department of Cardiology, Gifu Heart Center, Gifu, Japan
| | - Yosuke Katayama
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Akiko Matsuo
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | | | - Tsunekazu Kakuta
- Department of Cardiology, Tsuchiura Kyoto General Hospital, Ibaraki, Japan
| | | | - Hiroyoshi Yokoi
- Department of Cardiology, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Hiroshi Ohira
- Department of Cardiology, Edogawa Hospital, Tokyo, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Mitsutoshi Oguri
- Department of Cardiology, Kasugai Municipal Hospital, Aichi, Japan
| | - Fumi Yamamoto
- Department of Cardiology, Ureshino Medical Center National Hospital Organization, Saga, Japan
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
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The stability of flow velocity and intracoronary resistance in the intracoronary electrocardiogram-triggered pressure ratio. Sci Rep 2021; 11:13824. [PMID: 34226618 PMCID: PMC8257648 DOI: 10.1038/s41598-021-93181-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/22/2021] [Indexed: 01/10/2023] Open
Abstract
Assessment of coronary artery lesions using the fractional flow reserve and instantaneous flow reserve (iFR) measurements has been found to reduce the incidence of further cardiovascular events. Here, we investigated differences in terms of coronary flow velocity and resistance within the analysis interval between the iFR and the intracoronary electrocardiogram (IC-ECG)-triggered distal/aortic pressure (Pd/Pa) ratio (ICE-T). We enrolled 23 consecutive patients (n = 33 stenoses) who required coronary flow measurements. ICE-T was defined as the average Pd/Pa ratio in the period corresponding to the isoelectric line of the IC-ECG. We compared the index value, flow velocity, and intracoronary resistance during the analysis intervals of the iFR and the ICE-T, both at rest and under hyperemia. ICE-T values and ICE-T intracoronary resistance were both found to be significantly lower, whereas flow velocity was significantly higher than those of the iFR at both rest and under hyperemia (P < 0.001), and all fluctuations in ICE-T values were also significantly smaller than those in the iFR. In conclusion, the ICE-T appears theoretically superior to pressure-dependent indices for analyzing phases with low and stable resistance, without an increase in invasiveness.
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33
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Ghorbanniahassankiadeh A, Marks DS, LaDisa JF. Correlation of Computational Instantaneous Wave-Free Ratio With Fractional Flow Reserve for Intermediate Multivessel Coronary Disease. J Biomech Eng 2021; 143:051011. [PMID: 33454732 DOI: 10.1115/1.4049746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Indexed: 01/14/2023]
Abstract
This study computationally assesses the accuracy of an instantaneous wave-free ratio (iFR) threshold range compared to standard modalities such as fractional flow reserve (FFR) and coronary flow reserve (CFR) for multiple intermediate lesions near the left main (LM) coronary bifurcation. iFR is an adenosine-independent index encouraged for assessment of coronary artery disease (CAD), but different thresholds are debated. This becomes particularly challenging in cases of multivessel disease when sensitivity to downstream lesions is unclear. Idealized LM coronary arteries with 34 different intermediate stenoses were created and categorized (Medina) as single and multiple lesion groups. Computational fluid dynamics modeling was performed with physiologic boundary conditions using an open-source software (simvascular1) to solve the time-dependent Navier-Stokes equations. A strong linear relationship between iFR and FFR was observed among studied models, indicating computational iFR values of 0.92 and 0.93 are statistically equivalent to an FFR of 0.80 in single and multiple lesion groups, respectively. At the clinical FFR value (i.e., 0.8), a triple-lesion group had smaller CFR compared to the single and double lesion groups (e.g., triple = 3.077 versus single = 3.133 and double = 3.132). In general, the effect of additional intermediate downstream lesions (minimum lumen area > 3 mm2) was not statistically significant for iFR and CFR. A computational iFR of 0.92 best predicts an FFR of 0.80 and may be recommended as threshold criteria for computational assessment of LM stenosis following additional validation using patient-specific models.
