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Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, Banning AP, Budaj A, Buechel RR, Chiariello GA, Chieffo A, Christodorescu RM, Deaton C, Doenst T, Jones HW, Kunadian V, Mehilli J, Milojevic M, Piek JJ, Pugliese F, Rubboli A, Semb AG, Senior R, Ten Berg JM, Van Belle E, Van Craenenbroeck EM, Vidal-Perez R, Winther S. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 2024; 45:3415-3537. [PMID: 39210710 DOI: 10.1093/eurheartj/ehae177] [Citation(s) in RCA: 502] [Impact Index Per Article: 502.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Boerhout CKM, Echavarría-Pinto M, de Waard GA, Lee JM, Mejía-Rentería H, Hun Lee S, Jung JH, Hoshino M, Matsuo H, Madera-Cambero M, Eftekhari A, Effat MA, Murai T, Marques K, Doh JH, Christiansen EH, Banerjee R, Nam CW, Niccoli G, Nakayama M, Tanaka N, Shin ES, Beijk MAM, van Royen N, Knaapen P, Escaned J, Kakuta T, Koo BK, Piek JJ, van de Hoef TP, Meuwissen M. Impact of hyperaemic stenosis resistance on long-term outcomes of stable angina in the ILIAS Registry. EUROINTERVENTION 2024; 20:e699-e706. [PMID: 38840578 PMCID: PMC11145309 DOI: 10.4244/eij-d-23-00713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 02/02/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The hyperaemic stenosis resistance (HSR) index was introduced to provide a more comprehensive indicator of the haemodynamic severity of a coronary lesion. HSR combines both the pressure drop across a lesion and the flow through it. As such, HSR overcomes the limitations of the more traditional fractional flow reserve (FFR) or coronary flow reserve (CFR) indices. AIMS We aimed to identify the diagnostic and prognostic value of HSR and evaluate the clinical implications. METHODS Patients with chronic coronary syndromes (CCS) and obstructive coronary artery disease were selected from the multicentre ILIAS Registry. For this study, only patients with combined Doppler flow and pressure measurements were included. RESULTS A total of 853 patients with 1,107 vessels were included. HSR more accurately identified the presence of inducible ischaemia compared to FFR and CFR (area under the curve 0.71 vs 0.66 and 0.62, respectively; p<0.005 for both). An abnormal HSR measurement was an independent and important predictor of target vessel failure at 5-year follow-up (hazard ratio 3.80, 95% confidence interval: 2.12-6.73; p<0.005). In vessels deferred from revascularisation, HSR seems to identify more accurately those vessels that may benefit from revascularisation rather than FFR and/or CFR. CONCLUSIONS The present study affirms the theoretical advantages of the HSR index for the detection of ischaemia-Âinducing coronary lesions in a large CCS population. (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry [ILIAS Registry], ClinicalTrials.gov: NCT04485234).
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Affiliation(s)
| | - Mauro Echavarría-Pinto
- Hospital General ISSSTE Querétaro, Querétaro, Mexico and Facultad de Medicina, Universidad Autónoma de Querétaro, Querétaro, Mexico
| | - Guus A de Waard
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hernán Mejía-Rentería
- Hospital Clínico San Carlos IdISSC, Complutense University of Madrid and CIBERCV, Madrid, Spain
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Ji-Hyun Jung
- Sejong General Hospital, Sejong Heart Institute, Bucheon, Republic of Korea
| | - Masahiro Hoshino
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | | | - Ashkan Eftekhari
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mohamed A Effat
- Division of Cardiovascular Health and Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Tadashi Murai
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Koen Marques
- Heart Center, Amsterdam UMC, Amsterdam, the Netherland
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | | | - Rupak Banerjee
- Mechanical and Materials Engineering Department, University of Cincinnati, Cincinnati, OH, USA and Research Services, Veteran Affairs Medical Center, Cincinnati, OH, USA
| | - Chang-Wook Nam
- Department of Internal Medicine and Cardiovascular Center, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Giampaolo Niccoli
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Masafumi Nakayama
- Cardiovascular Center, Toda Central General Hospital, Toda, Japan
- Department of Cardiology, Tokyo D Tower Hospital, Koto City, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | | | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul Knaapen
- Heart Center, Amsterdam UMC, Amsterdam, the Netherland
| | - Javier Escaned
- Hospital Clínico San Carlos IdISSC, Complutense University of Madrid and CIBERCV, Madrid, Spain
| | - Tsunekzu Kakuta
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Bon-Kwon Koo
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jan J Piek
- Heart Center, Amsterdam UMC, Amsterdam, the Netherland
| | - Tim P van de Hoef
- Heart Center, Amsterdam UMC, Amsterdam, the Netherland
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
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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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Stegehuis V, Boerhout C, Kikuta Y, Cambero-Madera M, van Royen N, Matsuo H, Nakayama M, de Waard G, Knaapen P, Nijjer S, Petraco R, Siebes M, Davies J, Escaned J, van de Hoef T, Piek J. Impact of stenosis resistance and coronary flow capacity on fractional flow reserve and instantaneous wave-free ratio discordance: a combined analysis of DEFINE-FLOW and IDEAL. Neth Heart J 2023; 31:434-443. [PMID: 37594612 PMCID: PMC10602988 DOI: 10.1007/s12471-023-01796-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The pressure-derived parameters fractional flow reserve (FFR) and the emerging instantaneous wave-free ratio (iFR) are the most widely applied invasive coronary physiology indices to guide revascularisation. However, approximately 15-20% of intermediate stenoses show discordant FFR and iFR, and therapeutical consensus is lacking. AIMS We sought to associate hyperaemic stenosis resistance index, coronary flow reserve (CFR) and coronary flow capacity (CFC) to FFR/iFR discordance. METHODS We assessed pressure and flow measurements of 647 intermediate lesions (593 patients) of two multi-centre international studies. RESULTS FFR and iFR were discordant in 15% of all lesions (97 out of 647). FFR+/iFR- lesions had similar hyperaemic average peak velocity (hAPV), CFR and CFC as FFR-/iFR- lesions, whereas FFR-/iFR+ lesions had similar hAPV, CFR and CFC as FFR+/iFR+ lesions (p > 0.05 for all). FFR+/iFR- lesions were associated with lower baseline stenosis resistance, but not hyperaemic stenosis resistance, compared with FFR-/iFR+ lesions (p < 0.001). CONCLUSIONS Discordance with FFR+/iFR- is characterised by maximal flow values, CFR, and CFC patterns similar to FFR-/iFR- concordance that justifies conservative therapy. Discordance with FFR-/iFR+ on the other hand, is characterised by low flow values, CFR, and CFC patterns similar to iFR+/FFR+ concordance that may benefit from percutaneous coronary intervention.
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Affiliation(s)
- Valérie Stegehuis
- Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC-location AMC, Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands
| | - Coen Boerhout
- Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC-location AMC, Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Niels van Royen
- Department of Cardiology, Radboud University Nijmegen, Nijmegen, The Netherlands
| | | | | | - Guus de Waard
- Amsterdam UMC-location VUMC, Department of Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, VU University, Amsterdam, The Netherlands
| | - Paul Knaapen
- Amsterdam UMC-location VUMC, Department of Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, VU University, Amsterdam, The Netherlands
| | | | | | - Maria Siebes
- Department of Biomedical Engineering and Physics, Amsterdam UMC-location AMC, Amsterdam, The Netherlands
| | | | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Tim van de Hoef
- Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC-location AMC, Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan Piek
- Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC-location AMC, Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands.
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Koo BK, Lee JM, Hwang D, Park S, Shiono Y, Yonetsu T, Lee SH, Kawase Y, Ahn JM, Matsuo H, Shin ES, Hu X, Ding D, Fezzi S, Tu S, Low AF, Kubo T, Nam CW, Yong AS, Harding SA, Xu B, Hur SH, Choo GH, Tan HC, Mullasari A, Hsieh IC, Kakuta T, Akasaka T, Wang J, Tahk SJ, Fearon WF, Escaned J, Park SJ. Practical Application of Coronary Physiologic Assessment: Asia-Pacific Expert Consensus Document: Part 1. JACC. ASIA 2023; 3:689-706. [PMID: 38095005 PMCID: PMC10715899 DOI: 10.1016/j.jacasi.2023.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/13/2023] [Accepted: 07/08/2023] [Indexed: 12/30/2023]
Abstract
Coronary physiologic assessment is performed to measure coronary pressure, flow, and resistance or their surrogates to enable the selection of appropriate management strategy and its optimization for patients with coronary artery disease. The value of physiologic assessment is supported by a large body of evidence that has led to major recommendations in clinical practice guidelines. This expert consensus document aims to convey practical and balanced recommendations and future perspectives for coronary physiologic assessment for physicians and patients in the Asia-Pacific region based on updated information in the field that including both wire- and image-based physiologic assessment. This is Part 1 of the whole consensus document, which describes the general concept of coronary physiology, as well as practical information on the clinical application of physiologic indices and novel image-based physiologic assessment.
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Affiliation(s)
- Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sungjoon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Seung Hun Lee
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yoshiaki Kawase
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Daixin Ding
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
| | - Simone Fezzi
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Adrian F. Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Takashi Kubo
- Department of Cardiology, Tokyo Medical University, Hachioji Medical Center, Tokyo, Japan
| | - Chang-Wook Nam
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Andy S.C. Yong
- Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia
| | - Scott A. Harding
- Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Bo Xu
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Seung-Ho Hur
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Gim Hooi Choo
- Department of Cardiology, Cardiac Vascular Sentral KL (CVSKL), Kuala Lumpur, Malaysia
| | - Huay Cheem Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Ajit Mullasari
- Department of Cardiology, Madras Medical Mission, Chennai, India
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Seung-Jea Tahk
- Department of Cardiology, Ajou University Medical Center, Suwon, Korea
| | - William F. Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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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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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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Towards a Deep-Learning Approach for Prediction of Fractional Flow Reserve from Optical Coherence Tomography. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12146964] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Cardiovascular disease (CVD) is the number one cause of death worldwide, and coronary artery disease (CAD) is the most prevalent CVD, accounting for 42% of these deaths. In view of the limitations of the anatomical evaluation of CAD, Fractional Flow Reserve (FFR) has been introduced as a functional diagnostic index. Herein, we evaluate the feasibility of using deep neural networks (DNN) in an ensemble approach to predict the invasively measured FFR from raw anatomical information that is extracted from optical coherence tomography (OCT). We evaluate the performance of various DNN architectures under different formulations: regression, classification—standard, and few-shot learning (FSL) on a dataset containing 102 intermediate lesions from 80 patients. The FSL approach that is based on a convolutional neural network leads to slightly better results compared to the standard classification: the per-lesion accuracy, sensitivity, and specificity were 77.5%, 72.9%, and 81.5%, respectively. However, since the 95% confidence intervals overlap, the differences are statistically not significant. The main findings of this study can be summarized as follows: (1) Deep-learning (DL)-based FFR prediction from reduced-order raw anatomical data is feasible in intermediate coronary artery lesions; (2) DL-based FFR prediction provides superior diagnostic performance compared to baseline approaches that are based on minimal lumen diameter and percentage diameter stenosis; and (3) the FFR prediction performance increases quasi-linearly with the dataset size, indicating that a larger train dataset will likely lead to superior diagnostic performance.
