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Yoneyama S, Hoyano M, Ozaki K, Ikegami R, Kubota N, Okubo T, Yanagawa T, Kurokawa T, Akiyama T, Washiyama Y, Kashimura T, Inomata T. Pd/Pa fluctuation with continuous ATP administration indicates inaccurate FFR measurement caused by insufficient hyperemia. Heart Vessels 2025; 40:8-15. [PMID: 38981910 DOI: 10.1007/s00380-024-02438-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 07/03/2024] [Indexed: 07/11/2024]
Abstract
Continuous intravenous adenosine triphosphate (ATP) administration is the standard method for inducing maximal hyperemia in fractional flow reserve (FFR) measurements. Several cases have demonstrated fluctuations in the ratio of mean distal coronary pressure to mean arterial pressure (Pd/Pa) value during ATP infusion, which raised our suspicions of FFR value inaccuracy. This study aimed to investigate our hypothesis that Pd/Pa fluctuations may indicate inaccurate FFR measurements caused by insufficient hyperemia. We examined 57 consecutive patients with angiographically intermediate coronary lesions who underwent fractional flow reverse (FFR) measurements in our hospital between November 2016 and September 2018. Pd/Pa was measured after continuous ATP administration (150 μg/kg/min) via a peripheral forearm vein for 5 min (FFRA); and we analyzed the FFR value variation in the final 20 s of the 5 min, defining 'Fluctuation' as variation range > 0.03. Then, 2 mg of nicorandil was administered into the coronary artery during continued ATP infusion, and the Pd/Pa was remeasured (FFRA+N). Fluctuations were observed in 23 of 57 patients. The cases demonstrating discrepancies of > 0.05 between FFRA and FFRA+N were observed more frequently in the fluctuation group than in the non-fluctuation group (12/23 vs. 1/34; p < 0.0001). The discrepancy between FFRA and FFRA+N values was smaller in the non-fluctuation group (mean difference ± SD; -0.00026 ± 0.04636 vs. 0.02608 ± 0.1316). Pd/Pa fluctuation with continuous ATP administration could indicate inaccurate FFR measurements caused by incomplete hyperemia. Additional vasodilator administration may achieve further hyperemia when Pd/Pa fluctuations are observed.
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Affiliation(s)
- Shintaro Yoneyama
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan.
| | - Makoto Hoyano
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Kazuyuki Ozaki
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Ryutaro Ikegami
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Naoki Kubota
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takeshi Okubo
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takao Yanagawa
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takakuni Kurokawa
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takumi Akiyama
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Yuzo Washiyama
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takeshi Kashimura
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
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Hada M, Usui E, Wakasa N, Hoshino M, Kanaji Y, Nagamine T, Nogami K, Ueno H, Setoguchi M, Tahara T, Mineo T, Yonetsu T, Sasano T, Kakuta T. Discordant diagnosis of coronary microvascular dysfunction by microvascular resistance reserve: Transthoracic Doppler echocardiography vs bolus thermodilution method. Hellenic J Cardiol 2024:S1109-9666(24)00263-X. [PMID: 39672538 DOI: 10.1016/j.hjc.2024.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2024] [Revised: 11/10/2024] [Accepted: 12/05/2024] [Indexed: 12/15/2024] Open
Abstract
OBJECTIVE Epicardial stenosis and coronary microvascular dysfunction (CMD) may coexist in patients with chronic coronary syndrome (CCS). Microvascular resistance reserve (MRR) has been demonstrated to be a valid cross-modality metric using continuous saline infusion thermodilution and intracoronary Doppler flow velocity methods. This study aimed to investigate the prevalence and diagnostic concordance of CMD defined by MRR using two methods-stress transthoracic Doppler echocardiography (S-TDE) and the invasive bolus thermodilution method (B-Thermo)-in patients with functionally significant epicardial stenosis. METHODS We retrospectively investigated 204 left anterior descending artery (LAD) territories in CCS. All patients underwent physiological assessment using a pressure-temperature wire and S-TDE before elective fractional flow reserve (FFR)-guided percutaneous coronary intervention. The concordance rate was evaluated using κ values. RESULTS In the final analysis, the median age was 72 years, and 72.5% of patients were male. The median FFR value was 0.69. MRRS-TDE and MRRB-Thermo were similar (3.41 vs 3.48, P = 0.877), whereas only a weak, albeit significant relationship was observed between these two metrics (r = 0.167, P = 0.017). CMD was diagnosed in 20.6% and 32.8% of patients using S-TDE and B-Thermo, respectively, when a cutoff MRR value of 2.7 was applied. The concordance rate of CMD diagnosis between the two methods was low (κ = 0.079). CONCLUSION MRRS-TDE and MRRB-Thermo showed a very weak correlation in the LAD territory with functionally significant stenosis in patients with CCS. The prevalence of CMD diagnosed using MRRS-TDE and MRRB-Thermo was not comparable, and the diagnostic concordance of CMD using these two methods was very low.
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Affiliation(s)
- Masahiro Hada
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Eisuke Usui
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Nobutaka Wakasa
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Yoshihisa Kanaji
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Tatsuhiro Nagamine
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Kai Nogami
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Hiroki Ueno
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Mirei Setoguchi
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Tomohiro Tahara
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Takashi Mineo
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan.
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Mensink FB, Los J, Oemrawsingh RM, von Birgelen C, Ijsselmuiden A, Meuwissen M, Cheng JM, van Wijk DF, Smits PC, Paradies V, van der Heijden DJ, Rai H, ten Cate TJF, Camaro C, Damman P, van Nunen LX, Dimitriu-Leen AC, van Wely MH, Cetinyurek-Yavuz A, Byrne RA, van Royen N, van Geuns RJM. Functional and morphological improvement of significant non-culprit coronary artery stenosis by LDL-C reduction with a PCSK9 antibody: Rationale and design of the randomized FITTER trial. Heliyon 2024; 10:e38077. [PMID: 39430462 PMCID: PMC11489145 DOI: 10.1016/j.heliyon.2024.e38077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Accepted: 09/17/2024] [Indexed: 10/22/2024] Open
Abstract
Non-culprit coronary artery lesions are commonly present in patients presenting with an acute coronary syndrome (ACS). Additional stenting of non-culprit lesions in addition to the culprit lesion intends to prevent secondary events caused by these lesions. At the same time, multiple trials have demonstrated the potential of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in reducing plaque size and changing plaque composition of non-culprit lesions. Whether intensive low-density lipoprotein cholesterol (LDL-C) reduction with PCSK9 inhibitor evolocumab improves non-culprit vessel hemodynamics, reduces the risk of plaque rupture of important non-culprit lesions, and might obviate the need for additional stenting has not been investigated. The "Functional Improvement of non-infarcT related coronary artery stenosis by Extensive LDL-C Reduction with a PCSK9 Antibody" (FITTER) trial is a multi-center, randomized, double-blind, placebo-controlled clinical trial for patients presenting with ACS and multivessel disease (MVD). After treatment of the culprit lesion, fractional flow reserve (FFR) is performed in non-culprit vessels amenable for percutaneous coronary intervention (PCI). Coronary intervention in patients with hemodynamically important non-critical lesions (FFR: 0.67-0.85) is staged after baseline imaging using near-infrared spectroscopy (NIRS) and intravascular ultrasound (IVUS). Eligible patients are randomized and treated for 12 weeks with either evolocumab or placebo, in addition to high-intensity statin therapy. Follow-up angiography with repeat FFR and IVUS-NIRS is scheduled at 12 weeks. Staged PCI is performed at the operator's discretion.The FITTER trial is the first study to evaluate the effect of maximal LDL-C reduction by the PCSK9 inhibitor evolocumab on invasively measured FFR, plaque size, and plaque composition in hemodynamically important non-culprit lesions, during a treatment period of just 12 weeks after an ACS. Currently, all patients have been included (August 2023) and data analysis is ongoing. Trial registration number clinicaltrials.gov NCT04141579.
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Affiliation(s)
- Frans B. Mensink
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jonathan Los
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rohit M. Oemrawsingh
- Department of Cardiology, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | | | - Alexander Ijsselmuiden
- Department of Cardiology, Amphia Hospital, Breda, the Netherlands
- Department of Cardiology, Maastricht University Medical Center, the Netherlands
| | | | - Jin M. Cheng
- Department of Cardiology, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
- Department of Cardiology, Amphia Hospital, Breda, the Netherlands
| | - Diederik F. van Wijk
- Department of Cardiology, Noordwest Ziekenhuisgroep, Locatie Alkmaar, Alkmaar, the Netherlands
| | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Himanshu Rai
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Cardiovascular Research Institute Dublin and Department of Cardiology, Mater Private Network, Dublin, Ireland
| | - Tim JF. ten Cate
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Cyril Camaro
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lokien X. van Nunen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Marleen H. van Wely
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Robert A. Byrne
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Cardiovascular Research Institute Dublin and Department of Cardiology, Mater Private Network, Dublin, Ireland
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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Kern MJ, Seto AH. Does PPG, the Other Dimension to FFR, Better Predict Post-PCI Results? Circulation 2024; 150:598-599. [PMID: 39159226 DOI: 10.1161/circulationaha.124.070439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2024]
Affiliation(s)
- Morton J Kern
- Interventional Cardiology (M.J.K.)
- Long Beach Veteran's Administration Medical Center, Long Beach, CA (M.J.K.)
- University of California Irvine, Orange, CA (M.J.K., A.H.S.)
| | - Arnold H Seto
- Cardiac Catheterization Laboratory (A.H.S.)
- University of California Irvine, Orange, CA (M.J.K., A.H.S.)
- Charles R. Drew University, Los Angeles, CA (A.H.S.)