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Affiliation(s)
- Arash Ghorbanniahassankiadeh
- Department of Biomedical Engineering, Medical College of Wisconsin and Marquette University, 8701 W Watertown Plank Road, Milwaukee, WI 53226
| | - David S Marks
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226
| | - John F LaDisa
- Department of Biomedical Engineering, Medical College of Wisconsin and Marquette University, 8701 W Watertown Plank Road, Milwaukee, WI 53226; Department of Physiology, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226; Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226
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34
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Celebi OO. The Diagnostic Accuracy of the Instantaneous Wave-Free Ratio. Angiology 2021; 72:693. [PMID: 33813875 DOI: 10.1177/00033197211006975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Ozlem Ozcan Celebi
- Department of Cardiology, 64241University of Health Sciences, Ankara City Hospital, Turkey
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35
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Al-Lamee R, Rajkumar CA, Ganesananthan S, Jeremias A. Optimising physiological endpoints of percutaneous coronary intervention. EUROINTERVENTION 2021; 16:e1470-e1483. [PMID: 33792544 PMCID: PMC9753914 DOI: 10.4244/eij-d-20-00988] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Invasive coronary physiology to select patients for coronary revascularisation has become established in contemporary guidelines for the management of stable coronary artery disease. Compared to revascularisation based on angiography alone, the use of coronary physiology has been shown to improve clinical outcomes and cost efficiency. However, recent data from randomised controlled trials have cast doubt upon the value of ischaemia testing to select patients for revascularisation. Importantly, 20-40% of patients have persistence or recurrence of angina after angiographically successful percutaneous coronary intervention (PCI). This state-of-the-art review is focused on the transitioning role of invasive coronary physiology from its use as a dichotomous test for ischaemia with fixed cut-points, towards its utility for real-time guidance of PCI to optimise physiological results. We summarise the contemporary evidence base for ischaemia testing in stable coronary artery disease, examine emerging indices which allow advanced physiological guidance of PCI, and discuss the rationale and evidence base for post-PCI physiological assessments to assess the success of revascularisation.
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Affiliation(s)
- Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, 2nd Floor, B Block, Hammersmith Hospital, Du Cane Road, London, W12 0HS, United Kingdom
| | - Christopher A. Rajkumar
- National Heart and Lung Institute, Imperial College London, London, United Kingdom,Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Allen Jeremias
- Department of Cardiology, St. Francis Hospital, The Heart Center, Roslyn, NY, USA
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Hwang D, Yang S, Zhang J, Koo BK. Physiologic Assessment after Coronary Stent Implantation. Korean Circ J 2021; 51:189-201. [PMID: 33655719 PMCID: PMC7925968 DOI: 10.4070/kcj.2020.0548] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/10/2021] [Indexed: 12/13/2022] Open
Abstract
The presence of myocardial ischemia is a prerequisite for the benefit of coronary revascularization. In the cardiac catheterization laboratory, fractional flow reserve and non-hyperemic pressure ratios are used to define the ischemia-causing coronary stenosis, and several randomized studies showed the benefit of physiology-guided coronary revascularization. However, physiology-guided revascularization does not necessarily guarantee the relief of ischemia. Recent studies reported that residual ischemia might exist in up to 15-20% of cases after angiographically successful percutaneous coronary intervention (PCI). Therefore, post-PCI physiologic assessment is necessary for judging the appropriateness of PCI, detecting the lesions that may benefit from additional PCI, and risk stratification after PCI. This review will focus on the current evidence for post-PCI physiologic assessment, how to interpret these findings, and the future perspectives of physiologic assessment after PCI.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jinlong Zhang
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Bon Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
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Modi B, Perera D. How to select patients requiring coronary revascularisation using coronary physiology. JRSM Cardiovasc Dis 2021; 10:2048004020979476. [PMID: 33614020 PMCID: PMC7868490 DOI: 10.1177/2048004020979476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/29/2020] [Accepted: 11/18/2020] [Indexed: 01/10/2023] Open
Abstract
The coronary angiogram is an indicator of flow limiting coronary artery disease but coronary physiology at the time of angiography is vital in assessing the true functional significance of coronary artery disease. With advances in guidewire technology and the greater use of physiology within the catheter laboratory, there is now a slow evolution of physiological indices in being able to reliably assess the functional significance of individual lesions and also the adequacy of revascularization in a growing range of clinical scenarios. As co-registration of physiology with the angiogram and intravascular imaging will become easier, we will find ourselves increasingly in an era of 'Precision PCI'.