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Westra J, Eftekhari A, Renkens M, Mejía-Rentería H, Sejr-Hansen M, Stegehuis V, Holm NR, de Winter RJ, Piek JJ, Escaned J, Wykrzykowska JJ, Christiansen EH. Characterization of quantitative flow ratio and fractional flow reserve discordance using doppler flow and clinical follow-up. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1181-1190. [PMID: 35041147 DOI: 10.1007/s10554-022-02522-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/04/2022] [Indexed: 11/27/2022]
Abstract
The physiological mechanisms of quantitative flow ratio and fractional flow reserve disagreement are not fully understood. We aimed to characterize the coronary flow and resistance profile of intermediate stenosed epicardial coronary arteries with concordant and discordant FFR and QFR. Post-hoc analysis of the DEFINE-FLOW study. Anatomical and Doppler-derived physiological parameters were compared for lesions with FFR+QFR- (n = 18) vs. FFR+QFR+ (n = 43) and for FFR-QFR+ (n = 34) vs. FFR-QFR- (n = 139). The association of QFR results with the two-year rate of target vessel failure was assessed in the proportion of vessels (n = 195) that did not undergo revascularization. Coronary flow reserve was higher [2.3 (IQR: 2.1-2.7) vs. 1.9 (IQR: 1.5-2.4)], hyperemic microvascular resistance lower [1.72 (IQR: 1.48-2.31) vs. 2.26 (IQR: 1.79-2.87)] and anatomical lesion severity less severe [% diameter stenosis 45.5 (IQR: 41.5-52.5) vs. 58.5 (IQR: 53.1-64.0)] for FFR+QFR- lesions compared with FFR+QFR+ lesions. In comparison of FFR-QFR+ vs. FFR-QFR- lesions, lesion severity was more severe [% diameter stenosis 55.2 (IQR: 51.7-61.3) vs. 43.4 (IQR: 35.0-50.6)] while coronary flow reserve [2.2 (IQR: 1.9-2.9) vs. 2.2 (IQR: 1.9-2.6)] and hyperemic microvascular resistance [2.34 (IQR: 1.85-2.81) vs. 2.57 (IQR: 2.01-3.22)] did not differ. The agreement and diagnostic performance of FFR using hyperemic stenosis resistance (> 0.80) as reference standard was higher compared with QFR and coronary flow reserve. Disagreement between FFR and QFR is partly explained by physiological and anatomical factors. Clinical Trials Registration https://www.clinicaltrials.gov ; Unique identifier: NCT01813435.
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Affiliation(s)
- Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Mick Renkens
- Department of Cardiology, Amsterdam UMC (Location AMC), Amsterdam, The Netherlands
| | | | - Martin Sejr-Hansen
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Valérie Stegehuis
- Department of Cardiology, Amsterdam UMC (Location AMC), Amsterdam, The Netherlands
| | - Niels Ramsing Holm
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Robert-Jan de Winter
- Department of Cardiology, Amsterdam UMC (Location AMC), Amsterdam, The Netherlands
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC (Location AMC), Amsterdam, The Netherlands
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos, Madrid, Spain
| | - J J Wykrzykowska
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
- Department of Cardiology, Groningen UMC, Groningen, The Netherlands
| | - Evald Høj Christiansen
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark.
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Reynolds HR, Merz CNB, Berry C, Samuel R, Saw J, Smilowitz NR, de Souza ACDA, Sykes R, Taqueti VR, Wei J. Coronary Arterial Function and Disease in Women With No Obstructive Coronary Arteries. Circ Res 2022; 130:529-551. [PMID: 35175840 PMCID: PMC8911308 DOI: 10.1161/circresaha.121.319892] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Ischemic heart disease (IHD) is the leading cause of mortality in women. While traditional cardiovascular risk factors play an important role in the development of IHD in women, women may experience sex-specific IHD risk factors and pathophysiology, and thus female-specific risk stratification is needed for IHD prevention, diagnosis, and treatment. Emerging data from the past 2 decades have significantly improved the understanding of IHD in women, including mechanisms of ischemia with no obstructive coronary arteries and myocardial infarction with no obstructive coronary arteries. Despite this progress, sex differences in IHD outcomes persist, particularly in young women. This review highlights the contemporary understanding of coronary arterial function and disease in women with no obstructive coronary arteries, including coronary anatomy and physiology, mechanisms of ischemia with no obstructive coronary arteries and myocardial infarction with no obstructive coronary arteries, noninvasive and invasive diagnostic strategies, and management of IHD.
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Affiliation(s)
- Harmony R Reynolds
- Sarah Ross Soter Center for Women’s Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, G12 8TA, UK, West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK, Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Rohit Samuel
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacqueline Saw
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nathaniel R Smilowitz
- Sarah Ross Soter Center for Women’s Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Ana Carolina do A.H. de Souza
- Cardiovascular Imaging Program, Departments of Radiology and Medicine (Cardiology), Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Sykes
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, G12 8TA, UK, West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Viviany R. Taqueti
- Cardiovascular Imaging Program, Departments of Radiology and Medicine (Cardiology), Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Janet Wei
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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11
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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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12
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Banerjee RK, Ramadurai S, Manegaonkar SM, Rao MB, Rakkimuthu S, Effat MA. Comparison Between 5- and 1-Year Outcomes Using Cutoff Values of Pressure Drop Coefficient and Fractional Flow Reserve for Diagnosing Coronary Artery Diseases. Front Physiol 2021; 12:689517. [PMID: 34335296 PMCID: PMC8317064 DOI: 10.3389/fphys.2021.689517] [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: 04/01/2021] [Accepted: 05/28/2021] [Indexed: 12/02/2022] Open
Abstract
Background The current pressure-based coronary diagnostic index, fractional flow reserve (FFR), has a limited efficacy in the presence of microvascular disease (MVD). To overcome the limitations of FFR, the objective is to assess the recently introduced pressure drop coefficient (CDP), a fundamental fluid dynamics-based combined pressure–flow index. Methods We hypothesize that CDP will result in improved clinical outcomes in comparison to FFR. To test the hypothesis, chi-square test was performed to compare the percent major adverse cardiac events (%MACE) at 5 years between (a) FFR < 0.75 and CDP > 27.9 and (b) FFR < 0.80 and CDP > 25.4 groups using a prospective cohort study. Furthermore, Kaplan–Meier survival curves were compared between the FFR and CDP groups. The results were considered statistically significant for p < 0.05. The outcomes of the CDP arm were presumptive as clinical decision was solely based on the FFR. Results For the complete patient group, the %MACE in the CDP > 27.9 group (10 out of 35, 29%) was lower in comparison to the FFR < 0.75 group (11 out of 20, 55%), and the difference was near significant (p = 0.05). The survival analysis showed a significantly higher survival rate (p = 0.01) in the CDP > 27.9 group (n = 35) when compared to the FFR < 0.75 group (n = 20). The results remained similar for the FFR = 0.80 cutoff. The comparison of the 5-year MACE outcomes with the 1-year outcomes for the complete patient group showed similar trends, with a higher statistical significance for a longer follow-up period of 5 years. Conclusion Based on the MACE and survival analysis outcomes, CDP could possibly be an alternate diagnostic index for decision-making in the cardiac catheterization laboratory. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT01719016.
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Affiliation(s)
- Rupak K Banerjee
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States.,Research Services, Veteran Affairs Medical Services, Cincinnati, OH, United States
| | - Sruthi Ramadurai
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States
| | - Shreyash M Manegaonkar
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States
| | - Marepalli B Rao
- Department of Environmental and Public Health Sciences, University of Cincinnati, Cincinnati, OH, United States
| | - Sathyaprabha Rakkimuthu
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States
| | - Mohamed A Effat
- Department of Cardiology, University of Cincinnati Medical Center, Cincinnati, OH, United States
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13
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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14
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van de Hoef TP, Echavarria-Pinto M, Meuwissen M, Stegehuis VE, Escaned J, Piek JJ. Contribution of Age-Related Microvascular Dysfunction to Abnormal Coronary: Hemodynamics in Patients With Ischemic Heart Disease. JACC Cardiovasc Interv 2020; 13:20-29. [PMID: 31918939 DOI: 10.1016/j.jcin.2019.08.052] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study sought to investigate the contribution of age-related microcirculatory dysfunction to abnormal coronary hemodynamics in patients with coronary atherosclerosis. BACKGROUND Impairment in myocardial blood supply in patients with coronary atherosclerosis can be accentuated due to age-related changes in microcirculatory function. METHODS Intracoronary pressure and flow were measured with the Doppler technique in 299 vessels (228 patients), and the thermodilution technique in 120 vessels (99 patients). In 172 patients, Doppler measurements were also performed in unobstructed vessels. Associations of coronary hemodynamics with aging were studied in both the stenosed and unobstructed arteries. RESULTS Aging was associated with a progressive increase in minimal microvascular resistance and a progressive decrease in hyperemic flow in both obstructed and nonobstructed coronary arteries. As such, coronary flow reserve decreased with advancing age. Epicardial stenosis severity assessed by resting Pd/Pa, basal stenosis resistance index, and hyperemic stenosis resistance index was equivalent across age groups. By contrast, fractional flow reserve increased with advancing age. Consequently, the adjusted risk of a fractional flow reserve/coronary flow reserve pattern reflective of concomitant focal epicardial and diffuse or microvascular disease (relative risk: 1.6; 95% confidence interval: 1.1 to 2.3; p = 0.017) increased with advancing age, whilst the adjusted risk of a fractional flow reserve/coronary flow reserve pattern reflective of non-flow-limiting stenosis with a healthy microcirculation decreased (relative risk: 0.7; 95% CI: 0.5 to 1.0; p = 0.022). CONCLUSIONS Aging is associated with progressive pan-myocardial impairment of coronary vasodilatory capacity due to an increase in minimal microvascular resistance. Concomitant aging-related impairment in microvascular function impacts the pathophysiology of ischemic heart disease in the individual patient and is not adequately identified by hyperemic coronary pressure measurements alone.