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Mineo R, Salanitri FP, Bellitto G, Kavasidis I, Filippo OD, Millesimo M, Ferrari GMD, Aldinucci M, Giordano D, Palazzo S, D'Ascenzo F, Spampinato C. A Convolutional-Transformer Model for FFR and iFR Assessment From Coronary Angiography. IEEE TRANSACTIONS ON MEDICAL IMAGING 2024; 43:2866-2877. [PMID: 38954582 DOI: 10.1109/tmi.2024.3383283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
The quantification of stenosis severity from X-ray catheter angiography is a challenging task. Indeed, this requires to fully understand the lesion's geometry by analyzing dynamics of the contrast material, only relying on visual observation by clinicians. To support decision making for cardiac intervention, we propose a hybrid CNN-Transformer model for the assessment of angiography-based non-invasive fractional flow-reserve (FFR) and instantaneous wave-free ratio (iFR) of intermediate coronary stenosis. Our approach predicts whether a coronary artery stenosis is hemodynamically significant and provides direct FFR and iFR estimates. This is achieved through a combination of regression and classification branches that forces the model to focus on the cut-off region of FFR (around 0.8 FFR value), which is highly critical for decision-making. We also propose a spatio-temporal factorization mechanisms that redesigns the transformer's self-attention mechanism to capture both local spatial and temporal interactions between vessel geometry, blood flow dynamics, and lesion morphology. The proposed method achieves state-of-the-art performance on a dataset of 778 exams from 389 patients. Unlike existing methods, our approach employs a single angiography view and does not require knowledge of the key frame; supervision at training time is provided by a classification loss (based on a threshold of the FFR/iFR values) and a regression loss for direct estimation. Finally, the analysis of model interpretability and calibration shows that, in spite of the complexity of angiographic imaging data, our method can robustly identify the location of the stenosis and correlate prediction uncertainty to the provided output scores.
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Vira A, Balanescu DV, George JA, Dixon SR, Hanson ID, Safian RD. Diagnostic Performance of Diastolic Hyperemia-Free Ratio Compared With Invasive Fractional Flow Reserve for Evaluation of Coronary Artery Disease. Am J Cardiol 2024; 214:55-58. [PMID: 38199309 DOI: 10.1016/j.amjcard.2023.12.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/04/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024]
Abstract
Hyperemic and nonhyperemic pressure ratios are frequently used to assess the hemodynamic significance of coronary artery disease and to guide the need for myocardial revascularization. However, there are limited data on the diagnostic performance of the diastolic hyperemia-free ratio (DFR). We evaluated the diagnostic performance of the DFR compared with invasive fractional flow reserve (FFR). We performed a prospective, single-center study of 308 patients (343 lesions) who underwent DFR and FFR for evaluation of visually estimated 40% to 90% stenoses. Diagnostic performance of the DFR compared with FFR was evaluated using linear regression, Bland-Altman analysis, and receiver operating characteristic curves. The overall diagnostic accuracy of the DFR was 83%; the accuracy rates were 86%, 40%, and 95% when the DFR was <0.86, 0.88 to 0.90, and >0.93, respectively. The sensitivity, specificity, positive predicative value, and negative predictive value were 60%, 91%, 71%, and 87%, respectively. The Pearson correlation coefficient was 0.75 (p <0.05). The Bland-Altman analysis showed a mean difference of 0.09, and the area under the receiver operating characteristic curve was 0.88 (95% confidence interval 0.84 to 0.92, p <0.05). In conclusion, the DFR has a good diagnostic performance compared with FFR but 17% of the measurements were discordant. The diagnostic accuracy of the DFR was only 40% when the DFR was 0.88 to 0.90, suggesting that FFR may be useful in these arteries.
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Affiliation(s)
- Amit Vira
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan
| | - Dinu-Valentin Balanescu
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan
| | - Julie A George
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan
| | - Simon R Dixon
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan
| | - Ivan D Hanson
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan
| | - Robert D Safian
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan.
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Albayati MA, Patel A, Modi B, Saha P, Karim L, Perera D, Smith A, Modarai B. Intra-arterial Fractional Flow Reserve Measurements Provide an Objective Assessment of the Functional Significance of Peripheral Arterial Stenoses. Eur J Vasc Endovasc Surg 2024; 67:332-340. [PMID: 37500005 PMCID: PMC10917690 DOI: 10.1016/j.ejvs.2023.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 07/05/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE Peripheral arterial stenoses (PAS) are commonly investigated with duplex ultrasound (DUS) and angiography, but these are not functional tests. Fractional flow reserve (FFR), a pressure based index, functionally assesses the ischaemic potential of coronary stenoses, but its utility in PAS is unknown. FFR in the peripheral vasculature in patients with limb ischaemia was investigated. METHODS Patients scheduled for angioplasty and or stenting of isolated iliac and superficial femoral artery stenoses were recruited. Resting trans-lesional pressure gradient (Pd/Pa) and FFR were measured after adenosine provoked hyperaemia using an intra-arterial 0.014 inch flow and pressure sensing wire (ComboWire XT, Philips). Prior to revascularisation, exercise ABPI (eABPI) and DUS derived peak systolic velocity ratio (PSVR) of the index lesion were determined. Calf muscle oxygenation was measured using blood oxygenation level dependent cardiovascular magnetic resonance prior to and after revascularisation. RESULTS Forty-one patients (32, 78%, male, mean age 65 ± 11 years) with 61 stenoses (iliac 32; femoral 29) were studied. For lesions < 80% stenosis, resting Pd/Pa was not influenced by the degree of stenosis (p = .074); however, FFR was discriminatory, decreasing as the severity of stenosis increased (p = .019). An FFR of < 0.60 was associated with critical limb threatening ischaemia (area under the curve [AUC] 0.87; 95% CI 0.75 - 0.95), in this study performing better than angiographic % stenosis (0.79; 0.63 - 0.89), eABPI (0.72; 0.57 - 0.83), and PSVR (0.65; 0.51 - 0.78). FFR correlated strongly with calf oxygenation (rho, 0.76; p < .001). A greater increase in FFR signalled resolution of symptoms and signs (ΔFFR 0.25 ± 0.15 vs. 0.13 ± 0.09; p = .009) and a post-angioplasty and stenting FFR of > 0.74 predicted successful revascularisation (combined sensitivity and specificity of 95%; AUC 0.98; 0.91 - 1.00). CONCLUSION This pilot study demonstrates that FFR can objectively measure the functional significance of PAS that compares favourably with visual and DUS based assessments. Its role as a quality control adjunct that confirms optimal vessel patency after angioplasty and or stenting also merits further investigation.
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Affiliation(s)
- Mostafa A Albayati
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Ashish Patel
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Bhavik Modi
- Department of Cardiology, School of Cardiovascular and Metabolic Medicine and Sciences, King's BHF Centre of Excellence, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Prakash Saha
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Lawen Karim
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Divaka Perera
- Department of Cardiology, School of Cardiovascular and Metabolic Medicine and Sciences, King's BHF Centre of Excellence, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Alberto Smith
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Bijan Modarai
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom.
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Hu F, Ding D, Westra J, Li Y, Yu W, Wang Z, Kubo T, Chico JLG, Chen Y, Wijns W, Tu S. Diagnostic accuracy of optical flow ratio: an individual patient-data meta-analysis. EUROINTERVENTION 2023; 19:e145-e154. [PMID: 36950895 PMCID: PMC10242661 DOI: 10.4244/eij-d-22-01098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 01/18/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Optical flow ratio (OFR) is a novel method for the fast computation of fractional flow reserve (FFR) from optical coherence tomography. AIMS We aimed to evaluate the diagnostic accuracy of OFR in assessing intermediate coronary stenosis using wire-based FFR as the reference. METHODS We performed an individual patient-level meta-analysis of all available studies with paired OFR and FFR assessments. The primary outcome was vessel-level diagnostic concordance of the OFR and FFR, using a cut-off of ≤0.80 to define ischaemia and ≤0.90 to define suboptimal post-percutaneous coronary intervention (PCI) physiology. This meta-analysis was registered in PROSPERO (CRD42021287726). RESULTS Five studies were finally included, providing 574 patients and 626 vessels (404 pre-PCI and 222 post-PCI) with paired OFR and FFR from 9 international centres. Vessel-level diagnostic concordance of the OFR and FFR was 91% (95% confidence interval [CI]: 88%-94%), 87% (95% CI: 82%-91%), and 90% (95% CI: 87%-92%) in pre-PCI, post-PCI, and overall, respectively. The overall sensitivity, specificity, and positive and negative predictive values were 84% (95% CI: 79%-88%), 94% (95% CI: 92%-96%), 90% (95% CI: 86%-93%), and 89% (95% CI: 86%-92%), respectively. Multivariate logistic regression indicated that a low pullback speed (odds ratio [OR] 7.02, 95% CI: 1.68-29.43; p=0.008) was associated with a higher risk of obtaining OFR values at least 0.10 higher than FFR. Increasing the minimal lumen area was associated with a lower risk of obtaining an OFR at least 0.10 lower than FFR (OR 0.39, 95% CI: 0.18-0.82; p=0.013). CONCLUSIONS This individual patient data meta-analysis demonstrated a high diagnostic accuracy of OFR. OFR has the potential to provide an improved integration of intracoronary imaging and physiological assessment for the accurate evaluation of coronary artery disease.