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Affiliation(s)
- Bhavik Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, UK
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, UK
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38
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Impact of aging on the effects of intracoronary adenosine, peak hyperemia and its duration during fractional flow reserve assessment. Coron Artery Dis 2021; 32:625-631. [PMID: 33471468 DOI: 10.1097/mca.0000000000001019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Functional assessment of coronary stenoses is crucial for determining the correct therapeutic strategy. Age-related modifications in cardiovascular function could alter the functional significance of an intermediate coronary lesion. Therefore, the aim of the present study was to investigate the impact of age on fractional flow reserve (FFR) measurements in patients with intermediate coronary artery disease. METHODS We included patients undergoing coronary angiography at our Division of Cardiology from June 2008 to February 2019 for elective indication or recent acute coronary syndrome and receiving FFR assessment for an intermediate coronary stenosis (angiographic 40-70% stenoses). FFR measurement was performed by pressure-recording guidewire (Prime Wire; Volcano Imaging System Philips Healthcare, San Diego, California, USA), after induction of hyperemia with intracoronary boluses of adenosine (from 60 to 720 μg, with dose doubling at each step). RESULTS We included in our study 276 patients, undergoing FFR evaluation on 314 lesions, that were divided according to age (< or ≥70 years). Elderly patients displayed a higher cardiovascular risk profile and received more often specific therapy. We found significantly higher FFR values and lower Delta FFR and time to recovery in patients with age ≥70 years old even with high-dose adenosine. Elderly patients showed a trend in lower percentage of positive FFRs, especially with high-dose (P = 0.09). Overall, any FFR ≤ 0.80 was observed in 33.5% of younger patients and 21.1% of patients ≥70 years (P = 0.02). Results were confirmed after correction for baseline differences [adjusted odds ratio (95% confidence interval) = 0.60 (0.33-1.09), P = 0.08]. CONCLUSION This is one of the first studies investigating the impact of age on the measurement of FFR with high-dose adenosine. Patients with age >70 years old with intermediate CAD are more likely to have higher FFR values and lower duration of hyperemia after adenosine boluses, as compared with younger patients.
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39
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Modi BN, Rahman H, Ryan M, Ellis H, Pavlidis A, Redwood S, Clapp B, Chowienczyk P, Perera D. Comparison of fractional flow reserve, instantaneous wave-free ratio and a novel technique for assessing coronary arteries with serial lesions. EUROINTERVENTION 2020; 16:577-583. [PMID: 31543499 DOI: 10.4244/eij-d-19-00635] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
AIMS Physiological indices such as fractional flow reserve (FFR), instantaneous wave-free ratio (iFR) and resting distal coronary to aortic pressure (Pd/Pa) are increasingly used to guide revascularisation. However, reliable assessment of individual stenoses in serial coronary disease remains an unmet need. This study aimed to compare conventional pressure-based indices, a reference Doppler-based resistance index (hyperaemic stenosis resistance [hSR]) and a recently described mathematical correction model to predict the contribution of individual stenoses in serial disease. METHODS AND RESULTS Resting and hyperaemic pressure wire pullbacks were performed in 54 patients with serial disease. For each stenosis, FFR, iFR, and Pd/Pa were measured by the translesional gradient in each index and the predicted FFR (FFRpred) derived mathematically from hyperaemic pullback data. "True" stenosis significance by each index was assessed following PCI of the accompanying stenosis or measurements made in a large disease-free branch. In 27 patients, Doppler average peak flow velocity (APV) was also measured to calculate hSR (hSR=∆P/APV, where ∆P=translesional pressure gradient). FFR underestimated individual stenosis severity, inversely proportional to cumulative FFR (r=0.5, p<0.001). Mean errors for FFR, iFR and Pd/Pa were 33%, 20% and 24%, respectively, and 14% for FFRpred (p<0.001). Stenosis misclassification rates based on FFR 0.80, iFR 0.89 and Pd/Pa 0.91 thresholds were not significantly different (17%, 24% and 20%, respectively) but were higher than FFRpred (11%, p<0.001). Apparent and true hSR correlated strongly (r=0.87, p<0.001, mean error 0.19±0.3), with only 7% of stenoses misclassified. CONCLUSIONS Individual stenosis severity is significantly underestimated in the presence of serial disease, using both hyperaemic and resting pressure-based indices. hSR is less prone to error but challenges in optimising Doppler signals limit clinical utility. A mathematical correction model, using data from hyperaemic pressure wire pullback, produces similar accuracy to hSR and is superior to conventional pressure-based indices.