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Affiliation(s)
- Tim P van de Hoef
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Cardiovascular Institute, Hospital Clínico San Carlos, and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.
| | - Mauro Echavarria-Pinto
- Cardiovascular Institute, Hospital Clínico San Carlos, and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Hospital General ISSSTE - Facultad de Medicina, Universidad Autónoma de Querétaro, Querétaro, México
| | | | - Valerie E Stegehuis
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Faculty of Medicine, Complutense University, Madrid, Spain
| | - Jan J Piek
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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15
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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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16
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van de Hoef TP, de Waard GA, Meuwissen M, Voskuil M, Chamuleau SAJ, van Royen N, Piek JJ. Invasive coronary physiology: a Dutch tradition. Neth Heart J 2020; 28:99-107. [PMID: 32780339 PMCID: PMC7419414 DOI: 10.1007/s12471-020-01461-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Invasive coronary physiology has been applied since the early days of percutaneous transluminal coronary angioplasty, and has become a rapidly emerging field of research. Many physiology indices have been developed, tested in clinical studies, and are now applied in daily clinical practice. Recent clinical practice guidelines further support the use of advanced invasive physiology methods to optimise the diagnosis and treatment of patients with acute and chronic coronary syndromes. This article provides a succinct review of the history of invasive coronary physiology, the basic concepts of currently available physiological parameters, and will particularly highlight the Dutch contribution to this field of invasive coronary physiology.
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Affiliation(s)
- T P van de Hoef
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - G A de Waard
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Meuwissen
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - M Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - S A J Chamuleau
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - N van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J J Piek
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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17
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Yokota S, Borren NM, Ottervanger JP, Mouden M, Timmer JR, Knollema S, Jager PL. Does fractional flow reserve overestimate severity of LAD lesions? J Nucl Cardiol 2020; 27:1306-1313. [PMID: 31044405 DOI: 10.1007/s12350-019-01712-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 03/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Fractional Flow Reserve (FFR) is increasingly used to estimate the severity of coronary stenoses, prior to coronary revascularization. However, it has been suggested that FFR overestimates the severity of Left Anterior Descending (LAD) lesions. Our aim was to verify whether in patients without ischemia on Myocardial Perfusion Imaging, FFR of the LAD is more often abnormal in comparison to FFR of other coronary arteries. METHODS Prospective cohort study of consecutive patients who underwent FFR measurement because of persistent or worsening of angina complaints, within 6 months after normal Myocardial Perfusion Imaging. FFR measurements of a graft or diagonal branch were excluded. A FFR ≤ 0.80 denoted a functionally relevant stenosis. RESULTS In 133 patients, 167 FFR measurements were performed, of which 85 in the LAD. Mean age of the patients was 64.8 ± 10.5 years, 40% were women. There were no differences in baseline characteristics between patients undergoing LAD and non-LAD measurements. An abnormal FFR was observed in 35.3% of the LAD measurements, compared to 9.8% in the non-LAD measurements (P = 0.001). Also after adjusting for age and gender, the FFR remained more frequently abnormal in the LAD with OR 5.2 (95% CI 2.2 to 12.3). Of the abnormal FFR LAD measurements, 70% were visually considered non-obstructive on invasive angiography. CONCLUSIONS In selected patients without ischemia on MPI, FFR measurement of the LAD is significantly more often abnormal. The majority of these patients has no obstructive lesions on invasive angiography. Possibly, FFR overestimates severity of LAD lesions, with risk of unnecessary revascularization.
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Affiliation(s)
- Shu Yokota
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Nanette M Borren
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
- Department of Nuclear Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Jan Paul Ottervanger
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
| | - Mohamed Mouden
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Jorik R Timmer
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Siert Knollema
- Department of Nuclear Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Pieter L Jager
- Department of Nuclear Medicine, Isala Hospital, Zwolle, The Netherlands
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18
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Stegehuis VE, Wijntjens GW, van de Hoef TP, Casadonte L, Kirkeeide RL, Siebes M, Spaan JA, Gould KL, Johnson NP, Piek JJ. Distal Evaluation of Functional performance with Intravascular sensors to assess the Narrowing Effect-combined pressure and Doppler FLOW velocity measurements (DEFINE-FLOW) trial: Rationale and trial design. Am Heart J 2020; 222:139-146. [PMID: 32062172 DOI: 10.1016/j.ahj.2019.08.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 08/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND It remains uncertain if invasive coronary physiology beyond fractional flow reserve (FFR) can refine lesion selection for revascularization or provide additional prognostic value. Coronary flow reserve (CFR) equals the ratio of hyperemic to baseline flow velocity and has a wealth of invasive and noninvasive data supporting its validity. Because of fundamental physiologic relationships, binary classification of FFR and CFR disagrees in approximately 30%-40% of cases. Optimal management of these discordant cases requires further study. AIM The aim of the study was to determine the prognostic value of combined FFR and CFR measurements to predict the 24-month rate of major adverse cardiac events. Secondary end points include repeatability of FFR and CFR, angina burden, and the percentage of successful FFR/CFR measurements which will not be excluded by the core laboratory. METHODS This prospective, nonblinded, nonrandomized, and multicenter study enrolled 455 subjects from 12 sites in Europe and Japan. Patients underwent physiologic lesion assessment using the 0.014" Philips Volcano ComboWire XT that provides simultaneous pressure and Doppler velocity sensors. Intermediate coronary lesions received only medical treatment unless both FFR (≤0.8) and CFR (<2.0) were below thresholds. The primary outcome is a 24-month composite of death from any cause, myocardial infarction, and revascularization. CONCLUSION The DEFINE-FLOW study will determine the prognostic value of invasive CFR assessment when measured simultaneously with FFR, with a special emphasis on discordant classifications. Our hypothesis is that lesions with an intact CFR ≥ 2.0 but reduced FFR ≤ 0.8 will have a 2-year outcome with medical treatment similar to lesions with FFR> 0.80 and CFR ≥ 2.0. Enrollment has been completed, and final follow-up will occur in November 2019.
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19
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Prognostic implications of resting distal coronary-to-aortic pressure ratio compared with fractional flow reserve: a 10-year follow-up study after deferral of revascularisation. Neth Heart J 2020; 28:96-103. [PMID: 31965471 PMCID: PMC6977812 DOI: 10.1007/s12471-020-01365-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Introduction The distal coronary-to-aortic pressure ratio (Pd/Pa) is a non-hyperaemic physiological index to assess the functional severity of coronary stenoses. Studies comparing Pd/Pa with fractional flow reserve (FFR) show superior diagnostic efficiency for myocardial ischaemia. Nevertheless, a direct comparison regarding long-term clinical outcomes is still not available. The present observational study compared the prognostic value of Pd/Pa and FFR for major adverse cardiac events (MACE) during a 10-year follow-up period after deferral of revascularisation. Methods Between April 1997 and September 2006, we evaluated 154 coronary stenoses (154 patients) in which revascularisation was deferred with intracoronary pressure and flow measurements during the resting and hyperaemic state. Long-term follow-up (median: 11.8 years) was performed to document the occurrence of MACE, defined as a composite of cardiac death, myocardial infarction and target vessel revascularisation. Results The study population comprised angiographically intermediate coronary stenoses, with a mean diameter stenosis of 53 ± 8%, and intermediate physiological severity with a median FFR of 0.82 (Q1, Q3: 0.76, 0.88). The association of Pd/Pa with long-term MACE was similar to that of FFR [FFR-standardised hazard ratio (sHR): 0.77, 95% confidence interval (CI): 0.61–0.98; Pd/Pa-sHR: 0.80, 95% CI: 0.67–0.96]. In the presence of disagreement between Pd/Pa and FFR, normal Pd/Pa was generally associated with high coronary flow reserve (CFR) and a favourable clinical outcome, whereas abnormal Pd/Pa was generally associated with CFR around the ischaemic cut-point and an impaired clinical outcome, regardless of the accompanying FFR value. Conclusion The present study suggests that Pd/Pa provides at least equivalent prognostic value compared with FFR. When Pd/Pa disagreed with FFR, the baseline index conferred superior prognostic value in this study population. Electronic supplementary material The online version of this article (10.1007/s12471-020-01365-6) contains supplementary material, which is available to authorized users.
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Modi BN, Rahman H, Kaier T, Ryan M, Williams R, Briceno N, Ellis H, Pavlidis A, Redwood S, Clapp B, Perera D. Revisiting the Optimal Fractional Flow Reserve and Instantaneous Wave-Free Ratio Thresholds for Predicting the Physiological Significance of Coronary Artery Disease. Circ Cardiovasc Interv 2019; 11:e007041. [PMID: 30562079 DOI: 10.1161/circinterventions.118.007041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND There has been a gradual upward creep of revascularization thresholds for both fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), before the clinical outcome trials for both indices. The increase in revascularization that has potentially resulted is at odds with increasing evidence questioning the benefits of revascularizing stable coronary disease. Using an independent invasive reference standard, this study primarily aimed to define optimal thresholds for FFR and iFR and also aimed to compare the performance of iFR, FFR, and resting distal coronary pressure (Pd)/central aortic pressure (Pa). METHODS AND RESULTS Pd and Pa were measured in 75 patients undergoing coronary angiography±percutaneous coronary intervention with resting Pd/Pa, iFR, and FFR calculated. Doppler average peak flow velocity was simultaneously measured and hyperemic stenosis resistance calculated as hyperemic stenosis resistance=Pa-Pd/average peak flow velocity (using hyperemic stenosis resistance >0.80 mm Hg/cm per second as invasive reference standard). An FFR threshold of 0.75 had an optimum diagnostic accuracy (84%), whereas for iFR this was 0.86 (76%). At these thresholds, the discordance in classification between indices was 11%. The accuracy of contemporary thresholds (FFR, 0.80; iFR, 0.89) was significantly lower (78.7% and 65.3%, respectively) with a 25% rate of discordance. The optimal threshold for Pd/Pa was 0.88 (77.3% accuracy). When comparing indices at optimal thresholds, FFR showed the best diagnostic performance (area under the curve, 0.91 FFR versus 0.79 iFR and 0.77 Pd/Pa, P=0.002). CONCLUSIONS Contemporary thresholds provide suboptimal diagnostic accuracy compared with an FFR threshold of 0.75 and iFR threshold of 0.86 (cutoffs in derivation studies). Whether more rigorous thresholds would result in selecting populations gaining greater symptom and prognostic benefit needs assessing in future trials of physiology-guided revascularization.