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Affiliation(s)
- Fukang Hu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Daixin Ding
- The Lambe Institute for Translational Research, Smart Sensors Laboratory and CURAM, University of Galway, Galway, Ireland
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Yingguang Li
- Kunshan Industrial Technology Research Institute, Suzhou, People's Republic of China
| | - Wei Yu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Zhiqing Wang
- Department of Cardiology, Fujian Medical University Union Hospital, Fujian, China
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | | | - Yundai Chen
- Department of Cardiology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - William Wijns
- The Lambe Institute for Translational Research, Smart Sensors Laboratory and CURAM, University of Galway, Galway, Ireland
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, People's Republic of China
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9
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Pellegrini D, Caramori PRA, Soccol RC, Lasevitch R, Agostini GL, Dussin A, Ferreira FVC, Wagner MB, Bodanese LC. Prognostic Assessment of Fractional Flow Reserve in Different Strata in Patients with Coronary Artery Disease. Arq Bras Cardiol 2023; 120:e20211051. [PMID: 37341225 PMCID: PMC10263408 DOI: 10.36660/abc.20211051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 01/23/2023] [Accepted: 04/05/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND There are limited real-world data on the clinical course of untreated coronary lesions according to their functional severity. OBJECTIVE To evaluate the 5-year clinical outcomes of patients with revascularized lesions with fractional flow reserve (FFR) ≤ 0.8 and patients with non-revascularized lesions with FFR > 0.8. METHODS The FFR assessment was performed in 218 patients followed for up to 5 years. Participants were classified based on FFR into ischemia group (≤ 0.8, intervention group, n = 55), low-normal FFR group (> 0.8-0.9, n = 91), and high-normal FFR group (> 0.9, n = 72). The primary endpoint was major adverse cardiac events (MACEs), a composite of death, myocardial infarction, and need for repeat revascularization. The significance level was set at 0.05; therefore, results with a p-value < 0.05 were considered statistically significant. RESULTS Most patients were male (62.8%) with a mean age of 64.1 years. Diabetes was present in 27%. On coronary angiography, the severity of stenosis was 62% in the ischemia group, 56.4% in the low-normal FFR group, and 54.3% in the high-normal FFR group (p<0.05). Mean follow-up was 3.5 years. The incidence of MACEs was 25.5%, 13.2%, and 11.1%, respectively (p=0.037). MACE incidence did not differ significantly between the low-normal and high-normal FFR groups. CONCLUSION Patients with FFR indicative of ischemia had poorer outcomes than those in non-ischemia groups. There was no difference in the incidence of events between the low-normal and high-normal FFR groups. Long-term studies with a large sample size are needed to better assess cardiovascular outcomes in patients with moderate coronary stenosis with FFR values between 0.8 and 1.0.
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Affiliation(s)
- Denise Pellegrini
- Pontifícia Universidade Católica do Rio Grande do SulPorto AlegreRSBrasilPontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS – Brasil
| | - Paulo R. A. Caramori
- Hospital São LucasPUCRSPorto AlegreRSBrasilHospital São Lucas da PUCRS, Porto Alegre, RS – Brasil
| | - Ricardo Czarnobai Soccol
- Hospital São LucasPUCRSPorto AlegreRSBrasilHospital São Lucas da PUCRS, Porto Alegre, RS – Brasil
| | - Ricardo Lasevitch
- Hospital São LucasPUCRSPorto AlegreRSBrasilHospital São Lucas da PUCRS, Porto Alegre, RS – Brasil
| | - Gustavo Luís Agostini
- Hospital São LucasPUCRSPorto AlegreRSBrasilHospital São Lucas da PUCRS, Porto Alegre, RS – Brasil
| | - Alice Dussin
- Pontifícia Universidade Católica do Rio Grande do SulPorto AlegreRSBrasilPontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS – Brasil
| | | | - Mario Bernardes Wagner
- Pontifícia Universidade Católica do Rio Grande do SulPorto AlegreRSBrasilPontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS – Brasil
| | - Luiz Carlos Bodanese
- Hospital São LucasPUCRSPorto AlegreRSBrasilHospital São Lucas da PUCRS, Porto Alegre, RS – Brasil
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10
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Boutaleb AM, Ghafari C, Ungureanu C, Carlier S. Fractional flow reserve and non-hyperemic indices: Essential tools for percutaneous coronary interventions. World J Clin Cases 2023; 11:2123-2139. [PMID: 37122527 PMCID: PMC10131021 DOI: 10.12998/wjcc.v11.i10.2123] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/22/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Hemodynamical evaluation of a coronary artery lesion is an important diagnostic step to assess its functional impact. Fractional flow reserve (FFR) received a class IA recommendation from the European Society of Cardiology for the assessment of angiographically moderate stenosis. FFR evaluation of coronary artery disease offers improvement of the therapeutic strategy, deferring unnecessary procedures for lesions with a FFR > 0.8, improving patients' management and clinical outcome. Post intervention, an optimal FFR > 0.9 post stenting should be reached and > 0.8 post drug eluting balloons. Non-hyperemic pressure ratio measurements have been validated in previous studies with a common threshold of 0.89. They might overestimate the hemodynamic significance of some lesions but remain useful whenever hyperemic agents are contraindicated. FFR remains the gold standard reference for invasive assessment of ischemia. We illustrate this review with two cases introducing the possibility to estimate also non-invasively FFR from reconstructed 3-D angiograms by quantitative flow ratio. We conclude introducing a hybrid approach to intermediate lesions (DFR 0.85-0.95) potentially maximizing clinical decision from all measurements.
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Affiliation(s)
- Amine Mamoun Boutaleb
- Department of Cardiology, Ibn Rochd University Hospital, Casablanca 20230, Casablanca, Morocco
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
| | - Chadi Ghafari
- Department of Cardiology, University of Mons, Mons 7000, Belgium
| | - Claudiu Ungureanu
- Department of Cardiology, University of Mons, Mons 7000, Belgium
- Catheterization Unit, Jolimont Hospital, La Louvière 7100, Belgium, Belgium
| | - Stéphane Carlier
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
- Department of Cardiology, University of Mons, Mons 7000, Belgium
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11
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Matsumoto H, Higuchi S, Tanaka H, Masaki R, Kondo S, Tsujita H, Shinke T. Insufficient adenosine-induced hyperemia is a major determinant of discordance between non-hyperemic pressure ratio and fractional flow reserve. Sci Rep 2023; 13:729. [PMID: 36639567 PMCID: PMC9839754 DOI: 10.1038/s41598-023-27929-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023] Open
Abstract
Adenosine occasionally overestimates fractional flow reserve (FFR) values (i.e., insufficient adenosine-induced hyperemia), leading to low non-hyperemic pressure ratios (NHPR)-high FFR discordance. We investigated the impact of insufficient adenosine-induced hyperemia on NHPR-FFR discordance and the reclassification of functional significance. We measured resting distal-to-aortic pressure ratio (Pd/Pa) and FFR by using adenosine (FFRADN) and papaverine (FFRPAP) in 326 patients (326 vessels). FFRADN overestimation was calculated as FFRADN - FFRPAP. We explored determinants of low Pd/Pa - high FFRADN discordance (Pd/Pa ≤ 0.92 and FFRADN > 0.80) versus high Pd/Pa - low FFRADN discordance (Pd/Pa > 0.92 and FFRADN ≤ 0.80). Reclassification of functional significance was defined as FFRADN > 0.80 and FFRPAP ≤ 0.80. Multivariable analysis identified FFRADN overestimation (p = 0.002) and heart rate at baseline (p = 0.048) as independent determinants of the low Pd/Pa-high FFRADN discordance. In the low Pd/Pa-high FFRADN group (n = 26), papaverine produced a further decline in the FFR value in 21 vessels (81%) compared with FFRADN, and the reclassification was observed in 17 vessels (65%). Insufficient adenosine-induced hyperemia is a major determinant of the low resting Pd/Pa-high FFR discordance. Physicians should bear in mind that the presence of low NHPR-high FFR discordance may indicate a false-negative FFR result.
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Affiliation(s)
- Hidenari Matsumoto
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan.
| | - Satoshi Higuchi
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Hideaki Tanaka
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Ryota Masaki
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Seita Kondo
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Hiroaki Tsujita
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
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12
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Chiabrando JG, Seropian IM. A Correct FFR Trace Interpretation Is Important for a Clinical Decision. JACC Case Rep 2022; 4:1387. [PMID: 36299655 PMCID: PMC9588584 DOI: 10.1016/j.jaccas.2022.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
| | - Ignacio M. Seropian
- Interventional Cardiology Department, Hospital Italiano de Buenos Aires 4190, Presidente Juan Domingo Peron Street, Buenos Aires City C1199, Argentina
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13
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Matsumoto H, Masaki R, Higuchi S, Tanaka H, Kondo S, Tsujita H, Shinke T. Impact of overestimation of fractional flow reserve by adenosine on anatomical-functional mismatch. Sci Rep 2022; 12:14962. [PMID: 36056128 PMCID: PMC9440099 DOI: 10.1038/s41598-022-19330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/29/2022] [Indexed: 11/08/2022] Open
Abstract
Adenosine occasionally results in overestimation of fractional flow reserve (FFR) values, compared with other hyperemic stimuli. We aimed to elucidate the association of overestimation of FFR by adenosine with anatomically significant but functionally non-significant lesions (anatomical-functional mismatch) and its influence on reclassification of functional significance. Distal-to-aortic pressure ratio (Pd/Pa) was measured using adenosine (Pd/PaADN) and papaverine (Pd/PaPAP) in 326 patients (326 vessels). The overestimation of FFR was calculated as Pd/PaADN-Pd/PaPAP. The anatomical-functional mismatch was defined as diameter stenosis > 50% and Pd/PaADN > 0.80. Reclassification was indicated by Pd/PaADN > 0.80 and Pd/PaPAP ≤ 0.80. The mismatch (n = 72) had a greater overestimation of FFR than the non-mismatch (n = 99): median 0.02 (interquartile range 0.01-0.05) versus 0.01 (0.00-0.04), p = 0.014. Multivariable analysis identified the overestimation of FFR (p = 0.003), minimal luminal diameter (p = 0.001), and non-left anterior descending artery (LAD) location (p < 0.001) as determinants of the mismatch. Reclassification was indicated in 29% of the mismatch and was more frequent in the LAD than in the non-LAD (52% vs. 20%, p = 0.005). The overestimation of FFR is an independent determinant of anatomical-functional mismatch. Anatomical-functional mismatch, specifically in the LAD, may suggest a false-negative result.