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Affiliation(s)
- Bhavik N Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, United Kingdom
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40
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Vakharia K, Waqas M, Fayyaz N, Young A, Levy EI, Davies JM, Siddiqui AH. Instantaneous Wave-Free Ratio Measurement During Intracranial Submaximal Angioplasty: Case Series and 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 19:422-428. [PMID: 32372085 DOI: 10.1093/ons/opaa058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 02/02/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Instantaneous wave-free ratios (iFRs) are functional measures of arterial stenosis that have become essential to interventional cardiology procedures. Their use for intracranial submaximal angioplasty (angioplasty with an undersized balloon) has not been studied extensively. OBJECTIVE To describe the feasibility and technique of iFR measurement for stenosis assessment during intracranial angioplasty. METHODS We present a series of consecutive patients treated between January 1, 2017 and June 30, 2018 with submaximal intracranial angioplasty in whom pre- and postprocedure iFR measurements were obtained with a Verrata-Volcano pressure wire (Philips, Amsterdam, The Netherlands). We collected patient data on age, sex, comorbid conditions, presenting complaints, modified Rankin scale (mRS) score at admission, neurological findings, procedure duration, fluoroscopy time, intraprocedural complications, length of hospital stay, and mRS score at last clinical follow-up (favorable outcome, 0-2). Angiographic stenosis severity and iFR values were recorded before and after angioplasty. RESULTS A total of 12 patients underwent iFR-guided angioplasty during the study period. The median patient age was 69.5 yr (range 48-81 yr). All patients had symptomatic intracranial arterial stenosis (3-basilar, 2-vertebral, 6-middle cerebral, 1-internal carotid). Preangioplasty stenosis ranged from 55% to 90%. The median postangioplasty reduction in stenosis was 17% (range 9%-30%). Preangioplasty values ranged from 0.30 to 0.40 (n = 4). Postangioplasty values ranged from 0.6 to 0.9 (n = 5). iFR values improved considerably in all patients. No procedure-related complications occurred. The median follow-up was 8.9 mo (range 3-25 mo). Follow-up outcomes were favorable in 10 patients. CONCLUSION iFR measurement before and after intracranial angioplasty is feasible. It may be used to assess the adequacy of intracranial angioplasty.
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Affiliation(s)
- Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Najya Fayyaz
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Amanda Young
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York.,Jacobs Institute, Buffalo, New York
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York.,Jacobs Institute, Buffalo, New York.,Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York.,Jacobs Institute, Buffalo, New York
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41
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Vancheri F, Longo G, Vancheri S, Henein M. Coronary Microvascular Dysfunction. J Clin Med 2020; 9:E2880. [PMID: 32899944 PMCID: PMC7563453 DOI: 10.3390/jcm9092880] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 01/09/2023] Open
Abstract
Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed "ischemia with non-obstructive coronary artery disease" (INOCA) and for a small proportion of "myocardial infarction with non-obstructive coronary artery disease" (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).
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Affiliation(s)
- Federico Vancheri
- Department of Internal Medicine, S.Elia Hospital, 93100 Caltanissetta, Italy
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S.Elia Hospital, 93100 Caltanissetta, Italy;
| | - Sergio Vancheri
- Radiology Department, I.R.C.C.S. Policlinico San Matteo, 27100 Pavia, Italy;
| | - Michael Henein
- Institute of Public Health and Clinical Medicine, Umea University, SE-90187 Umea, Sweden;
- Department of Fluid Mechanics, Brunel University, Middlesex, London UB8 3PH, UK
- Molecular and Nuclear Research Institute, St George’s University, London SW17 0RE, UK
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42
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Verdoia M, Gioscia R, Nardin M, Negro F, Tonon F, Suryapranata H, Khedi E, Marcolongo M, De Luca G. Impact of Age on the Functional Evaluation of Intermediate Coronary Stenoses With Instantaneous Wave-Free Ratio and Fractional Flow Reserve. Angiology 2020; 72:62-69. [PMID: 32815383 DOI: 10.1177/0003319720947578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The optimal strategy for assessing the ischemic significance of intermediate coronary stenoses with adenosine-induced fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) is still debated. Few studies have previously assessed the impact of age on FFR and iFR, which was the aim of our study. Patients undergoing FFR and iFR evaluation for intermediate (40%-70%) coronary lesions were included and divided according to age. Fractional flow reserve was performed by intracoronary boluses of adenosine (60-1440 μg). Instantaneous wave-free ratio was automatically calculated. Among 148 patients undergoing FFR measurement of 166 lesions, 45.3% were ≥70 years. Elderly patients had higher minimal lumen diameter (P = .03). We also observed a linear relationship between iFR and FFR independently of age. Fractional flow reserve values were higher in the elderly patients, whereas iFR was not related to age. A total of 33 lesions had a positive iFR with no difference for age (17.3% vs 22%, P = .56), while FFR <0.80 was more infrequent in the elderly patients (17.1% vs 34.8%, P = .02). In intermediate coronary stenoses, iFR and FFR correlation is unaffected by age. Fractional flow reserve is higher in the elderly patients, whereas iFR is less affected by age. Future large-scale studies are needed to define whether iFR should be the preferred choice in elderly patients.