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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, United Kingdom
| | - Haseeb Rahman
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Thomas Kaier
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Matthew Ryan
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Rupert Williams
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Natalia Briceno
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Howard Ellis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Antonis Pavlidis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Simon Redwood
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Brian Clapp
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - 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, United Kingdom
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Ikeoka K, Watanabe T, Shinoda Y, Minamisaka T, Fukuoka H, Inui H, Ueno K, Inoue S, Mine K, Hoshida S. Pressure- and Velocity-Based Physiological Assessment of Stenotic Lesions at Hyperemia in Superficial Femoral Artery Disease: Importance of Hyperemic Stenosis Resistance. Ann Vasc Dis 2019; 12:362-366. [PMID: 31636747 PMCID: PMC6766760 DOI: 10.3400/avd.oa.19-00034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: In superficial femoral artery (SFA) stenosis, stenosis resistance may increase, but the relationship between stenosis resistance and stenotic severity remains to be seen. This study aimed to investigate the physiological response, through a hyperemic condition, and the pathophysiological significance of Doppler flow and stenosis resistance in SFA. Methods: Twenty-four limbs with focal stenosis of the SFA were analyzed. We assessed the fractional flow reserve (FFR), hyperemic stenosis resistance (h-SR), and vascular flow reserve (VFR) of the SFA with a pressure/Doppler flow sensor-tipped combination guidewire before and after endovascular therapy (EVT). Results: FFR, h-SR, and VFR changed significantly after EVT. h-SR was more strongly correlated with % area stenosis, measured by intravascular ultrasound than FFR (FFR: r=-0.716, h-SR: r=0.741, p<0.0001, respectively). However, VFR was not associated with % area stenosis. A receiver operating characteristic curve showed cut-offs h-SR >0.36 mmHg·sec/cm, and FFR <0.88 predicted >75% area stenosis with area under curves of 0.883 and 0.828, respectively. Conclusion: h-SR can indicate stenotic severity in an SFA focal lesion more prominently than FFR and may be a new physiological index to determine indication for EVT. VFR was not feasible for assessment in SFA focal stenosis.
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Affiliation(s)
- Kuniyasu Ikeoka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Osaka, Japan
| | - Tetsuya Watanabe
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Osaka, Japan
| | - Yukinori Shinoda
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Osaka, Japan
| | - Tomoko Minamisaka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Osaka, Japan
| | - Hidetada Fukuoka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Osaka, Japan
| | - Hirooki Inui
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Osaka, Japan
| | - Keisuke Ueno
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Osaka, Japan
| | - Soki Inoue
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Osaka, Japan
| | - Kentaro Mine
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Osaka, Japan
| | - Shiro Hoshida
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Osaka, Japan
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Gewirtz H. Coronary circulation: Pressure/flow parameters for assessment of ischemic heart disease. J Nucl Cardiol 2019; 26:459-470. [PMID: 29637523 DOI: 10.1007/s12350-018-1270-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 03/23/2018] [Indexed: 01/10/2023]
Abstract
Both invasive and non-invasive parameters have been reported for assessment of the physiological status of the coronary circulation. Fractional flow reserve and coronary (or myocardial) flow reserve may be obtained by invasive or non-invasive means. These metrics of coronary stenosis severity have achieved wide clinical acceptance for guiding revascularization decisions and risk stratification. Other indices are obtained invasively (e.g., instantaneous wave-free ratio, iFR; hyperemic stenosis resistance) or non-invasively (e.g., PET absolute myocardial blood flow (mL/min/g)) and have been used for the same purposes. Both iFR, and whole-cycle distal coronary to aortic mean pressure (Pd/Pa) are measured under basal condition and used for assessment of hemodynamic stenosis severity as is index of basal stenosis resistance (BSR). These metrics typically are dichotomized at an empirically derived cut point into "normal" and "abnormal" categories for purposes of clinical decision making and data analysis. Once dichotomized the indices do not always point in the same direction and so confusion may arise. This review, therefore, will present basic principles relevant to understanding commonly employed metrics of the physiological status of the coronary circulation, potential strengths and weaknesses, and hopefully an improved appreciation of the clinical information provided by each.
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Affiliation(s)
- Henry Gewirtz
- Department of Medicine (Cardiology Division), Harvard Medical School, Massachusetts General Hospital, Boston, MA, 02114, USA.
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23
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Wijntjens GW, van Lavieren MA, van de Hoef TP, Echavarría-Pinto M, Meuwissen M, Stegehuis VE, Murai T, Escaned J, Piek JJ. Pressure-derived estimations of coronary flow reserve are inferior to flow-derived coronary flow reserve as diagnostic and risk stratification tools. Int J Cardiol 2019; 279:6-11. [DOI: 10.1016/j.ijcard.2018.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/25/2018] [Accepted: 11/05/2018] [Indexed: 11/29/2022]
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van der Hoeven NW, de Waard GA, Quirós A, De Hoyos A, Broyd CJ, Nijjer SS, van de Hoef TP, Petraco R, Driessen RS, Mejía-Rentería H, Kikuta Y, Echavarría Pinto M, van de Ven PM, Meuwissen M, Knaapen P, Piek JJ, Davies JE, van Royen N, Escaned J. Comprehensive physiological evaluation of epicardial and microvascular coronary domains using vascular conductance and zero flow pressure. EUROINTERVENTION 2019; 14:e1593-e1600. [PMID: 29688179 DOI: 10.4244/eij-d-18-00021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Assessment of the coronary circulation has been based largely on pressure ratios (epicardial) and resistance (micro-vessels). Simultaneous assessment of epicardial (CEPI) and microvascular conductance (CMICRO) provides an intuitive approach using the same units for both coronary domains and expressing the actual deliverability of blood. The aim of this study was to develop a novel integral method for assessing the functional severity of epicardial and microvascular disease. METHODS AND RESULTS We performed intracoronary pressure and Doppler flow velocity measurements in 403 vessels in 261 patients with stable coronary artery disease. Hyperaemic mid-to-late diastolic pressure and flow velocity (PV) relationships were calculated. The slope of the aortic PV indicates the overall conductance and the slope of the distal PV relationship represents CMICRO. The intercept with the x-axis represents zero-flow pressure (Pzf). CEPI was derived from microvascular and overall conductance. Median CEPI was higher compared to CMICRO (4.2 [2.1-8.0] versus 1.3 [1.0-1.7] cm/s/mmHg, p<0.001). CMICRO was independent of stenosis severity (1.3 [1.0-1.7] in FFR ≤0.80 versus 1.4 [1.0-1.8] in FFR >0.8, p=0.797). ROC curves (using FFR and HSR concordant vessels as standard) demonstrated an excellent ability of CEPI to characterise significant stenoses (AUC 0.93). When CEPI<CMICRO, a decrease in flow velocity and coronary pressure (optimal cut-off value 0.97, AUC 0.90) was demonstrated. CONCLUSIONS A comprehensive assessment of separate CEPI and CMICRO was feasible. CEPI has a remarkable diagnostic efficiency to detect a clinically relevant stenosis. When CEPI<CMICRO, distal flow and pressure decrease steeply, indicating myocardial ischaemia. CMICRO can be used to explore the severity of microvascular disease.
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Ahmad Y, Götberg M, Cook C, Howard JP, Malik I, Mikhail G, Frame A, Petraco R, Rajkumar C, Demir O, Iglesias JF, Bhindi R, Koul S, Hadjiloizou N, Gerber R, Ramrakha P, Ruparelia N, Sutaria N, Kanaganayagam G, Ariff B, Fertleman M, Anderson J, Chukwuemeka A, Francis D, Mayet J, Serruys P, Davies J, Sen S. Coronary Hemodynamics in Patients With Severe Aortic Stenosis and Coronary Artery Disease Undergoing Transcatheter Aortic Valve Replacement: Implications for Clinical Indices of Coronary Stenosis Severity. JACC Cardiovasc Interv 2018; 11:2019-2031. [PMID: 30154062 PMCID: PMC6197079 DOI: 10.1016/j.jcin.2018.07.019] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/10/2018] [Accepted: 07/17/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVES In this study, a systematic analysis was conducted of phasic intracoronary pressure and flow velocity in patients with severe aortic stenosis (AS) and coronary artery disease, undergoing transcatheter aortic valve replacement (TAVR), to determine how AS affects: 1) phasic coronary flow; 2) hyperemic coronary flow; and 3) the most common clinically used indices of coronary stenosis severity, instantaneous wave-free ratio and fractional flow reserve. BACKGROUND A significant proportion of patients with severe aortic stenosis (AS) have concomitant coronary artery disease. The effect of the valve on coronary pressure, flow, and the established invasive clinical indices of stenosis severity have not been studied. METHODS Twenty-eight patients (30 lesions, 50.0% men, mean age 82.1 ± 6.5 years) with severe AS and coronary artery disease were included. Intracoronary pressure and flow assessments were performed at rest and during hyperemia immediately before and after TAVR. RESULTS Flow during the wave-free period of diastole did not change post-TAVR (29.78 ± 14.9 cm/s vs. 30.81 ± 19.6 cm/s; p = 0.64). Whole-cycle hyperemic flow increased significantly post-TAVR (33.44 ± 13.4 cm/s pre-TAVR vs. 40.33 ± 17.4 cm/s post-TAVR; p = 0.006); this was secondary to significant increases in systolic hyperemic flow post-TAVR (27.67 ± 12.1 cm/s pre-TAVR vs. 34.15 ± 17.5 cm/s post-TAVR; p = 0.02). Instantaneous wave-free ratio values did not change post-TAVR (0.88 ± 0.09 pre-TAVR vs. 0.88 ± 0.09 post-TAVR; p = 0.73), whereas fractional flow reserve decreased significantly post-TAVR (0.87 ± 0.08 pre-TAVR vs. 0.85 ± 0.09 post-TAVR; p = 0.001). CONCLUSIONS Systolic and hyperemic coronary flow increased significantly post-TAVR; consequently, hyperemic indices that include systole underestimated coronary stenosis severity in patients with severe AS. Flow during the wave-free period of diastole did not change post-TAVR, suggesting that indices calculated during this period are not vulnerable to the confounding effect of the stenotic aortic valve.
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Affiliation(s)
- Yousif Ahmad
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden
| | - Christopher Cook
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - James P Howard
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Iqbal Malik
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ghada Mikhail
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Angela Frame
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ricardo Petraco
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Christopher Rajkumar
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Ozan Demir
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Juan F Iglesias
- Cardiology Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden
| | - Nearchos Hadjiloizou
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Robert Gerber
- Department of Cardiology, Conquest Hospital, St. Leonards-on-Sea, United Kingdom
| | - Punit Ramrakha
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Neil Ruparelia
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nilesh Sutaria
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Gajen Kanaganayagam
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ben Ariff
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael Fertleman
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jon Anderson
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Andrew Chukwuemeka
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Darrel Francis
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Jamil Mayet
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Patrick Serruys
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Justin Davies
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Sayan Sen
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom.
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Stegehuis VE, Wijntjens GW, Murai T, Piek JJ, van de Hoef TP. Assessing the Haemodynamic Impact of Coronary Artery Stenoses: Intracoronary Flow Versus Pressure Measurements. Eur Cardiol 2018; 13:46-53. [PMID: 30310471 DOI: 10.15420/ecr.2018:7:2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Fractional flow reserve (FFR)-guided percutaneous coronary intervention results in better long-term clinical outcomes compared with coronary angiography alone in intermediate stenoses in stable coronary artery disease (CAD). Coronary physiology measurements have emerged for clinical decision making in interventional cardiology, but the focus lies mainly on epicardial vessels rather than the impact of these stenoses on the myocardial microcirculation. The latter can be quantified by measuring the coronary flow reserve (CFR), a combined pressure and flow index with a strong ability to predict clinical outcomes in CAD. However, combined pressure-flow measurements show 30-40 % discordance despite similar diagnostic accuracy between FFR and CFR, which is explained by the effect of microvascular resistance on both indices. Both epicardial and microcirculatory involvement has been acknowledged in ischaemic heart disease, but clinical implementation remains difficult as it requires individual proficiency. The recent introduced pressure-only index instantaneous wave-free ratio, a resting adenosine-free stenosis assessment, led to a revival of interest in coronary physiology measurements. This review focuses on elaborating the coronary physiological parameters and potential of combined pressure-flow measurements in daily clinical practice.