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Affiliation(s)
- Hidenari Matsumoto
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan.
| | - Ryota Masaki
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Satoshi Higuchi
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Hideaki Tanaka
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Seita Kondo
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Hiroaki Tsujita
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
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14
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Zimmermann FM, Fearon WF. What makes an ideal hyperemic drug? Int J Cardiol 2022; 362:22-23. [PMID: 35671899 DOI: 10.1016/j.ijcard.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/28/2022] [Accepted: 06/01/2022] [Indexed: 11/05/2022]
Affiliation(s)
| | - William F Fearon
- Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University, Stanford, CA, United States of America; VA Palo Alto Health Care System, Palo Alto, CA, United States of America.
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15
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Jeremias A, Nijjer S, Davies J, DiMario C. Physiologic Assessment and Guidance in the Cardiac Catheterization Laboratory. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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16
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Comparison of efficacy and safety of intracoronary nicardipine and adenosine for fractional flow reserve assessment of coronary stenosis. Int J Cardiol 2022; 356:1-5. [PMID: 35395290 DOI: 10.1016/j.ijcard.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/17/2022] [Accepted: 04/01/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Administration of intracoronary (IC) adenosine allows an easily feasible, inexpensive, and more rapid alternative method for fractional flow reserve (FFR). It is common practice in many centers worldwide. Nicardipine is a strong coronary vasodilator but its efficacy and safety for assessing FFR is not established. The purpose of present study was to compare the efficacy and safety of IC nicardipine and adenosine for assessing FFR. METHODS One hundred and fifty-nine patients with a total of 193 vessels undergoing clinically indicated FFR assessment of intermediate coronary stenoses were included. For the initial assessment of FFR, hyperemia was induced by an IC adenosine. After a washout period of 3 min, FFR was reassessed using 200 μg of IC nicardipine. RESULTS Hyperemic efficacy among two different stimuli was compared. The mean FFR with IC adenosine was 0.83 ± 0.09 and that with an IC nicardipine was 0.84 ± 0.09. The median FFR with an IC adenosine was 0.83 (0.78-0.91) and that with an IC nicardipine was 0.85 (0.79-0.91) (p-value 0.246). Both FFR values showed an excellent correlation (R2 = 0.982, p < 0.001). Nicardipine produced fewer changes in heart rate, less chest pain and less flushing than adenosine. Transient atrioventricular block occurred in 29 patients with IC adenosine and none with IC nicardipine. CONCLUSIONS IC bolus injection of nicardipine could be introduced as a safe and practical alternative method of inducing hyperemia during FFR measurements. Compared to IC adenosine, IC nicardipine has a similar hyperemic efficacy and excellent side-effect profile.
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17
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Westra J, Sejr-Hansen M, Koltowski L, Mejía-Rentería H, Tu S, Kochman J, Zhang Y, Liu T, Campo G, Hjort J, Mogensen LJH, Erriquez A, Andersen BK, Eftekhari A, Escaned J, Christiansen EH, Holm NR. Reproducibility of quantitative flow ratio: the QREP study. EUROINTERVENTION 2022; 17:1252-1259. [PMID: 34219667 PMCID: PMC9724855 DOI: 10.4244/eij-d-21-00425] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Quantitative flow ratio (QFR) is a tool for physiological lesion assessment based on invasive coronary angiography. AIMS We aimed to assess the reproducibility of QFR computed from the same angiograms as assessed by multiple observers from different, international sites. METHODS We included 50 patients previously enrolled in dedicated QFR studies. QFR was computed twice, one month apart by five blinded observers. The main analysis was the coefficient of variation (CV) as a measure of intra- and inter-observer reproducibility. Key secondary analysis was the identification of clinical and procedural characteristics predicting reproducibility. RESULTS The intra-observer CV ranged from 2.3% (1.5-2.8) to 10.2% (6.6-12.0) among the observers. The inter-observer CV was 9.4% (8.0-10.5). The QFR observer, low angiographic quality, and low fractional flow reserve (FFR) were independent predictors of a large absolute difference between repeated QFR measurements defined as a difference larger than the median difference (>0.03). CONCLUSIONS The inter- and intra-observer reproducibility for QFR computed from the same angiograms ranged from high to poor among multiple observers from different sites with an average agreement of 0.01±0.08 for repeated measurements. The reproducibility was dependent on the observer, angiographic quality and the coronary artery stenosis severity as assessed by FFR.
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Affiliation(s)
- Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | | | - Lukasz Koltowski
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | - Shengxian Tu
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Janusz Kochman
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Yimin Zhang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Tommy Liu
- Department of Cardiology, Hagaziekenhuis, The Hague, the Netherlands
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Ferrara, Italy and Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
| | - Jakob Hjort
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | | | - Andrea Erriquez
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Ferrara, Italy and Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
| | | | - Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Javier Escaned
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
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18
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Marin F, Scarsini R, Terentes-Printzios D, Kotronias RA, Ribichini F, Banning AP, De Maria GL. The Role of Coronary Physiology in Contemporary Percutaneous Coronary Interventions. Curr Cardiol Rev 2022; 18:e080921196264. [PMID: 34521331 PMCID: PMC9241117 DOI: 10.2174/1573403x17666210908114154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/21/2021] [Accepted: 03/02/2021] [Indexed: 01/10/2023] Open
Abstract
Invasive assessment of coronary physiology has radically changed the paradigm of myocardial revascularization in patients with coronary artery disease. Despite the prognostic improvement associated with ischemia-driven revascularization strategy, functional assessment of angiographic intermediate epicardial stenosis remains largely underused in clinical practice. Multiple tools have been developed or are under development in order to reduce the invasiveness, cost, and extra procedural time associated with the invasive assessment of coronary physiology. Besides epicardial stenosis, a growing body of evidence highlights the role of coronary microcirculation in regulating coronary flow with consequent pathophysiological and clinical and prognostic implications. Adequate assessment of coronary microcirculation function and integrity has then become another component of the decision-making algorithm for optimal diagnosis and treatment of coronary syndromes. This review aims at providing a comprehensive description of tools and techniques currently available in the catheterization laboratory to obtain a thorough and complete functional assessment of the entire coronary tree (both for the epicardial and microvascular compartments).
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Affiliation(s)
- Federico Marin
- Division of Cardiology, University of Verona, Verona, Italy.,Oxford Heart Centre, Oxford University Hospitals, Oxford, United Kingdom
| | | | | | - Rafail A Kotronias
- Oxford Heart Centre, Oxford University Hospitals, Oxford, United Kingdom
| | | | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals, Oxford, United Kingdom
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19
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Tanaka H, Matsumoto H, Takahashi H, Hosonuma M, Sato S, Ogura K, Oishi Y, Masaki R, Sakai K, Sekimoto T, Kondo S, Tsujita H, Tsukamoto S, Sumida A, Okada N, Inoue K, Shinke T. Linear concentration-response relationship of serum caffeine with adenosine-induced fractional flow reserve overestimation: a comparison with papaverine. EUROINTERVENTION 2021; 17:e925-e931. [PMID: 34647891 PMCID: PMC9725067 DOI: 10.4244/eij-d-21-00453] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Caffeine intake from one cup of coffee one hour before adenosine stress tests, corresponding to serum caffeine levels of 3-4 mg/L, is thought to be acceptable for non-invasive imaging. AIMS We aimed to elucidate whether serum caffeine is independently associated with adenosine-induced fractional flow reserve (FFR) overestimation and their concentration-response relationship. METHODS FFR was measured using adenosine (FFRADN) and papaverine (FFRPAP) in 209 patients. FFRADN overestimation was defined as FFRADN - FFRPAP. The locally weighted scatterplot smoothing (LOWESS) approach was applied to evaluate the relationship between serum caffeine level and FFRADN overestimation. Multiple regression analysis was used to determine independent factors associated with FFRADN overestimation. RESULTS Caffeine was ingested at <12 hours in 85 patients, at 12-24 hours in 35 patients, and at >24 hours in 89 patients. Multiple regression analysis identified serum caffeine level as the strongest factor associated with FFRADN overestimation (p<0.001). The LOWESS curve demonstrated that FFRADN overestimation started from just above the lower detection limit of serum caffeine and increased approximately 0.01 FFR unit per 1 mg/L increase in serum caffeine level with a linear relationship. The 90th percentile of serum caffeine levels for the ≤12-hour, the 12-24-hour, and the >24-hour groups corresponded to FFRADN overestimations by 0.06, 0.03, and 0.02, respectively. CONCLUSIONS Serum caffeine overestimates FFRADN values in a linear concentration-response manner. FFRADN overestimation occurs at much lower serum caffeine levels than those that were previously believed. Our results highlight that standardised caffeine control is required for reliable adenosine-induced FFR measurements.