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology Ospedale degli Infermi, ASL Biella, Biella, Italy.,Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Rocco Gioscia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Matteo Nardin
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.,Internal Medicine, 18515ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Federica Negro
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Francesco Tonon
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Harry Suryapranata
- Department of Cardiology, UMC St. 6034Radboud, Nijmegen, the Netherlands
| | - Elvin Khedi
- Department of Cardiology, ISALA Hospital, Zwolle, the Netherlands
| | - Marco Marcolongo
- Division of Cardiology Ospedale degli Infermi, ASL Biella, Biella, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
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43
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Carson JM, Chakshu NK, Sazonov I, Nithiarasu P. Artificial intelligence approaches to predict coronary stenosis severity using non-invasive fractional flow reserve. Proc Inst Mech Eng H 2020; 234:1337-1350. [PMID: 32741245 PMCID: PMC7675765 DOI: 10.1177/0954411920946526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Fractional flow reserve is the current reference standard in the assessment of the functional impact of a stenosis in coronary heart disease. In this study, three models of artificial intelligence of varying degrees of complexity were compared to fractional flow reserve measurements. The three models are the multivariate polynomial regression, which is a statistical method used primarily for correlation; the feed-forward neural network; and the long short-term memory, which is a type of recurrent neural network that is suited to modelling sequences. The models were initially trained using a virtual patient database that was generated from a validated one-dimensional physics-based model. The feed-forward neural network performed the best for all test cases considered, which were a single vessel case from a virtual patient database, a multi-vessel network from a virtual patient database, and 25 clinically invasive fractional flow reserve measurements from real patients. The feed-forward neural network model achieved around 99% diagnostic accuracy in both tests involving virtual patients, and a respectable 72% diagnostic accuracy when compared to the invasive fractional flow reserve measurements. The multivariate polynomial regression model performed well in the single vessel case, but struggled on network cases as the variation of input features was much larger. The long short-term memory performed well for the single vessel cases, but tended to have a bias towards a positive fractional flow reserve prediction for the virtual multi-vessel case, and for the patient cases. Overall, the feed-forward neural network shows promise in successfully predicting fractional flow reserve in real patients, and could be a viable option if trained using a large enough data set of real patients.
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Affiliation(s)
- Jason M Carson
- Zienkiewicz Centre for Computational Engineering, College of Engineering, Swansea University, Swansea, UK.,Swansea University Medical School, Swansea University, Swansea, UK.,HDR UK Wales and Northern Ireland, Health Data Research UK, London, UK
| | - Neeraj Kavan Chakshu
- Zienkiewicz Centre for Computational Engineering, College of Engineering, Swansea University, Swansea, UK
| | - Igor Sazonov
- Zienkiewicz Centre for Computational Engineering, College of Engineering, Swansea University, Swansea, UK
| | - Perumal Nithiarasu
- Zienkiewicz Centre for Computational Engineering, College of Engineering, Swansea University, Swansea, UK
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44
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Stegehuis VE, Wijntjens GWM, Nijjer SS, de Waard GA, van de Hoef TP, Sen S, Petraco R, Echavarría-Pinto M, Meuwissen M, Danad I, Knaapen P, Escaned J, Davies JE, van Royen N, Piek JJ. Objective Identification of Intermediate Lesions Inducing Myocardial Ischemia Using Sequential Intracoronary Pressure and Flow Measurements. J Am Heart Assoc 2020; 9:e015559. [PMID: 32573324 PMCID: PMC7670511 DOI: 10.1161/jaha.119.015559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Although ischemic heart disease has a complex and multilevel origin, the diagnostic approach is mainly focused on focal obstructive disease as assessed by pressure‐derived indexes. The prognostic relevance of coronary flow over coronary pressure has been suggested and implies that identification of relevant perfusion abnormalities by invasive physiology techniques is critical for the correct identification of patients who benefit from