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Affiliation(s)
- Valérie E Stegehuis
- AMC Heart Center, Academic Medical Center, University of Amsterdam Amsterdam, the Netherlands
| | - Gilbert Wm Wijntjens
- AMC Heart Center, Academic Medical Center, University of Amsterdam Amsterdam, the Netherlands
| | - Tadashi Murai
- AMC Heart Center, Academic Medical Center, University of Amsterdam Amsterdam, the Netherlands
| | - Jan J Piek
- AMC Heart Center, Academic Medical Center, University of Amsterdam Amsterdam, the Netherlands
| | - Tim P van de Hoef
- AMC Heart Center, Academic Medical Center, University of Amsterdam Amsterdam, the Netherlands
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Williams RP, Asrress KN, Lumley M, Arri S, Patterson T, Ellis H, Manou‐Stathopoulou V, Macfarlane C, Chandran S, Moschonas K, Oakeshott P, Lockie T, Chiribiri A, Clapp B, Perera D, Plein S, Marber MS, Redwood SR. Deleterious Effects of Cold Air Inhalation on Coronary Physiological Indices in Patients With Obstructive Coronary Artery Disease. J Am Heart Assoc 2018; 7:e008837. [PMID: 30762468 PMCID: PMC6064824 DOI: 10.1161/jaha.118.008837] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 04/11/2018] [Indexed: 01/09/2023]
Abstract
Background Cold air inhalation during exercise increases cardiac mortality, but the pathophysiology is unclear. During cold and exercise, dual-sensor intracoronary wires measured coronary microvascular resistance ( MVR ) and blood flow velocity ( CBF ), and cardiac magnetic resonance measured subendocardial perfusion. Methods and Results Forty-two patients (62±9 years) undergoing cardiac catheterization, 32 with obstructive coronary stenoses and 10 without, performed either (1) 5 minutes of cold air inhalation (5°F) or (2) two 5-minute supine-cycling periods: 1 at room temperature and 1 during cold air inhalation (5°F) (randomized order). We compared rest and peak stress MVR , CBF , and subendocardial perfusion measurements. In patients with unobstructed coronary arteries (n=10), cold air inhalation at rest decreased MVR by 6% ( P=0.41), increasing CBF by 20% ( P<0.01). However, in patients with obstructive stenoses (n=10), cold air inhalation at rest increased MVR by 17% ( P<0.01), reducing CBF by 3% ( P=0.85). Consequently, in patients with obstructive stenoses undergoing the cardiac magnetic resonance protocol (n=10), cold air inhalation reduced subendocardial perfusion ( P<0.05). Only patients with obstructive stenoses performed this protocol (n=12). Cycling at room temperature decreased MVR by 29% ( P<0.001) and increased CBF by 61% ( P<0.001). However, cold air inhalation during cycling blunted these adaptations in MVR ( P=0.12) and CBF ( P<0.05), an effect attributable to defective early diastolic CBF acceleration ( P<0.05) and associated with greater ST -segment depression ( P<0.05). Conclusions In patients with obstructive coronary stenoses, cold air inhalation causes deleterious changes in MVR and CBF . These diminish or abolish the normal adaptations during exertion that ordinarily match myocardial blood supply to demand.
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Affiliation(s)
- Rupert P. Williams
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Kaleab N. Asrress
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Matthew Lumley
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Satpal Arri
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Tiffany Patterson
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Howard Ellis
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | | | - Catherine Macfarlane
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Shruthi Chandran
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Kostantinos Moschonas
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Pippa Oakeshott
- Population Health Research InstituteSt George's University of LondonUnited Kingdom
| | - Timothy Lockie
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Amedeo Chiribiri
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Brian Clapp
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Divaka Perera
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Sven Plein
- Leeds UniversityLeeds Teaching Hospitals NHS TrustLeedsUnited Kingdom
| | - Michael S. Marber
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Simon R. Redwood
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
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AL-Obaidi FR, Fearon WF, Yong AS. Invasive physiological indices to determine the functional significance of coronary stenosis. IJC HEART & VASCULATURE 2018; 18:39-45. [PMID: 29876502 PMCID: PMC5988484 DOI: 10.1016/j.ijcha.2018.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/13/2018] [Indexed: 01/10/2023]
Abstract
Physiological measurements are now commonly used to assess coronary lesions in the cardiac catheterisation laboratory, and this practice is evidence-based and supported by clinical guidelines. Fractional flow reserve is currently the gold standard method to determine whether coronary lesions are functionally significant, and is used to guide revascularization. There are however several other physiological measurements that have been proposed as alternatives to the fractional flow reserve. This review aims to comprehensively discuss physiological indices that can be used in the cardiac catheterisation laboratory to determine the functional significance of coronary lesions. We will focus on their advantages and disadvantages, and the current evidence supporting their use.
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Affiliation(s)
- Firas R. AL-Obaidi
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- College of Medicine, University of Thi Qar, Iraq
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andy S.C. Yong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- ANZAC Research Institute, Concord Hospital, Sydney, Australia
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Motwani M, Motlagh M, Gupta A, Berman DS, Slomka PJ. Reasons and implications of agreements and disagreements between coronary flow reserve, fractional flow reserve, and myocardial perfusion imaging. J Nucl Cardiol 2018; 25:104-119. [PMID: 26715599 DOI: 10.1007/s12350-015-0375-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 12/02/2015] [Indexed: 01/10/2023]
Abstract
Information on coronary physiology and myocardial blood flow (MBF) in patients with suspected angina is increasingly important to inform treatment decisions. A number of different techniques including myocardial perfusion imaging (MPI), noninvasive estimation of MBF, and coronary flow reserve (CFR), as well as invasive methods for CFR and fractional flow reserve (FFR) are now readily available. However, despite their incorporation into contemporary guidelines, these techniques are still poorly understood and their interpretation to guide revascularization decisions is often inconsistent. In particular, these inconsistencies arise when there are discrepancies between the various techniques. The purpose of this article is therefore to review the basic principles, techniques, and clinical value of MPI, FFR, and CFR-with particular focus on interpreting their agreements and disagreements.
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Affiliation(s)
- Manish Motwani
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mahsaw Motlagh
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anuj Gupta
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr J Slomka
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Ahn SG, Suh J, Hung OY, Lee HS, Bouchi YH, Zeng W, Gandhi R, Eshtehardi P, Gogas BD, Samady H. Discordance Between Fractional Flow Reserve and Coronary Flow Reserve: Insights From Intracoronary Imaging and Physiological Assessment. JACC Cardiovasc Interv 2018; 10:999-1007. [PMID: 28521932 DOI: 10.1016/j.jcin.2017.03.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/15/2017] [Accepted: 03/06/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the epicardial and microvascular substrates associated with discordances between fractional flow reserve (FFR) and coronary flow reserve (CFR) values. BACKGROUND Discordances between FFR and CFR remain poorly characterized. METHODS FFR, hyperemic stenosis resistance (HSR), and intravascular ultrasound were performed as indexes of epicardial function and CFR and hyperemic microvascular resistance (HMR) as measures of microvascular function in 94 patients with moderate coronary stenosis. Maximal plaque burden (PBmax), HSR, and HMR were calculated in 4 quadrants based on values of FFR ≤0.80 and CFR ≤2.0 as follows: concordant normal (preserved FFR and CFR), concordant abnormal (low FFR and CFR), discordant low FFR and preserved CFR, and discordant preserved FFR and low CFR. RESULTS Sixty-four patients (68%) had concordant FFR and CFR findings, and 30 patients (32%) had discordant FFR and CFR. Compared with patients with preserved FFR and CFR, those with low FFR and CFR had higher PBmax (p = 0.003), higher HSR (p < 0.001), and similar HMR. Among patients with preserved FFR, those with reduced CFR had similar PBmax and HSR but a trend toward higher HMR (p = 0.058) compared with patients with preserved CFR. Among patients with reduced FFR, those with preserved CFR had lower PBmax (p = 0.004), a trend toward lower HSR (p = 0.065), and lower HMR (p = 0.03) compared with patients with reduced CFR. Furthermore, compared with patients with preserved FFR and low CFR, those with low FFR and preserved CFR had higher HSR (p = 0.022) but lower HMR (p = 0.003). CONCLUSIONS In patients with moderate coronary stenosis, preserved FFR and low CFR is associated with increased microvascular resistance, while low FFR and preserved CFR has modest epicardial stenosis and preserved microvascular function.
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Affiliation(s)
- Sung Gyun Ahn
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jon Suh
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea; Division of Cardiology, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, Bucheon, Korea
| | - Olivia Y Hung
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Hee Su Lee
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Yasir H Bouchi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Wenjie Zeng
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rounak Gandhi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Parham Eshtehardi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bill D Gogas
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Habib Samady
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
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Gosling RC, Morris PD, Lawford PV, Hose DR, Gunn JP. Predictive Physiological Modeling of Percutaneous Coronary Intervention - Is Virtual Treatment Planning the Future? Front Physiol 2018; 9:1107. [PMID: 30154734 PMCID: PMC6103238 DOI: 10.3389/fphys.2018.01107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/23/2018] [Indexed: 01/10/2023] Open
Abstract
Computational modeling has been used routinely in the pre-clinical development of medical devices such as coronary artery stents. The ability to simulate and predict physiological and structural parameters such as flow disturbance, wall shear-stress, and mechanical strain patterns is beneficial to stent manufacturers. These methods are now emerging as useful clinical tools, used by physicians in the assessment and management of patients. Computational models, which can predict the physiological response to intervention, offer clinicians the ability to evaluate a number of different treatment strategies in silico prior to treating the patient in the cardiac catheter laboratory. For the first time clinicians can perform a patient-specific assessment prior to making treatment decisions. This could be advantageous in patients with complex disease patterns where the optimal treatment strategy is not clear. This article reviews the key advances and the potential barriers to clinical adoption and translation of these virtual treatment planning models.