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Affiliation(s)
- Hideaki Tanaka
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Hidenari Matsumoto
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Haruya Takahashi
- Division of Food Science and Biotechnology, Graduate School of Agriculture, Kyoto University, Uji, Kyoto, Japan
| | - Masahiro Hosonuma
- Department of Clinical Immuno Oncology, Clinical Research Institute for Clinical Pharmacology and Therapeutics, Showa University, Tokyo, Japan
| | - Shunya Sato
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Kunihiro Ogura
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Yosuke Oishi
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Ryota Masaki
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Koshiro Sakai
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Teruo Sekimoto
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Seita Kondo
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Hiroaki Tsujita
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Shigeto Tsukamoto
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Arihiro Sumida
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Natsumi Okada
- Department of Clinical Immuno Oncology, Clinical Research Institute for Clinical Pharmacology and Therapeutics, Showa University, Tokyo, Japan
| | - Kazuo Inoue
- Department of Hospital Pharmaceutics, Showa University School of Pharmacy, Tokyo, Japan
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
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20
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Feenstra RGT, van Lavieren MA, Echavarria-Pinto M, Wijntjens GW, Stegehuis VE, Meuwissen M, de Winter RJ, Beijk MAM, Lerman A, Escaned J, Piek JJ, van de Hoef TP. Respiration-related variations in Pd/Pa ratio and fractional flow reserve in resting conditions and during intravenous adenosine administration. Catheter Cardiovasc Interv 2021; 99:844-852. [PMID: 34766734 PMCID: PMC9543847 DOI: 10.1002/ccd.30012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/06/2021] [Accepted: 10/17/2021] [Indexed: 01/09/2023]
Abstract
Aims We evaluated the occurrence and physiology of respiration‐related beat‐to‐beat variations in resting Pd/Pa and FFR during intravenous adenosine administration, and its impact on clinical decision‐making. Methods and Results Coronary pressure tracings in rest and at plateau hyperemia were analyzed in a total of 39 stenosis from 37 patients, and respiratory rate was calculated with ECG‐derived respiration (EDR) in 26 stenoses from 26 patients. Beat‐to‐beat variations in FFR occurred in a cyclical fashion and were strongly correlated with respiratory rate (R2 = 0.757, p < 0.001). There was no correlation between respiratory rate and variations in resting Pd/Pa. When single‐beat averages were used to calculate FFR, mean ΔFFR was 0.04 ± 0.02. With averaging of FFR over three or five cardiac cycles, mean ΔFFR decreased to 0.02 ± 0.02, and 0.01 ± 0.01, respectively. Using a FFR ≤ 0.80 threshold, stenosis classification changed in 20.5% (8/39), 12.8% (5/39) and 5.1% (2/39) for single‐beat, three‐beat and five‐beat averaged FFR. The impact of respiration was more pronounced in patients with pulmonary disease (ΔFFR 0.05 ± 0.02 vs 0.03 ± 0.02, p = 0.021). Conclusion Beat‐to‐beat variations in FFR during plateau hyperemia related to respiration are common, of clinically relevant magnitude, and frequently lead FFR to cross treatment thresholds. A five‐beat averaged FFR, overcomes clinically relevant impact of FFR variation.
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Affiliation(s)
- Rutger G T Feenstra
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Martijn A van Lavieren
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Mauro Echavarria-Pinto
- Hospital General ISSSTE - Facultad de Medicina, Universidad Autónoma De Querétaro, Querétaro, Mexico
| | - Gilbert W Wijntjens
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Valerie E Stegehuis
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | | | - Robbert J de Winter
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Amir Lerman
- Division of Cardiovascular Diseases, and Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos, IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Jan J Piek
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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21
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Lal K, Gosling R, Ghobrial M, Williams GJ, Rammohan V, Hose DR, Lawford PV, Narracott A, Fenner J, Gunn JP, Morris PD. Operator-dependent variability of angiography-derived fractional flow reserve and the implications for treatment. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2021; 2:263-270. [PMID: 34223175 PMCID: PMC8242185 DOI: 10.1093/ehjdh/ztab012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/17/2021] [Accepted: 01/28/2021] [Indexed: 01/30/2023]
Abstract
AIMS To extend the benefits of physiologically guided percutaneous coronary intervention to many more patients, angiography-derived, or 'virtual' fractional flow reserve (vFFR) has been developed, in which FFR is computed, based upon the images, instead of being measured invasively. The effect of operator experience with these methods upon vFFR accuracy remains unknown. We investigated variability in vFFR results based upon operator experience with image-based computational modelling techniques. METHODS AND RESULTS Virtual fractional flow reserve was computed using a proprietary method (VIRTUheart) from the invasive angiograms of patients with coronary artery disease. Each case was processed by an expert (>100 vFFR cases) and a non-expert (<20 vFFR cases) operator and results were compared. The primary outcome was the variability in vFFR between experts and non-experts and the impact this had upon treatment strategy (PCI vs. conservative management). Two hundred and thirty-one vessels (199 patients) were processed. Mean non-expert and expert vFFRs were similar overall [0.76 (0.13) and 0.77 (0.16)] but there was significant variability between individual results (variability coefficient 12%, intraclass correlation coefficient 0.58), with only moderate agreement (κ = 0.46), and this led to a statistically significant change in management strategy in 27% of cases. Variability was significantly lower, and agreement higher, for expert operators; a change in their recommended management occurred in 10% of repeated expert measurements and 14% of inter-expert measurements. CONCLUSION Virtual fractional flow reserve results are influenced by operator experience of vFFR processing. This had implications for treatment allocation. These results highlight the importance of training and quality assurance to ensure reliable, repeatable vFFR results.
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Affiliation(s)
- Katherine Lal
- Department of Infection, Immunity and Cardiovascular Disease, Mathematical Modelling in Medicine Group, University of Sheffield, Beech Hill Road, Sheffield S102RX, UK
| | - Rebecca Gosling
- Department of Infection, Immunity and Cardiovascular Disease, Mathematical Modelling in Medicine Group, University of Sheffield, Beech Hill Road, Sheffield S102RX, UK
- Department of Cardiology, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
- Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, UK
| | - Mina Ghobrial
- Department of Infection, Immunity and Cardiovascular Disease, Mathematical Modelling in Medicine Group, University of Sheffield, Beech Hill Road, Sheffield S102RX, UK
| | - Gareth J Williams
- Department of Infection, Immunity and Cardiovascular Disease, Mathematical Modelling in Medicine Group, University of Sheffield, Beech Hill Road, Sheffield S102RX, UK
| | - Vignesh Rammohan
- Department of Infection, Immunity and Cardiovascular Disease, Mathematical Modelling in Medicine Group, University of Sheffield, Beech Hill Road, Sheffield S102RX, UK
- Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, UK
| | - D Rod Hose
- Department of Infection, Immunity and Cardiovascular Disease, Mathematical Modelling in Medicine Group, University of Sheffield, Beech Hill Road, Sheffield S102RX, UK
- Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, UK
| | - Patricia V Lawford
- Department of Infection, Immunity and Cardiovascular Disease, Mathematical Modelling in Medicine Group, University of Sheffield, Beech Hill Road, Sheffield S102RX, UK
- Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, UK
| | - Andrew Narracott
- Department of Infection, Immunity and Cardiovascular Disease, Mathematical Modelling in Medicine Group, University of Sheffield, Beech Hill Road, Sheffield S102RX, UK
- Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, UK
| | - John Fenner
- Department of Infection, Immunity and Cardiovascular Disease, Mathematical Modelling in Medicine Group, University of Sheffield, Beech Hill Road, Sheffield S102RX, UK
- Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, UK
| | - Julian P Gunn
- Department of Infection, Immunity and Cardiovascular Disease, Mathematical Modelling in Medicine Group, University of Sheffield, Beech Hill Road, Sheffield S102RX, UK
- Department of Cardiology, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
- Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, UK
| | - Paul D Morris
- Department of Infection, Immunity and Cardiovascular Disease, Mathematical Modelling in Medicine Group, University of Sheffield, Beech Hill Road, Sheffield S102RX, UK
- Department of Cardiology, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
- Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, UK
- Corresponding author. Tel: +44 114 271 2863, Fax: +44 114 271 1863,
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22
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Zimmermann F, Mast T, Johnson NP, Everts I, Hennigan B, Berry C, Johnson D, De Bruyne B, Fearon W, Oldroyd KG, Pijls NH, Tonino PA, van 't Veer M. Deep learning for prediction of fractional flow reserve from resting coronary pressure curves. EUROINTERVENTION 2021; 17:51-58. [PMID: 32863244 PMCID: PMC9890578 DOI: 10.4244/eij-d-20-00648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND It would be ideal for a non-hyperaemic index to predict fractional flow reserve (FFR) more accurately, given FFR's extensive validation in a multitude of clinical settings. AIMS The aim of this study was to derive a novel non-hyperaemic algorithm based on deep learning and to validate it in an internal validation cohort against FFR. METHODS The ARTIST study is a post hoc analysis of three previously published studies. In a derivation cohort (random 80% sample of the total cohort) a deep neural network was trained (deep learning) with paired examples of resting coronary pressure curves and their FFR values. The resulting algorithm was validated against unseen resting pressure curves from a random 20% sample of the total cohort. The primary endpoint was diagnostic accuracy of the deep learning-derived algorithms against binary FFR ≤0.8. To reduce the variance in the precision, we used a fivefold cross-validation procedure. RESULTS A total of 1,666 patients with 1,718 coronary lesions and 2,928 coronary pressure tracings were included. The diagnostic accuracy of our convolutional neural network (CNN) and recurrent neural networks (RNN) against binary FFR ≤0.80 was 79.6±1.9% and 77.6±2.3%, respectively. There was no statistically significant difference between the accuracy of our neural networks to predict binary FFR and the most accurate non-hyperaemic pressure ratio (NHPR). CONCLUSIONS Compared to standard derivation of resting pressure ratios, we did not find a significant improvement in FFR prediction when resting data are analysed using artificial intelligence approaches. Our findings strongly suggest that a larger class of hidden information within resting pressure traces is not the main cause of the known disagreement between resting indices and FFR. Therefore, if clinicians want to use FFR for clinical decision making, hyperaemia induction should remain the standard practice.