coronary revascularization. The purpose of this study was to evaluate the diagnostic potential of a sequential approach using pressure‐derived indexes instantaneous wave‐free ratio (iFR), fractional flow reserve (FFR), and coronary flow reserve (CFR) measurements to determine the number of intermediate lesions associated with flow abnormalities after initial pressure measurements. Methods and Results A total of 366 intermediate lesions were assessed with simultaneous intracoronary pressure and flow velocity measurements. Contemporary clinical iFR, FFR, and CFR cut points for myocardial ischemia were applied. A total of 118 (32%) lesions were FFR+ and 136 (37%) lesions were iFR+. Subsequent CFR assessment resulted for FFR in a total of 91 (25%) FFR+/CFR+ and for iFR a total of 111 (30%) iFR+/CFR+ lesions. An iFR, FFR, and invasive flow velocity assessment approach would have yielded 20% of lesions (74 of 366) as ischemic. Conclusions Ultimately, 20% of intermediate lesions are associated with flow abnormalities after applying a pressure and flow velocity sequential approach. If iFR is borderline, FFR has limited additional value, in contrast with CFR. These results emphasize the use of coronary physiology in assessing stenosis severity but may also further question the contemporary reputation of a pressure‐based approach as a gold standard for the detection of myocardial ischemia in ischemic heart disease.
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Affiliation(s)
- Valérie E Stegehuis
- Department of Interventional Cardiology Amsterdam Cardiovascular Sciences Heart Center Amsterdam UMC-location AMC University of Amsterdam The Netherlands
| | - Gilbert W M Wijntjens
- Department of Interventional Cardiology Amsterdam Cardiovascular Sciences Heart Center Amsterdam UMC-location AMC University of Amsterdam The Netherlands
| | | | - Guus A de Waard
- Department of Interventional Cardiology Amsterdam Cardiovascular Sciences Heart Center Amsterdam UMC-location VUmc University of Amsterdam The Netherlands
| | - Tim P van de Hoef
- Department of Interventional Cardiology Amsterdam Cardiovascular Sciences Heart Center Amsterdam UMC-location AMC University of Amsterdam The Netherlands
| | - Sayan Sen
- Imperial College London London United Kingdom
| | | | | | | | - Ibrahim Danad
- Department of Interventional Cardiology Amsterdam Cardiovascular Sciences Heart Center Amsterdam UMC-location VUmc University of Amsterdam The Netherlands
| | - Paul Knaapen
- Department of Interventional Cardiology Amsterdam Cardiovascular Sciences Heart Center Amsterdam UMC-location VUmc University of Amsterdam The Netherlands
| | - Javier Escaned
- Cardiovascular Institute Hospital Universitario Clinico San Carlos Madrid Spain
| | | | - Niels van Royen
- Department of Cardiology Radboud University Medical Center Nijmegen The Netherlands
| | - Jan J Piek
- Department of Interventional Cardiology Amsterdam Cardiovascular Sciences Heart Center Amsterdam UMC-location AMC University of Amsterdam The Netherlands
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45
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Nakayama M, Uchiyama T, Hijikata N, Kobori Y, Tanaka N, Iwasaki K. Effect of QTU prolongation on hyperemic instantaneous wave-free ratio value: a prospective single-center study. Heart Vessels 2020; 35:909-917. [PMID: 31989184 PMCID: PMC7256076 DOI: 10.1007/s00380-020-01562-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/17/2020] [Indexed: 12/16/2022]
Abstract
We hypothesized that in patients with QT prolongation, resistance might not decrease in the wave-free period, because QTU prolongation cannot be detected by instantaneous wave-free ratio (iFR) analysis software. We investigated whether corrected QTU (QTUc) prolongation affects the hyperemic iFR value. Forty-two consecutive patients with intermediate stenosis (≥ 50%) in the left anterior descending coronary artery (LAD) were analyzed. Fractional flow reserve (FFR) and hyperemic iFR were simultaneously and continuously recorded with intravenous adenosine triphosphate (ATP) and papaverine infusions. In 17 patients with stenosis in the proximal LAD, coronary flow was measured. Patients were divided into two groups according to the median absolute deviation of the QTUc by ATP administration/QTUc by papaverine administration. FFR, hyperemic iFR, and flow data were compared between each stimulus and group. Moreover, influences of pressure and electrocardiogram parameters on differences in iFR values under ATP and papaverine administration were compared between the following two groups (group 1: the absolute difference of hyperemic iFR values between ATP and papaverine administration is ≤ 0.05; group 2: that is > 0.05). The paired t test and t test were used in analysis. Hyperemic iFR values of patients under the use of papaverine were lower than those of patients under the use of ATP when QTUc was more prolonged by papaverine administration than by ATP administration (ATP 0.74 ± 0.14, papaverine 0.71 ± 0.15, P = 0.025). No significant differences were observed in the FFR value and flow data between the groups. Regarding QTU, QTUc, and QTUc by ATP/QTUc by papaverine, significant differences were observed between group 1 and group 2. Pressure parameters did not induce significant differences. QTUc prolongation induced by papaverine was associated with lower hyperemic iFR values. An iFR-based assessment might lead to inappropriate treatment of patients with QTUc prolongation.