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Affiliation(s)
- Rebecca C. Gosling
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, United Kingdom
- INSIGNEO Institute for in Silico Medicine, Sheffield, United Kingdom
- *Correspondence: Rebecca C. Gosling,
| | - Paul D. Morris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, United Kingdom
- INSIGNEO Institute for in Silico Medicine, Sheffield, United Kingdom
- These authors have contributed equally to this work and are joint first authors
| | - Patricia V. Lawford
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- INSIGNEO Institute for in Silico Medicine, Sheffield, United Kingdom
| | - D. Rodney Hose
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- INSIGNEO Institute for in Silico Medicine, Sheffield, United Kingdom
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Julian P. Gunn
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, United Kingdom
- INSIGNEO Institute for in Silico Medicine, Sheffield, United Kingdom
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Verna E, Provasoli S, Ghiringhelli S, Morandi F, Salerno-Uriarte J. Abnormal coronary vasoreactivity in transient left ventricular apical ballooning (tako-tsubo) syndrome. Int J Cardiol 2018; 250:4-10. [DOI: 10.1016/j.ijcard.2017.07.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/31/2017] [Accepted: 07/11/2017] [Indexed: 01/26/2023]
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Hebbar UU, Effat MA, Peelukhana SV, Arif I, Banerjee RK. Delineation of epicardial stenosis in patients with microvascular disease using pressure drop coefficient: A pilot outcome study. World J Cardiol 2017; 9:813-821. [PMID: 29317987 PMCID: PMC5746623 DOI: 10.4330/wjc.v9.i12.813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/18/2017] [Accepted: 10/29/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To investigate the patient-outcomes of newly developed pressure drop coefficient (CDP) in diagnosing epicardial stenosis (ES) in the presence of concomitant microvascular disease (MVD).
METHODS Patients from our clinical trial were divided into two subgroups with: (1) cut-off of coronary flow reserve (CFR) < 2.0; and (2) diabetes. First, correlations were performed for both subgroups between CDP and hyperemic microvascular resistance (HMR), a diagnostic parameter for assessing the severity of MVD. Linear regression analysis was used for these correlations. Further, in each of the subgroups, comparisons were made between fractional flow reserve (FFR) < 0.75 and CDP > 27.9 groups for assessing major adverse cardiac events (MACE: Primary outcome). Comparisons were also made between the survival curves for FFR < 0.75 and CDP > 27.9 groups. Two tailed chi-squared and Fischer’s exact tests were performed for comparison of the primary outcomes, and the log-rank test was used to compare the Kaplan-Meier survival curves. P < 0.05 for all tests was considered statistically significant.
RESULTS Significant linear correlations were observed between CDP and HMR for both CFR < 2.0 (r = 0.58, P < 0.001) and diabetic (r = 0.61, P < 0.001) patients. In the CFR < 2.0 subgroup, the %MACE (primary outcomes) for CDP > 27.9 group (7.7%, 2/26) was lower than FFR < 0.75 group (3/14, 21.4%); P = 0.21. Similarly, in the diabetic subgroup, the %MACE for CDP > 27.9 group (12.5%, 2/16) was lower than FFR < 0.75 group (18.2%, 2/11); P = 0.69. Survival analysis for CFR < 2.0 subgroup indicated better event-free survival for CDP > 27.9 group (n = 26) when compared with FFR < 0.75 group (n = 14); P = 0.10. Similarly, for the diabetic subgroup, CDP > 27.9 group (n = 16) showed higher survival times compared to FFR group (n = 11); P = 0.58.
CONCLUSION CDP correlated significantly with HMR and resulted in better %MACE as well as survival rates in comparison to FFR. These positive trends demonstrate that CDP could be a potential diagnostic endpoint for delineating MVD with or without ES.
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Affiliation(s)
- Ullhas Udaya Hebbar
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH 45221, United States
| | - Mohamed A Effat
- Division of Cardiovascular Diseases, University of Cincinnati Medical Center, Veteran Affairs Medical Center, Cincinnati, OH 45221, United States
| | - Srikara V Peelukhana
- Department of Mechanical and Materials Engineering, University of Cincinnati, Veteran Affairs Medical Center, Cincinnati, OH 45221, United States
| | - Imran Arif
- Division of Cardiovascular Diseases, University of Cincinnati Medical Center, Veteran Affairs Medical Center, Cincinnati, OH 45221, United States
| | - Rupak K Banerjee
- Department of Mechanical and Materials Engineering, Veteran Affairs Medical Center, Cincinnati, OH 45221, United States
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Vijayan S, Barmby DS, Pearson IR, Davies AG, Wheatcroft SB, Sivananthan M. Assessing Coronary Blood Flow Physiology in the Cardiac Catheterisation Laboratory. Curr Cardiol Rev 2017; 13:232-243. [PMID: 28545351 PMCID: PMC5633718 DOI: 10.2174/1573403x13666170525102618] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 05/09/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023] Open
Abstract
Background: Contemporary management of coronary disease focuses on the treatment of stenoses in the major epicardial vessels. However, myocardial blood flow is known to be contingent on a range of factors in addition to the patency of the epicardial vessels. These include anatomical and physiological factors such as the extent of myocardium supplied by the vessel, systemic blood pres-sure, the natural variation in vascular tone in response to physiological needs which allows for coro-nary autoregulation and pathological factors such as the presence of downstream obstruction to flow due to disease of the small coronary vessels or myocardium. The assessment of clinical effectiveness and adequacy of coronary revascularisation requires the ability to comprehensively and accurately as-sess and measure myocardial perfusion. Conclusion: In this article, we review the current methods of evaluating coronary blood flow and my-ocardial perfusion in the cardiac catheterisation laboratory.
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Affiliation(s)
- Sethumadhavan Vijayan
- Interventional Fellow, Department of Cardiology, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom
| | - David S Barmby
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Ian R Pearson
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Andrew G Davies
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Stephen B Wheatcroft
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Mohan Sivananthan
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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35
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Ford TJ, Corcoran D, Berry C. Stable coronary syndromes: pathophysiology, diagnostic advances and therapeutic need. HEART (BRITISH CARDIAC SOCIETY) 2017; 104:284-292. [PMID: 29030424 PMCID: PMC5861393 DOI: 10.1136/heartjnl-2017-311446] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 12/13/2022]
Abstract
The diagnostic management of patients with angina pectoris typically centres on the detection of obstructive epicardial CAD, which aligns with evidence-based treatment options that include medical therapy and myocardial revascularisation. This clinical paradigm fails to account for the considerable proportion (approximately one-third) of patients with angina in whom obstructive CAD is excluded. This common scenario presents a diagnostic conundrum whereby angina occurs but there is no obstructive CAD (ischaemia and no obstructive coronary artery disease—INOCA). We review new insights into the pathophysiology of angina whereby myocardial ischaemia results from a deficient supply of oxygenated blood to the myocardium, due to various combinations of focal or diffuse epicardial disease (macrovascular), microvascular dysfunction or both. Macrovascular disease may be due to the presence of obstructive CAD secondary to atherosclerosis, or may be dynamic due to a functional disorder (eg, coronary artery spasm, myocardial bridging). Pathophysiology of coronary microvascular disease may involve anatomical abnormalities resulting in increased coronary resistance, or functional abnormalities resulting in abnormal vasomotor tone. We consider novel clinical diagnostic techniques enabling new insights into the causes of angina and appraise the need for improved therapeutic options for patients with INOCA. We conclude that the taxonomy of stable CAD could improve to better reflect the heterogeneous pathophysiology of the coronary circulation. We propose the term ‘stable coronary syndromes’ (SCS), which aligns with the well-established terminology for ‘acute coronary syndromes’. SCS subtends a clinically relevant classification that more fully encompasses the different diseases of the epicardial and microvascular coronary circulation.
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Affiliation(s)
- Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,University of New South Wales, Sydney, NSW, Australia
| | - David Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,British Society of Cardiovascular Research, Glasgow, UK
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,British Society of Cardiovascular Research, Glasgow, UK
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36
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Götberg M, Cook CM, Sen S, Nijjer S, Escaned J, Davies JE. The Evolving Future of Instantaneous Wave-Free Ratio and Fractional Flow Reserve. J Am Coll Cardiol 2017; 70:1379-1402. [PMID: 28882237 DOI: 10.1016/j.jacc.2017.07.770] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/12/2017] [Accepted: 07/25/2017] [Indexed: 01/10/2023]
Abstract
In this review, the authors reflect upon the role of coronary physiology in the modern management of coronary artery disease. They critically appraise the scientific background of the instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR), from early experimental studies to validation studies against indexes of ischemia, to clinical trials assessing outcome. At this important juncture for the field, the authors make predictions for the future of physiological stenosis assessment, outlining developments for both iFR and FFR in new clinical domains beyond the confines of stable angina. With a focus on the evolving future of iFR and FFR, the authors describe how physiological assessment with iFR may advance its application from simply justifying to guiding revascularization.
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Affiliation(s)
- Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden.
| | | | - Sayan Sen
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Sukhjinder Nijjer
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | | | - Justin E Davies
- Hammersmith Hospital, Imperial College London, London, United Kingdom
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37
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de Waard G, Di Mario C, Lerman A, Serruys P, van Royen N. Instantaneous wave-free ratio to guide coronary revascularisation: physiological framework, validation and differences from fractional flow reserve. EUROINTERVENTION 2017; 13:450-458. [DOI: 10.4244/eij-d-16-00456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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38
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de Waard GA, Fahrni G, de Wit D, Kitabata H, Williams R, Patel N, Teunissen PF, van de Ven PM, Umman S, Knaapen P, Perera D, Akasaka T, Sezer M, Kharbanda RK, van Royen N. Hyperaemic microvascular resistance predicts clinical outcome and microvascular injury after myocardial infarction. Heart 2017; 104:127-134. [PMID: 28663361 DOI: 10.1136/heartjnl-2017-311431] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Early detection of microvascular dysfunction after acute myocardial infarction (AMI) could identify patients at high risk of adverse clinical outcome, who may benefit from adjunctive treatment. Our objective was to compare invasively measured coronary flow reserve (CFR) and hyperaemic microvascular resistance (HMR) for their predictive power of long-term clinical outcome and cardiac magnetic resonance (CMR)-defined microvascular injury (MVI). METHODS Simultaneous intracoronary Doppler flow velocity and pressure measurements acquired immediately after revascularisation for AMI from five centres were pooled. Clinical follow-up was completed for 176 patients (mean age 60±10 years; 140(80%) male; ST-elevation myocardial infarction (STEMI) 130(74%) and non-ST-segment elevation myocardial infarction 46(26%)) with median follow-up time of 3.2 years. In 110 patients with STEMI, additional CMR was performed. RESULTS The composite end point of death and hospitalisation for heart failure occurred in 17 patients (10%). Optimal cut-off values to predict the composite end point were 1.5 for CFR and 3.0 mm Hg cm-1•s for HMR. CFR <1.5 was predictive for the composite end point (HR 3.5;95% CI 1.1 to 10.8), but not for its individual components. HMR ≥3.0 mm Hg cm-1 s was predictive for the composite end point (HR 7.0;95% CI 1.5 to 33.7) as well as both individual components. HMR had significantly greater area under the receiver operating characteristic curve for MVI than CFR. HMR remained an independent predictor of adverse clinical outcome and MVI, whereas CFR did not. CONCLUSIONS HMR measured immediately following percutaneous coronary intervention for AMI with a cut-off value of 3.0 mm Hg cm-1 s, identifies patients with MVI who are at high risk of adverse clinical outcome. For this purpose, HMR is superior to CFR.