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Affiliation(s)
- Frederik Zimmermann
- Catharina Hospital Eindhoven, Department of Cardiology, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands
| | - Thomas Mast
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Nils P. Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, USA
| | - Ivo Everts
- GoDataDriven, Amsterdam, the Netherlands
| | - Barry Hennigan
- British Heart Foundation Glasgow Cardiovascular Research Centre,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom
| | - Daniel Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, USA
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium,Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - William Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Keith G. Oldroyd
- British Heart Foundation Glasgow Cardiovascular Research Centre,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom
| | - Nico H.J. Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands,Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Pim A.L. Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Marcel van 't Veer
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands,Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
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23
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Yu W, Tanigaki T, Ding D, Wu P, Du H, Ling L, Huang B, Li G, Yang W, Zhang S, Yan F, Okubo M, Xu B, Matsuo H, Wijns W, Tu S. Accuracy of Intravascular Ultrasound-Based Fractional Flow Reserve in Identifying Hemodynamic Significance of Coronary Stenosis. Circ Cardiovasc Interv 2021; 14:e009840. [PMID: 33541105 DOI: 10.1161/circinterventions.120.009840] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ultrasonic flow ratio (UFR) is a novel method for fast computation of fractional flow reserve (FFR) from intravascular ultrasound images. The objective of this study is to evaluate the diagnostic performance of UFR using wire-based FFR as the reference. METHODS Post hoc computation of UFR was performed in consecutive patients with both intravascular ultrasound and FFR measurement in a core lab while the analysts were blinded to FFR. RESULTS A total of 167 paired comparisons between UFR and FFR from 94 patients were obtained. Median FFR was 0.80 (interquartile range, 0.68-0.89) and 50.3% had a FFR≤0.80. Median UFR was 0.81 (interquartile range, 0.69-0.91), and UFR showed strong correlation with FFR (r=0.87; P<0.001). The area under the curve was higher for UFR than intravascular ultrasound-derived minimal lumen area (0.97 versus 0.89, P<0.001). The diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio for UFR to identify FFR≤0.80 was 92% (95% CI, 87-96), 91% (95% CI, 82-96), 96% (95% CI, 90-99), 96% (95% CI, 89-99), 91% (95% CI, 93-96), 25.0 (95% CI, 8.2-76.2), and 0.10 (95% CI, 0.05-0.20), respectively. The agreement between UFR and FFR was independent of lesion locations (P=0.48), prior myocardial infarction (P=0.29), and imaging catheters (P=0.22). Intraobserver and interobserver variability of UFR analysis was 0.00±0.03 and 0.01±0.03, respectively. Median UFR analysis time was 102 (interquartile range, 87-122) seconds. CONCLUSIONS UFR had a strong correlation and good agreement with FFR. The fast computational time and excellent analysis reproducibility of UFR bears the potential of a wider adoption of integration of coronary imaging and physiology in the catheterization laboratory.
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Affiliation(s)
- Wei Yu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, China (W.Y., D.D., P.W., L.L., B.H., G.L., S.Z., S.T.)
| | - Toru Tanigaki
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (T.T., M.O., H.M.)
| | - Daixin Ding
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, China (W.Y., D.D., P.W., L.L., B.H., G.L., S.Z., S.T.)
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland Galway (D.D., W.W.)
| | - Peng Wu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, China (W.Y., D.D., P.W., L.L., B.H., G.L., S.Z., S.T.)
| | - Haiyan Du
- School of Biomedical Engineering, Southern Medical University, China (H.D., W.Y.)
| | - Li Ling
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, China (W.Y., D.D., P.W., L.L., B.H., G.L., S.Z., S.T.)
| | - Biao Huang
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, China (W.Y., D.D., P.W., L.L., B.H., G.L., S.Z., S.T.)
| | - Guanyu Li
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, China (W.Y., D.D., P.W., L.L., B.H., G.L., S.Z., S.T.)
| | - Wei Yang
- School of Biomedical Engineering, Southern Medical University, China (H.D., W.Y.)
| | - Su Zhang
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, China (W.Y., D.D., P.W., L.L., B.H., G.L., S.Z., S.T.)
| | - Fuhua Yan
- Department of Radiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, China (F.Y.)
| | - Munenori Okubo
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (T.T., M.O., H.M.)
| | - Bo Xu
- Catheterization Laboratories, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (B.X.)
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China (B.X.)
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (T.T., M.O., H.M.)
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland Galway (D.D., W.W.)
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, China (W.Y., D.D., P.W., L.L., B.H., G.L., S.Z., S.T.)
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24
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Modi B, Perera D. How to select patients requiring coronary revascularisation using coronary physiology. JRSM Cardiovasc Dis 2021; 10:2048004020979476. [PMID: 33614020 PMCID: PMC7868490 DOI: 10.1177/2048004020979476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/29/2020] [Accepted: 11/18/2020] [Indexed: 01/10/2023] Open
Abstract
The coronary angiogram is an indicator of flow limiting coronary artery disease but coronary physiology at the time of angiography is vital in assessing the true functional significance of coronary artery disease. With advances in guidewire technology and the greater use of physiology within the catheter laboratory, there is now a slow evolution of physiological indices in being able to reliably assess the functional significance of individual lesions and also the adequacy of revascularization in a growing range of clinical scenarios. As co-registration of physiology with the angiogram and intravascular imaging will become easier, we will find ourselves increasingly in an era of 'Precision PCI'.
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Affiliation(s)
- Bhavik Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, UK
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, UK
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25
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Myocardial Perfusion Simulation for Coronary Artery Disease: A Coupled Patient-Specific Multiscale Model. Ann Biomed Eng 2020; 49:1432-1447. [PMID: 33263155 PMCID: PMC8057976 DOI: 10.1007/s10439-020-02681-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/25/2020] [Indexed: 11/26/2022]
Abstract
Patient-specific models of blood flow are being used clinically to diagnose and plan treatment for coronary artery disease. A remaining challenge is bridging scales from flow in arteries to the micro-circulation supplying the myocardium. Previously proposed models are descriptive rather than predictive and have not been applied to human data. The goal here is to develop a multiscale patient-specific model enabling blood flow simulation from large coronary arteries to myocardial tissue. Patient vasculatures are segmented from coronary computed tomography angiography data and extended from the image-based model down to the arteriole level using a space-filling forest of synthetic trees. Blood flow is modeled by coupling a 1D model of the coronary arteries to a single-compartment Darcy myocardium model. Simulated results on five patients with non-obstructive coronary artery disease compare overall well to [\documentclass[12pt]{minimal}
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\begin{document}$$\text {H}_{{2}}$$\end{document}H2O PET exam data for both resting and hyperemic conditions. Results on a patient with severe obstructive disease link coronary artery narrowing with impaired myocardial blood flow, demonstrating the model’s ability to predict myocardial regions with perfusion deficit. This is the first report of a computational model for simulating blood flow from the epicardial coronary arteries to the left ventricle myocardium applied to and validated on human data.
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26
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Pellicano M, Ciccarelli G, Xaplanteris P, Di Gioia G, Milkas A, Colaiori I, Heyse A, Van Durme F, Vanderheyden M, Bartunek J, De Bruyne B, Barbato E. DISENGAGE Registry. Circ Cardiovasc Interv 2020; 13:e008640. [PMID: 33131299 DOI: 10.1161/circinterventions.119.008640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND During fractional flow reserve (FFR) measurement, the simple presence of the guiding catheter (GC) within the coronary ostium might create artificial ostial stenosis, affecting the hyperemic flow. We aimed to investigate whether selective GC engagement of the coronary ostium might impede hyperemic flow, and therefore impact FFR measurements and related clinical decision-making. METHODS In the DISENGAGE (Determination of Fractional Flow Reserve in Intermediate Coronary Stenosis With Guiding Catheter Disengagement) registry, FFR was prospectively measured twice (with GC engaged [FFReng] and disengaged [FFRdis]) in 202 intermediate stenoses of 173 patients. We assessed (1) whether ΔFFReng-FFRdis was significantly different from the intrinsic variability of repeated FFR measurements (test-retest repeatability); (2) whether the extent of ΔFFReng-FFRdis could be clinically significant and therefore able to impact clinical decision-making; and (3) whether ΔFFReng-FFRdis related to the stenosis location, that is, proximal and middle versus distal coronary segments. RESULTS Overall, FFR significantly changed after GC disengagement: FFReng 0.84±0.08 versus FFRdis 0.80±0.09, P<0.001. Particularly, in 38 stenoses (19%) with FFR values in the 0.81 to 0.85 range, GC disengagement was associated with a shift from above to below the 0.80 clinical cutoff, resulting into a change of the treatment strategy from medical therapy to percutaneous coronary intervention. The impact of GC disengagement was significantly more pronounced with stenoses located in proximal and middle as compared with distal coronary segments (ΔFFReng-FFRdis, proximal and middle 0.04±0.03 versus distal segments 0.03±0.03; P=0.042). CONCLUSIONS GC disengagement results in a shift of FFR values from above to below the clinical cutoff FFR value of 0.80 in 1 out of 5 measurements. This occurs mostly when the stenosis is located in proximal and middle coronary segments and the FFR value is close to the cutoff value.
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Affiliation(s)
- Mariano Pellicano
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan, Belgium (M.P., G.C., P.X., G.D.G., A.M., I.C., A.H., F.V.D., M.V., J.B., B.D.B.).,Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P., G.D.G., E.B.)
| | - Giovanni Ciccarelli
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P., G.D.G., E.B.)
| | - Panagiotis Xaplanteris
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan, Belgium (M.P., G.C., P.X., G.D.G., A.M., I.C., A.H., F.V.D., M.V., J.B., B.D.B.)
| | - Giuseppe Di Gioia
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan, Belgium (M.P., G.C., P.X., G.D.G., A.M., I.C., A.H., F.V.D., M.V., J.B., B.D.B.).,Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P., G.D.G., E.B.)
| | - Anastasios Milkas
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan, Belgium (M.P., G.C., P.X., G.D.G., A.M., I.C., A.H., F.V.D., M.V., J.B., B.D.B.)
| | - Iginio Colaiori
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan, Belgium (M.P., G.C., P.X., G.D.G., A.M., I.C., A.H., F.V.D., M.V., J.B., B.D.B.)
| | - Alex Heyse
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan, Belgium (M.P., G.C., P.X., G.D.G., A.M., I.C., A.H., F.V.D., M.V., J.B., B.D.B.)
| | - Frederik Van Durme
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan, Belgium (M.P., G.C., P.X., G.D.G., A.M., I.C., A.H., F.V.D., M.V., J.B., B.D.B.)
| | - Marc Vanderheyden
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan, Belgium (M.P., G.C., P.X., G.D.G., A.M., I.C., A.H., F.V.D., M.V., J.B., B.D.B.)
| | - Jozef Bartunek
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan, Belgium (M.P., G.C., P.X., G.D.G., A.M., I.C., A.H., F.V.D., M.V., J.B., B.D.B.)
| | - Bernard De Bruyne
- Cardiovascular Research Center Aalst, OLV Clinic, Moorselbaan, Belgium (M.P., G.C., P.X., G.D.G., A.M., I.C., A.H., F.V.D., M.V., J.B., B.D.B.)