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Affiliation(s)
- Masafumi Nakayama
- Cardiovascular Center, Todachuo General Hospital, Toda, Japan
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Waseda University, 2-2 Wakamatsucho, Shinjuku, Tokyo, 162-8480, Japan
| | | | | | - Yuichi Kobori
- Cardiovascular Center, Todachuo General Hospital, Toda, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachiouji Medical Center, Hachiouji, Japan
| | - Kiyotaka Iwasaki
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Waseda University, 2-2 Wakamatsucho, Shinjuku, Tokyo, 162-8480, Japan.
- Department of Modern Mechanical Engineering, Waseda University, Shinjuku, Tokyo, Japan.
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46
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Non-hyperaemic coronary pressure measurements to guide coronary interventions. Nat Rev Cardiol 2020; 17:629-640. [DOI: 10.1038/s41569-020-0374-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2020] [Indexed: 01/11/2023]
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47
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Comparison of Instantaneous Wave-Free Ratio (iFR) and Fractional Flow Reserve (FFR) with respect to Their Sensitivities to Cardiovascular Factors: A Computational Model-Based Study. J Interv Cardiol 2020; 2020:4094121. [PMID: 32508540 PMCID: PMC7240797 DOI: 10.1155/2020/4094121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/18/2020] [Accepted: 02/27/2020] [Indexed: 02/06/2023] Open
Abstract
While coronary revascularization strategies guided by instantaneous wave-free ratio (iFR) are, in general, noninferior to those guided by fractional flow reserve (FFR) with respect to the rate of major adverse cardiac events at one-year follow-up in patients with stable angina or an acute coronary syndrome, the overall accuracy of diagnosis with iFR in large patient cohorts is about 80% compared with the diagnosis with FFR. So far, it remains incompletely understood what factors contribute to the discordant diagnosis between iFR and FFR. In this study, a computational method was used to systemically investigate the respective effects of various cardiovascular factors on FFR and iFR. The results showed that deterioration in aortic valve disease (e.g., regurgitation or stenosis) led to a marked decrease in iFR and a mild increase in FFR given fixed severity of coronary artery stenosis and that increasing coronary microvascular resistance caused a considerable increase in both iFR and FFR, but the degree of increase in iFR was lower than that in FFR. These findings suggest that there is a high probability of discordant diagnosis between iFR and FFR in patients with severe aortic valve disease or coronary microcirculation dysfunction.