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Affiliation(s)
- Guus A de Waard
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Gregor Fahrni
- Oxford Heart Centre, Oxford University Hospitals, Oxford, UK
| | - Douwe de Wit
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Hironori Kitabata
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Rupert Williams
- Cardiovascular Division, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, UK
| | - Niket Patel
- Oxford Heart Centre, Oxford University Hospitals, Oxford, UK
| | - Paul F Teunissen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Sabahattin Umman
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Paul Knaapen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Divaka Perera
- Cardiovascular Division, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, UK
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Murat Sezer
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Niels van Royen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
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39
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van de Hoef TP, Petraco R, van Lavieren MA, Nijjer S, Nolte F, Sen S, Echavarria-Pinto M, Henriques JPS, Koch KT, Baan J, de Winter RJ, Siebes M, Spaan JAE, Tijssen JGP, Meuwissen M, Escaned J, Davies JE, Piek JJ. Basal stenosis resistance index derived from simultaneous pressure and flow velocity measurements. EUROINTERVENTION 2017; 12:e199-207. [PMID: 27290679 DOI: 10.4244/eijv12i2a33] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIMS Vasodilator-free basal stenosis resistance (BSR) equals fractional flow reserve (FFR) accuracy for ischaemia-inducing stenoses. Nonetheless, basal haemodynamic variability may impair BSR accuracy compared with hyperaemic stenosis resistance (HSR). We evaluated the influence of basal haemodynamic variability, as encountered in practice, on BSR accuracy versus HSR when derived from simultaneous pressure and flow velocity measurements, and determined its diagnostic performance for HSR-defined significant stenoses. METHODS AND RESULTS Simultaneous coronary pressure and flow velocity were obtained in 131 stenoses. The impact of basal haemodynamic conditions on BSR was evaluated by means of their relationship with the relative difference between BSR and HSR. Diagnostic performance of BSR, FFR, iFR, and resting Pd/Pa was assessed by comparing the area under the curve (AUC), using HSR as reference standard. The relative difference between BSR and HSR was not associated with basal heart rate, aortic pressure or rate pressure product. Among all stenoses, as well as within the 0.6-0.9 FFR range, BSR AUC was significantly greater than resting Pd/Pa and iFR AUC; all other AUCs were equivalent. CONCLUSIONS With simultaneous pressure and flow velocity measurements, basal conditions do not systematically limit BSR accuracy compared with HSR. Consequently, diagnostic performance of BSR is equivalent to FFR, and closely approximates HSR.
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Affiliation(s)
- Tim P van de Hoef
- AMC Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Niccoli G, Indolfi C, Davies JE. Evaluation of intermediate coronary stenoses in acute coronary syndromes using pressure guidewire. Open Heart 2017; 4:e000431. [PMID: 28761673 PMCID: PMC5515130 DOI: 10.1136/openhrt-2016-000431] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 08/15/2016] [Accepted: 08/30/2016] [Indexed: 01/10/2023] Open
Abstract
Fractional flow reserve (FFR) is increasingly used to guide myocardial revascularisation. However, supporting evidence regarding its use originates from studies that have enrolled mainly patients with stable angina, while patients with acute coronary syndromes (ACS) have not been included. Notably, multifactorial microvascular dysfunction and an increased sympathetic tone in patients with ACS may lead to blunted response to adenosine and false-negative results of FFR due to submaximal hyperaemia. This may raise the possibility of deferring treatment of stenosis that instead would have needed dilatation, thus leaving a residual risk of preventable cardiac events. In this literature review, we aim at summarising laboratory and clinical investigations concerning the use of FFR in culprit and non-culprit lesions in ACS. Furthermore, we will report recent data on instantaneous wave-free ratio, an adenosine-free index of functional stenosis severity, in stable coronary artery disease and in patients with ACS.
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Affiliation(s)
- Giampaolo Niccoli
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences & URT CNR, Magna Graecia University, Catanzaro, Italy
| | - Justin E Davies
- National Heart and Lung Institute, International Centre for Circulatory Health, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
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41
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Seo KW, Lim HS, Yoon MH, Tahk SJ, Choi SY, Choi BJ, Yang HM, Shin JH, Hwang GS, Park JS, Jin X. The impact of microvascular resistance on the discordance between anatomical and functional evaluations of intermediate coronary disease. EUROINTERVENTION 2017; 13:e185-e192. [PMID: 28134124 DOI: 10.4244/eij-d-16-00400] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS In intermediate coronary artery disease, discordance between anatomical and functional assessments persists and the diagnostic accuracy of an anatomical evaluation is not satisfactory for determining functional significance. We aimed to evaluate the impact of microvascular resistance on "anatomical-functional discordance". METHODS AND RESULTS In 97 intermediate coronary lesions of 83 patients, minimum lumen area (MLA), fractional flow reserve (FFR), Δ(Pd/Pa-FFR), and hyperaemic microvascular resistance index (hMVRI) were measured using intravascular ultrasound and an intracoronary dual pressure and Doppler sensor-tipped guidewire. hMVRI correlated with FFR and Δ(Pd/Pa-FFR) (r=0.611, p<0.001; r=-0.509, p<0.001; respectively). After the lesions were categorised into four groups based on functional significance (FFR 0.8) and the MLA cut-off for that (2.5 mm2), hMVRI was higher with a lower Δ(Pd/Pa-FFR) regardless of the MLA group in lesions with FFR >0.8, compared with those in lesions with FFR ≤0.8. hMVRI was independently associated with FFR and Δ(Pd/Pa-FFR) (β=0.443, p<0.001; β=-0.389, p<0.001; respectively). CONCLUSIONS Coronary microvascular resistance is associated with anatomical-functional discordance and the ischaemic potential of intermediate epicardial stenosis. In determining a treatment strategy, anatomy alone is insufficient and an integrated physiologic approach is important.
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Affiliation(s)
- Kyoung-Woo Seo
- Department of Cardiology, Ajou University School of Medicine, Suwon, South Korea
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Shome JS, Perera D, Plein S, Chiribiri A. Current perspectives in coronary microvascular dysfunction. Microcirculation 2017; 24. [DOI: 10.1111/micc.12340] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 12/06/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Joy S. Shome
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
| | - Divaka Perera
- Cardiovascular Division; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
| | - Sven Plein
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
- Division of Biomedical Imaging; Multidisciplinary Cardiovascular Research Centre; Leeds Institute of Cardiovascular and Metabolic Medicine; University of Leeds; Leeds UK
| | - Amedeo Chiribiri
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
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Wijntjens GW, van de Hoef TP, Kraak RP, Beijk MA, Sjauw KD, Vis MM, Madera Cambero MI, Brinckman SL, Plomp J, Baan J, Koch KT, Wykrzykowska JJ, Henriques JP, de Winter RJ, Piek JJ. The IMPACT Study (Influence of Sensor-Equipped Microcatheters on Coronary Hemodynamics and the Accuracy of Physiological Indices of Functional Stenosis Severity). Circ Cardiovasc Interv 2016; 9:CIRCINTERVENTIONS.116.004645. [DOI: 10.1161/circinterventions.116.004645] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 11/09/2016] [Indexed: 11/16/2022]
Abstract
Background—
The Navvus pressure sensor–equipped microcatheter allows to measure functional stenosis severity over a work-horse guidewire and is used as a more feasible alternative to regular sensor-equipped wires. However, Navvus is larger in diameter than contemporary sensor-equipped guidewires and may, thereby, influence functional measurements. The present study evaluates the hemodynamic influence of the Navvus microcatheter.
Methods and Results—
In patients with intermediate coronary stenosis, coronary pressure and flow velocity were measured using a dual sensor–equipped guidewire before and after introduction of Navvus. Patients were randomized to microcatheter-first or guidewire-first measurement. The primary end point was the difference in hyperemic stenosis resistance index between measurements before and after introduction of Navvus. Measurements were completed in 28 patients (28 stenoses). Mean hyperemic stenosis resistance was 0.37±0.19 Hg/cm/s for wire-only assessment and 0.48±0.26 Hg/cm/s after Navvus introduction (
P
<0.001). Bland–Altman analysis documented a mean bias of +0.11 Hg/cm/s (limits of agreement: −0.13 to 0.36), proportional to mean hyperemic stenosis resistance (Spearman ρ =0.61;
P
=0.001). Passing–Bablok analysis revealed absence of a constant difference but significant proportional difference between the methods. Mean fractional flow reserve was 0.86±0.06 for wire-only assessment and 0.82±0.07 after Navvus introduction (
P
<0.001). Bland–Altman analysis documented a mean bias of −0.033 (limits of agreement: −0.09 to 0.03), proportional to mean fractional flow reserve (Spearman ρ =0.40;
P
=0.036). Passing–Bablok analysis revealed significant constant and proportional differences between methods. Similar results were documented for resting indices of stenosis severity.
Conclusions—
Introduction of the Navvus microcatheter leads to clinically relevant stenosis severity overestimation in intermediate stenosis.
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Affiliation(s)
- Gilbert W.M. Wijntjens
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Tim P. van de Hoef
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Robin P. Kraak
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Marcel A. Beijk
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Krischan D. Sjauw
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - M. Marije Vis
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Maribel I. Madera Cambero
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Stijn L. Brinckman
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Jacobus Plomp
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Jan Baan
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Karel T. Koch
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Joanna J. Wykrzykowska
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - José P. Henriques
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Robbert J. de Winter
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
| | - Jan J. Piek
- From the AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (G.W.M.W., T.P.v.d.H., R.P.K., M.A.B., K.D.S., M.M.V., J.B., K.T.K., J.J.W., J.P.H., R.J.d.W., J.J.P.); and Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands (T.P.v.d.H., M.I.M.C., S.L.B., J.P.)