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (M.P., G.D.G., E.B.)
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27
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Elghamaz A, Myat A, de Belder A, Collison D, Cocks K, Stone GW, Oldroyd K. Continuous intracoronary versus standard intravenous infusion of adenosine for fractional flow reserve assessment: the HYPEREMIC trial. EUROINTERVENTION 2020; 16:560-567. [PMID: 31289017 DOI: 10.4244/eij-d-18-01067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to evaluate the accuracy of a continuous intracoronary (IC) adenosine infusion, administered through the novel HYPEREM™IC over-the-wire microcatheter, to measure fractional flow reserve (FFR). METHODS AND RESULTS The HYPEREMIC trial was a randomised, non-inferiority, crossover study in which patients with intermediate coronary lesions were enrolled for sequential pressure wire studies. FFR was measured using intravenous (IV) (140-180 mcg/kg/min) versus continuous non-weight-adjusted IC (360 mcg/min) adenosine. Patients were randomised and blinded to the order in which they received the adenosine, separated by a washout period. The primary endpoint was the mean hyperaemic FFR. Forty-one patients were enrolled at three UK sites between June and November 2016. The mean (standard deviation) FFR was 0.82 (±0.09) after IC versus 0.84 (±0.09) after IV adenosine. The difference of -0.02 (95% confidence interval [CI]: -0.03 to -0.01) confirmed the non-inferiority (margin <0.05) of IC to IV adenosine. Intracoronary adenosine was associated with a shorter mean time to maximal hyperaemia (difference -44 [95% CI: -59 to -29] seconds; p<0.0001). Chest discomfort was reported in 32/41 (78.0%) patients during IV adenosine versus 12/41 (29.3%) patients during IC adenosine. CONCLUSIONS Continuous IC adenosine was a reliable, faster and better tolerated method of achieving maximal hyperaemia compared to IV adenosine.
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Affiliation(s)
- Ahmed Elghamaz
- Cardiology Department, Northwick Park Hospital, London North West Healthcare NHS Trust, London, United Kingdom
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28
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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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Johnson DT, Fournier S, Kirkeeide RL, De Bruyne B, Gould KL, Johnson NP. Phasic pressure measurements for coronary and valvular interventions using fluid-filled catheters: Errors, automated correction, and clinical implications. Catheter Cardiovasc Interv 2020; 96:E268-E277. [PMID: 32077561 PMCID: PMC7539962 DOI: 10.1002/ccd.28780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/13/2019] [Accepted: 02/07/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We sought to develop an automatic method for correcting common errors in phasic pressure tracings for physiology-guided interventions on coronary and valvular stenosis. BACKGROUND Effective coronary and valvular interventions rely on accurate hemodynamic assessment. Phasic (subcycle) indexes remain intrinsic to valvular stenosis and are emerging for coronary stenosis. Errors, corrections, and clinical implications of fluid-filled catheter phasic pressure assessments have not been assessed in the current era of ubiquitous, high-fidelity pressure wire sensors. METHODS We recruited patients undergoing invasive coronary physiology assessment. Phasic aortic pressure signals were recorded simultaneously using a fluid-filled guide catheter and 0.014″ pressure wire before and after standard calibration as well as after pullback. We included additional subjects undergoing hemodynamic assessment before and after transcatheter aortic valve implantation. Using the pressure wire as reference standard, we developed an automatic algorithm to match phasic pressures. RESULTS Removing pressure offset and temporal shift produced the largest improvements in root mean square (RMS) error between catheter and pressure wire signals. However, further optimization <1 mmHg RMS error was possible by accounting for differential gain and the oscillatory behavior of the fluid-filled guide. The impact of correction was larger for subcycle (like systole or diastole) versus whole-cycle metrics, indicating a key role for valvular stenosis and emerging coronary pressure ratios. CONCLUSIONS When calibrating phasic aortic pressure signals using a pressure wire, correction requires these parameters: offset, timing, gain, and oscillations (frequency and damping factor). Automatically eliminating common errors may improve some clinical decisions regarding physiology-based intervention.
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Affiliation(s)
- Daniel T. Johnson
- Weatherhead PET Center, Division of Cardiology, Department of MedicineMcGovern Medical School at UTHealth and Memorial Hermann HospitalHoustonTexas
| | - Stephane Fournier
- Department of CardiologyCardiovascular Center Aalst OLV HospitalAalstBelgium
- Department of CardiologyLausanne University Center HospitalSwitzerland
| | - Richard L. Kirkeeide
- Weatherhead PET Center, Division of Cardiology, Department of MedicineMcGovern Medical School at UTHealth and Memorial Hermann HospitalHoustonTexas
| | - Bernard De Bruyne
- Department of CardiologyCardiovascular Center Aalst OLV HospitalAalstBelgium
| | - K. Lance Gould
- Weatherhead PET Center, Division of Cardiology, Department of MedicineMcGovern Medical School at UTHealth and Memorial Hermann HospitalHoustonTexas
| | - Nils P. Johnson
- Weatherhead PET Center, Division of Cardiology, Department of MedicineMcGovern Medical School at UTHealth and Memorial Hermann HospitalHoustonTexas
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30
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Johnson NP, Tonino PA. Fractional flow reserve substitutes in aortic stenosis. EUROINTERVENTION 2020; 16:e273-e275. [DOI: 10.4244/eijv16i4a46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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31
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Index of Microcirculatory Resistance Measured during Intracoronary Adenosine-Induced Hyperemia. J Interv Cardiol 2020; 2020:4829647. [PMID: 32508541 PMCID: PMC7243016 DOI: 10.1155/2020/4829647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/09/2020] [Accepted: 03/19/2020] [Indexed: 11/24/2022] Open
Abstract
Background The index of microcirculatory resistance is an invasive measure of coronary microvascular function that has to be calculated during maximal hyperemia, classically achieved with intravenous adenosine (IV). The aim of this study was to evaluate the use of intracoronary (IC) adenosine for the calculation of IMR. Methods and Results 31 patients with stable coronary artery disease were included in the study. Coronary pressure and thermodilution measurements were obtained at rest and during maximal hyperemia using a pressure-temperature sensor-tipped coronary guidewire. Duplicate measurements were performed using first IC and then IV adenosine. Dispersion of transit times was comparable for IC and IV adenosine. IMR values based on IC vs IV adenosine showed a high level of agreement and an intraclass correlation coefficient of 0.90. Applying an upper normal limit of 25, misclassification of IMR using IC adenosine was seen in just one patient in whom IC adenosine resulted in a lower value. A simplified procedure based on a single bolus dose of saline did not change the level of agreement or the rate of misclassification. Conclusions We found an excellent agreement between IMR values measured during hyperemia induced by IC as compared to IV adenosine. The use of IC adenosine may facilitate invasive assessment of microvascular function and is potentially time- and cost-saving with less patient discomfort as compared to IV infusion. The trail is registered with NCT03369184.
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32
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Matsumoto H, Mikuri M, Masaki R, Tanaka H, Ogura K, Arai T, Sakai R, Oishi Y, Okada N, Shinke T. Feasibility of intracoronary nicorandil for inducing hyperemia on fractional flow reserve measurement: Comparison with intracoronary papaverine. Int J Cardiol 2020; 314:1-6. [PMID: 32387252 DOI: 10.1016/j.ijcard.2020.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/22/2020] [Accepted: 05/04/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adenosine and adenosine triphosphate (ATP) are widely used to induce hyperemia for fractional flow reserve (FFR) measurements. Caffeine attenuates their hyperemic effects, but not those of nicorandil and papaverine. No studies have systematically compared the hyperemic efficacies of nicorandil, papaverine, and ATP with and without caffeine abstention. METHODS FFRs were measured using nicorandil 2 mg (FFRNC2), nicorandil 4 mg (FFRNC4), and papaverine (FFRPAP) in 40 patients (group 1), and using nicorandil 2 mg, ATP (FFRATP), ATP plus nicorandil (FFRATP+NC2), and papaverine in 20 patients with (group 2) and in 20 patients without caffeine abstention (group 3). RESULTS In group 1, FFRNC2 and FFRNC4 did not differ (p = 0.321) and were higher than FFRPAP (p < 0.001 and p = 0.0026). Likewise, FFRNC2 was higher than FFRPAP in groups 2 (p = 0.049) and 3 (p < 0.010). In the whole group, Bland-Altman analysis showed a modest mean difference (0.015, p < 0.001) and narrow 95% limits of agreement (-0.025 and 0.056). FFRNC2 and FFRPAP strongly correlated (r = 0.975, p < 0.001). Compared with FFRPAP, FFRATP and FFRATP+NC2 did not differ in group 2 (p = 1.0 and p = 0.780), but they were higher (p = 0.002 and p = 0.02) in group 3. Adjunctive nicorandil did not decline FFR further in groups 2 (p = 0.942) and 3 (p = 0.294). CONCLUSIONS Nicorandil 2 mg is a safe and practical alternative for patients who consume caffeine-containing products before the test or have contraindications for adenosine/ATP. Increasing the nicorandil dose to 4 mg or administering adjunctive nicorandil during ATP infusions does not offer any clinical advantages compared with administering nicorandil 2 mg alone.