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48
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Rivero F, Antuña P, García-Guimaraes M, Jiménez C, Cuesta J, Bastante T, Alfonso F. Correlation between fractional flow reserve and instantaneous wave-free ratio with morphometric assessment by optical coherence tomography in diabetic patients. Int J Cardiovasc Imaging 2020; 36:1193-1201. [PMID: 32221772 DOI: 10.1007/s10554-020-01819-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/18/2020] [Indexed: 10/24/2022]
Abstract
Currently there is lack of data regarding the use of optical coherence tomography (OCT) to depict the hemodynamic relevance of coronary stenoses in diabetic patients. We sought to assess the diagnostic accuracy of OCT-derived morphologic assessment in identifying hemodynamically significant coronary lesions as determined by both, the resting instantaneous wave-free ratio (iFR) and the hyperemic fractional flow reserve (FFR) in diabetic patients. Diabetic patients presenting with at least one intermediate coronary lesion were prospectively and consecutively enrolled. All lesions were systematically assessed by iFR, FFR and OCT. A total of 41 intermediate lesions were analysed. Mean iFR and FFR values were 0.90 ± 0.04 and 0.81 ± 0.06, respectively (intra-class correlation coefficient 0.49; 95% CI 0.22-0.79). A moderate correlation between iFR and OCT derived minimal lumen diameter (MLD, r = 0.49) and minimal lumen area (MLA, r = 0.50) was found. Conversely, there was a poor correlation between FFR and OCT-derived MLD (r = 0.34) and MLA (r = 0.32). The diagnostic efficiency of MLA and MLD to identify iFR significant stenoses showed an AUC of 0.82 (95% CI 0.69-0.95) for MLD and 0.83 (95% CI 0.71-0.96) for MLA. A worse diagnostic efficiency was found when FFR was used as the reference with an AUC of 0.71 (95% CI 0.54-0.87) for MLD and 0.70 (95% CI 0.53-0.87). OCT-derived MLA and MLD were the strongest independent anatomic predictors of abnormal iFR and FFR values. In diabetic patients, OCT-derived MLA and MLD showed a moderate diagnostic efficiency in identifying functionally significant coronary stenoses by FFR or iFR. In diabetics, anatomic OCT measurements better predicted resting than FFR-determined physiologically significant lesions.
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Affiliation(s)
- Fernando Rivero
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - Paula Antuña
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - Marcos García-Guimaraes
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - César Jiménez
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - Javier Cuesta
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - Teresa Bastante
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain.
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49
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Driessen RS, de Waard GA, Stuijfzand WJ, Raijmakers PG, Danad I, Bom MJ, Min JK, Leipsic JA, Ahmadi A, van de Ven PM, Knuuti J, van Rossum AC, Davies JE, van Royen N, Narula J, Knaapen P. Adverse Plaque Characteristics Relate More Strongly With Hyperemic Fractional Flow Reserve and Instantaneous Wave-Free Ratio Than With Resting Instantaneous Wave-Free Ratio. JACC Cardiovasc Imaging 2020; 13:746-756. [DOI: 10.1016/j.jcmg.2019.06.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 05/30/2019] [Accepted: 06/06/2019] [Indexed: 01/10/2023]
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50
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Murtaza G, Mukherjee D, Gharacholou SM, Nanjundappa A, Lavie CJ, Khan AA, Shanmugasundaram M, Paul TK. An Updated Review on Myocardial Bridging. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1169-1179. [PMID: 32173330 DOI: 10.1016/j.carrev.2020.02.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/03/2020] [Accepted: 02/17/2020] [Indexed: 02/08/2023]
Abstract
Myocardial bridging is a congenital coronary anomaly with normal epicardial coronary artery taking an intra-myocardial course also described as tunneled artery. The majority of patients with this coronary anomaly are asymptomatic and generally it is a benign condition. However, it is an important cause of myocardial ischemia, which may lead to anginal symptoms, acute coronary syndrome, cardiac arrhythmias and rarely sudden cardiac death. There are numerous studies published in the recent past on understanding the pathophysiology, diagnostic and management strategies of myocardial bridging. This review highlights some of the recent updates in the diagnosis and management of patients with myocardial bridging. We discuss the role of various non-invasive and invasive diagnostic methods to evaluate functional significance of bridging. In addition, role of medical therapy such as beta-blockers, percutaneous coronary intervention with stents/bioresorbable scaffolds and surgical unroofing in patients unresponsive to medical therapy is highlighted as well.
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Affiliation(s)
- Ghulam Murtaza
- Department of Internal Medicine, Division of Cardiology, East Tennessee State University, Johnson City, TN, USA
| | - Debabrata Mukherjee
- Division of Cardiology, Department of Internal Medicine, Texas Tech University, TX, USA
| | | | | | - Carl J Lavie
- Department of Cardiology, Ochsner Clinic, New Orleans, LA, USA
| | - Abdul Ahad Khan
- Department of Internal Medicine, Division of Cardiology, East Tennessee State University, Johnson City, TN, USA
| | | | - Timir K Paul
- Department of Internal Medicine, Division of Cardiology, East Tennessee State University, Johnson City, TN, USA.
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