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Nijjer S, Davies J. Physiologic Assessment in the Cardiac Catheterization Laboratory. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Sukhjinder Nijjer
- Hammersmith Hospital; Imperial College Healthcare NHS Trust; London UK
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46
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Asrress KN, Allahwala U, Bhindi R. Contemporary assessment of coronary hemodynamics in the catheter laboratory. Future Cardiol 2016; 12:601-604. [PMID: 27791386 DOI: 10.2217/fca-2016-0041] [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] Open
Affiliation(s)
- Kaleab N Asrress
- Department of Cardiology, Royal North Shore Hospital, Sydney, Kolling Institute, University of Sydney, Sydney, 2065, Australia
| | - Usaid Allahwala
- Department of Cardiology, Royal North Shore Hospital, Sydney, Kolling Institute, University of Sydney, Sydney, 2065, Australia
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Sydney, Kolling Institute, University of Sydney, Sydney, 2065, Australia
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47
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Meimoun P, Clerc J, Ardourel D, Djou U, Martis S, Botoro T, Elmkies F, Zemir H, Luycx-Bore A, Boulanger J. Assessment of left anterior descending artery stenosis of intermediate severity by fractional flow reserve, instantaneous wave-free ratio, and non-invasive coronary flow reserve. Int J Cardiovasc Imaging 2016; 33:999-1007. [PMID: 27752796 DOI: 10.1007/s10554-016-1000-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/07/2016] [Indexed: 01/14/2023]
Abstract
To test the usefulness of non-invasive coronary flow reserve (CFR) by transthoracic Doppler echocardiography by comparison to invasive fractional flow reserve (FFR) and instantaneous wave-free ratio (IFR), a new vasodilator-free index of coronary stenosis severity, in patients with left anterior descending artery (LAD) stenosis of intermediate severity (IS) and stable coronary artery disease. 94 consecutive patients (mean age 68 ± 10 years) with angiographic LAD stenosis of IS (50-70 % diameter stenosis), were prospectively studied. IFR was calculated as a trans-lesion pressure ratio during the wave-free period in diastole; FFR as distal pressure divided by mean aortic pressure during maximal hyperemia (using 180 μg intracoronary adenosine); and CFR as hyperemic peak LAD flow velocity divided by baseline flow velocity using intravenous adenosine (140 μg/kg/min over 2 min). The mean values of IFR, FFR, and CFR were 0.88 ± 0.07, 0.81 ± 0.09, and 2.4 ± 0.6 respectively. A significant correlation was found between CFR and FFR (r = 0. 68), FFR and IFR (r = 0.6), and between CFR and IFR (r = 0.5) (all, p < 0.01). Using a ROC curve analysis, the best cut-off to detect a significant lesion based on FFR assessment (FFR ≤ 0.8, n = 31) was IFR ≤ 0.88 with a sensitivity (Se) of 74 %, specificity (Sp) of 73 %, AUC 0.81 ± 0.04, accuracy 72 %; and CFR ≤ 2 with a Se = 77 %, Sp = 89 %, AUC 0.88 ± 0.04, accuracy 85 % (all, p < 0.001). In stable patients with LAD stenosis of IS, non-invasive CFR is a useful tool to detect a significant lesion based on FFR. Furthermore, there was a better correlation between CFR and FFR than between CFR and IFR, and a trend to a better diagnostic performance for CFR versus IFR.
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Affiliation(s)
- P Meimoun
- Department of Cardiology, Centre Hospitalier de Compiègne, 8 rue Henri Adnot, 60200, Compiègne, France.
| | - J Clerc
- Department of Cardiology, Centre Hospitalier de Compiègne, 8 rue Henri Adnot, 60200, Compiègne, France
| | - D Ardourel
- Department of Cardiology, Centre Hospitalier de Compiègne, 8 rue Henri Adnot, 60200, Compiègne, France
| | - U Djou
- Department of Cardiology, Centre Hospitalier de Compiègne, 8 rue Henri Adnot, 60200, Compiègne, France
| | - S Martis
- Department of Cardiology, Centre Hospitalier de Compiègne, 8 rue Henri Adnot, 60200, Compiègne, France
| | - T Botoro
- Department of Cardiology, Centre Hospitalier de Compiègne, 8 rue Henri Adnot, 60200, Compiègne, France
| | - F Elmkies
- Department of Cardiology, Centre Hospitalier de Compiègne, 8 rue Henri Adnot, 60200, Compiègne, France
| | - H Zemir
- Department of Cardiology, Centre Hospitalier de Compiègne, 8 rue Henri Adnot, 60200, Compiègne, France
| | - A Luycx-Bore
- Department of Cardiology, Centre Hospitalier de Compiègne, 8 rue Henri Adnot, 60200, Compiègne, France
| | - J Boulanger
- Department of Cardiology, Centre Hospitalier de Compiègne, 8 rue Henri Adnot, 60200, Compiègne, France
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Mohdnazri SR, Keeble TR, Sharp AS. Fractional Flow Reserve: Does a Cut-off Value add Value? Interv Cardiol 2016; 11:17-26. [PMID: 29588700 DOI: 10.15420/icr.2016:7:2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Fractional flow reserve (FFR) has been shown to improve outcomes when used to guide percutaneous coronary intervention (PCI). There have been two proposed cut-off points for FFR. The first was derived by comparing FFR against a series of non-invasive tests, with a value of ≤0.75 shown to predict a positive ischaemia test. It was then shown in the DEFER study that a vessel FFR value of ≥0.75 was associated with safe deferral of PCI. During the validation phase, a 'grey zone' for FFR values of between 0.76 and 0.80 was demonstrated, where a positive non-invasive test may still occur, but sensitivity and specificity were sub-optimal. Clinical judgement was therefore advised for values in this range. The FAME studies then moved the FFR cut-off point to ≤0.80, with a view to predicting outcomes. The ≤0.80 cut-off point has been adopted into clinical practice guidelines, whereas the lower value of ≤0.75 is no longer widely used. Here, the authors discuss the data underpinning these cut-off values and the practical implications for their use when using FFR guidance in PCI.
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Affiliation(s)
- Shah R Mohdnazri
- The Essex Cardiothoracic Centre, Basildon, UK.,Anglia Ruskin University, Chelmsford, UK
| | - Thomas R Keeble
- The Essex Cardiothoracic Centre, Basildon, UK.,Anglia Ruskin University, Chelmsford, UK
| | - Andrew Sp Sharp
- Royal Devon and Exeter Hospital, Exeter, UK.,University of Exeter, Exeter, UK
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Effat MA, Peelukhana SV, Banerjee RK. Clinical outcomes of combined flow-pressure drop measurements using newly developed diagnostic endpoint: Pressure drop coefficient in patients with coronary artery dysfunction. World J Cardiol 2016; 8:283-292. [PMID: 27022460 PMCID: PMC4807317 DOI: 10.4330/wjc.v8.i3.283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 11/02/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To combine pressure and flow parameter, pressure drop coefficient (CDP) will result in better clinical outcomes in comparison to the fractional flow reserve (FFR) group.
METHODS: To test this hypothesis, a comparison was made between the FFR < 0.75 and CDP > 27.9 groups in this study, for the major adverse cardiac events [major adverse cardiac events (MACE): Primary outcome] and patients’ quality of life (secondary outcome). Further, a comparison was also made between the survival curves for the FFR < 0.75 and CDP > 27.9 groups. Two-tailed χ2 test proportions were performed for the comparison of primary and secondary outcomes. Kaplan-Meier survival analysis was performed to compare the survival curves of FFR < 0.75 and CDP > 27.9 groups (MedcalcV10.2, Mariakerke, Belgium). Results were considered statistically significant for P < 0.05.
RESULTS: The primary outcomes (%MACE) in the FFR < 0.75 group (20%, 4 out of 20) was not statistically different (P = 0.24) from the %MACE occurring in CDP > 27.9 group (8.57%, 2 out of 35). Noteworthy is the reduction in the %MACE in the CDP > 27.9 group, in comparison to the FFR < 0.75 group. Further, the secondary outcomes were not statistically significant between the FFR < 0.75 and CDP > 27.9 groups. Survival analysis results suggest that the survival time for the CDP > 27.9 group (n = 35) is significantly higher (P = 0.048) in comparison to the survival time for the FFR < 0.75 group (n = 20). The results remained similar for a FFR = 0.80 cut-off.
CONCLUSION: Based on the above, CDP could prove to be a better diagnostic end-point for clinical revascularization decision-making in the cardiac catheterization laboratories.
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50
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Nijjer SS, Petraco R, van de Hoef TP, Sen S, van Lavieren MA, Foale RA, Meuwissen M, Broyd C, Echavarria-Pinto M, Al-Lamee R, Foin N, Sethi A, Malik IS, Mikhail GW, Hughes AD, Mayet J, Francis DP, Di Mario C, Escaned J, Piek JJ, Davies JE. Change in coronary blood flow after percutaneous coronary intervention in relation to baseline lesion physiology: results of the JUSTIFY-PCI study. Circ Cardiovasc Interv 2016; 8:e001715. [PMID: 26025217 DOI: 10.1161/circinterventions.114.001715] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) aims to increase coronary blood flow by relieving epicardial obstruction. However, no study has objectively confirmed this and assessed changes in flow over different phases of the cardiac cycle. We quantified the change in resting and hyperemic flow velocity after PCI in stenoses defined physiologically by fractional flow reserve and other parameters. METHODS AND RESULTS Seventy-five stenoses (67 patients) underwent paired flow velocity assessment before and after PCI. Flow velocity was measured over the whole cardiac cycle and the wave-free period. Mean fractional flow reserve was 0.68±0.02. Pre-PCI, hyperemic flow velocity is diminished in stenoses classed as physiologically significant compared with those classed nonsignificant (P<0.001). In significant stenoses, flow velocity over the resting wave-free period and hyperemic flow velocity did not differ statistically. After PCI, resting flow velocity over the wave-free period increased little (5.6±1.6 cm/s) and significantly less than hyperemic flow velocity (21.2±3 cm/s; P<0.01). The greatest increase in hyperemic flow velocity was observed when treating stenoses below physiological cut points; treating stenoses with fractional flow reserve ≤0.80 gained Δ28.5±3.8 cm/s, whereas those fractional flow reserve >0.80 had a significantly smaller gain (Δ4.6±2.3 cm/s; P<0.001). The change in pressure-only physiological indices demonstrated a curvilinear relationship to the change in hyperemic flow velocity but was flat for resting flow velocity. CONCLUSIONS Pre-PCI physiology is strongly associated with post-PCI increase in hyperemic coronary flow velocity. Hyperemic flow velocity increases 6-fold more when stenoses classed as physiologically significant undergo PCI than when nonsignificant stenoses are treated. Resting flow velocity measured over the wave-free period changes at least 4-fold less than hyperemic flow velocity after PCI.
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Affiliation(s)
- Sukhjinder S Nijjer
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Ricardo Petraco
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Tim P van de Hoef
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Sayan Sen
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Martijn A van Lavieren
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Rodney A Foale
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Martijn Meuwissen
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Christopher Broyd
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Mauro Echavarria-Pinto
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Rasha Al-Lamee
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Nicolas Foin
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Amarjit Sethi
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Iqbal S Malik
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Ghada W Mikhail
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Alun D Hughes
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Jamil Mayet
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Darrel P Francis
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Carlo Di Mario
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Javier Escaned
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Jan J Piek
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.)
| | - Justin E Davies
- From the National Heart and Lung Institute, Imperial College London, London, United Kingdom (S.S.N., R.P., S.S., R.A.F., C.B., R.A.-L., N.F., A.S., I.S.M., G.W.M., A.D.H., J.M., D.P.F., C.D.M., J.E.D.); AMC Heart Centre, Amsterdam Medical Centre, Amsterdam, The Netherlands (T.P.v.d.H., M.A.v.L., J.J.P.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.); Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.); and Cardiovascular National Institute of Health Research Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (C.D.M.).
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