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Affiliation(s)
- Hidenari Matsumoto
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan.
| | - Mikiko Mikuri
- Department of Cardiology, Kyojinkai Komatsu Hospital, Neyagawa, Japan
| | - Ryota Masaki
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Hideaki Tanaka
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Kunihiro Ogura
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Taitou Arai
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Rikuo Sakai
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Yosuke Oishi
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Natsumi Okada
- Department of Hospital Pharmaceutics, Showa University School of Pharmacy, Tokyo, Japan
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
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De Maria GL, Garcia-Garcia HM, Scarsini R, Hideo-Kajita A, Gonzalo López N, Leone AM, Sarno G, Daemen J, Shlofmitz E, Jeremias A, Tebaldi M, Bezerra HG, Tu S, Lemos PA, Ozaki Y, Dan K, Collet C, Banning AP, Barbato E, Johnson NP, Waksman R. Novel Indices of Coronary Physiology. Circ Cardiovasc Interv 2020; 13:e008487. [DOI: 10.1161/circinterventions.119.008487] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Fractional flow reserve is the current invasive gold standard for assessing the ischemic potential of an angiographically intermediate coronary stenosis. Procedural cost and time, the need for coronary vessel instrumentation, and the need to administer adenosine to achieve maximal hyperemia remain integral components of invasive fractional flow reserve. The number of new alternatives to fractional flow reserve has proliferated over the last ten years using techniques ranging from alternative pressure wire metrics to anatomic simulation via angiography or intravascular imaging. This review article provides a critical description of the currently available or under-development alternatives to fractional flow reserve with a special focus on the available evidence, pros, and cons for each with a view towards their clinical application in the near future for the functional assessment of coronary artery disease.
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Affiliation(s)
- Giovanni Luigi De Maria
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom (G.L.D.M., R.S., A.P.B.)
| | - Hector M. Garcia-Garcia
- MedStar Washington Hospital Centre, Interventional Cardiology Department, Washington, DC (Y.O., H.M.G.-G., A.H.-K., E.S., K.D., R.W.)
| | - Roberto Scarsini
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom (G.L.D.M., R.S., A.P.B.)
| | - Alexandre Hideo-Kajita
- MedStar Washington Hospital Centre, Interventional Cardiology Department, Washington, DC (Y.O., H.M.G.-G., A.H.-K., E.S., K.D., R.W.)
| | - Nieves Gonzalo López
- Interventional Cardiology Department, Hospital Clinico San Carlos, Madrid, Spain (N.G.L.)
| | | | - Giovanna Sarno
- Interventional Cardiology Department, Uppsala University, Sweden (G.S.)
| | - Joost Daemen
- Interventional Cardiologist at Erasmus University Rotterdam, the Netherlands (J.D.)
| | - Evan Shlofmitz
- MedStar Washington Hospital Centre, Interventional Cardiology Department, Washington, DC (Y.O., H.M.G.-G., A.H.-K., E.S., K.D., R.W.)
| | - Allen Jeremias
- Cardiac Catheterization Laboratory, St. Francis Hospital, Roslyn, NY (A.J.)
| | - Matteo Tebaldi
- Department of Cardiology, University of Ferrara, Italy (M.T.)
| | | | - Shengxian Tu
- Med-X Research Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, China (S.T.)
| | - Pedro A. Lemos
- Instituto do Coracao (InCor), Universidade de São Paulo, Brazil (P.A.L.)
- Hospital Israelita Albert Einstein, Brazil (P.A.L.)
| | - Yuichi Ozaki
- MedStar Washington Hospital Centre, Interventional Cardiology Department, Washington, DC (Y.O., H.M.G.-G., A.H.-K., E.S., K.D., R.W.)
| | - Kazuhiro Dan
- MedStar Washington Hospital Centre, Interventional Cardiology Department, Washington, DC (Y.O., H.M.G.-G., A.H.-K., E.S., K.D., R.W.)
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Belgium (C.C.)
| | - Adrian P. Banning
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom (G.L.D.M., R.S., A.P.B.)
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Nils P. Johnson
- McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX (N.P.J.)
| | - Ron Waksman
- MedStar Washington Hospital Centre, Interventional Cardiology Department, Washington, DC (Y.O., H.M.G.-G., A.H.-K., E.S., K.D., R.W.)
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Abstract
PURPOSE OF REVIEW This review discusses similarities and differences between cardiac positron emission tomography (PET), absolute myocardial blood flow, and flow reserve with invasive fractional flow reserve (FFR). RECENT FINDINGS Fundamentally, cardiac PET measures absolute myocardial blood flow whereas FFR provides a relative flow reserve. Cardiac PET offers a non-invasive and therefore lower risk alternative, able to image the entire left ventricle regardless of coronary anatomy. While cardiac PET can provide unique information about the subendocardium, FFR pullbacks offer unparalleled spatial resolution. Both diagnostic tests provide a highly repeatable and technically successful index of coronary hemodynamics that accounts for the amount of distal myocardial mass, albeit only indirectly with FFR. The randomized evidence base for FFR and its associated cost effectiveness remains unsurpassed. Cardiac PET and FFR have been intertwined since the very development of FFR over 25 years ago. Recent work has emphasized the ability of both techniques to guide revascularization decisions by high-quality physiology. In the past few years, cardiac PET has expanded its evidence base regarding clinical outcomes, whereas FFR has solidified its position in randomized studies as the invasive reference standard.
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Affiliation(s)
- Nils P. Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030 USA
- Memorial Hermann Hospital, Houston, TX USA
| | - K. Lance Gould
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030 USA
- Memorial Hermann Hospital, Houston, TX USA
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35
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Sonck J, Collet C, Mizukami T, Vandeloo B, Argacha JF, Barbato E, Andreini D, Bartorelli A, Cosyns B, De Bruyne B. Motorized fractional flow reserve pullback: Accuracy and reproducibility. Catheter Cardiovasc Interv 2020; 96:E230-E237. [PMID: 31967389 DOI: 10.1002/ccd.28733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/12/2019] [Accepted: 01/06/2020] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The present study aimed at determining the accuracy and reproducibility of motorized FFR pullbacks in patients with stable coronary artery disease. BACKGROUND Fractional flow reserve (FFR) is recommended for decision making regarding myocardial revascularization. The distribution of epicardial resistance along coronary vessels can be assessed using FFR pullbacks. METHODS Duplicated FFR pullbacks were acquired using a motorized device at a speed of 1 mm/s in intermediate coronary stenosis. In addition, a single FFR value was measured at an anatomical landmark. The agreement between FFR measurements was assessed using the Bland-Altman method, Pearson's correlation coefficient and area under the pullback curve (AUPC). RESULTS In 20 vessels, 37,326 FFR values were obtained. The mean FFR from the pullbacks was 0.91 ± 0.08 whereas the mean FFR at the distal location was 0.85 ± 0.09. The mean difference between pullbacks was -0.002 (LOA -0.058 to 0.054). The difference in AUPC between the two FFR pullbacks was 2.1 ± 1.6%. At pre-specified anatomical locations, the mean difference between the FFR derived from the pullback data and the measured FFR was 0 (LOA -0.040 to 0.039). The repeatability of the distal FFR measurement was high (bias -0.003, LOA -0.046 to 0.041). CONCLUSION A motorized FFR pullback was accurate to assess the distribution of epicardial resistance in patients with intermediate coronary artery disease. The reproducibility of the FFR pullback was high. Further studies are required to determine the potential usefulness of a hyperemic FFR pullback strategy for decision making and treatment planning.
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Affiliation(s)
- Jeroen Sonck
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Takuya Mizukami
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium.,Centrum Voor Hart en Vaatziekten, Vrije Universiteit Brussel, Belgium.,Department of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan
| | - Bert Vandeloo
- Centrum Voor Hart en Vaatziekten, Vrije Universiteit Brussel, Belgium
| | - Jean F Argacha
- Centrum Voor Hart en Vaatziekten, Vrije Universiteit Brussel, Belgium
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Antonio Bartorelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Bernard Cosyns
- Centrum Voor Hart en Vaatziekten, Vrije Universiteit Brussel, Belgium
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Nakayama M, Tanaka N, Yamashita J, Iwasaki K. Confirmation of maximal hyperemia by the incremental dose of intracoronary papaverine. Cardiovasc Interv Ther 2020; 35:371-378. [DOI: 10.1007/s12928-020-00641-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/08/2020] [Indexed: 12/30/2022]
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37
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Kern MJ, Seto AH. Better measurement repeatability of FFR than CFR: Role of the human error factor. Catheter Cardiovasc Interv 2019; 94:684-685. [DOI: 10.1002/ccd.28552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Morton J. Kern
- Long Beach Veteran's Administration Medical Center Long Beach California
| | - Arnold H. Seto
- Long Beach Veteran's Administration Medical Center Long Beach California
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38
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Picard F, Alansari O, Mogi S, Van't Veer M, Varenne O, Adjedj J. In vitro test-retest repeatability of invasive physiological indices to assess coronary flow. Catheter Cardiovasc Interv 2019; 94:677-683. [PMID: 30838771 DOI: 10.1002/ccd.28177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 01/02/2019] [Accepted: 02/18/2019] [Indexed: 11/11/2022]
Abstract
AIMS Several invasive techniques are available in clinical practice to assess coronary flow. Nevertheless, the test-retest repeatability of these techniques in a controlled setting has not been reported. Therefore, we sought to evaluate fractional flow reserve (FFR), coronary flow reserve (CFR), index of microvascular resistance (IMR), and absolute coronary blood flow (ABF) with absolute microvascular resistance (AMR) test-retest repeatability using a coronary flow simulator. METHODS AND RESULTS Using a coronary flow simulator (FFR WetLab version 2.0; Abbott Vascular, Santa Clara, CA), we created stenoses ranging from 0% to 70%, with 10% increments. Three different flows were established with their hyperemic phases, and two consecutive measurements were obtained, evaluating the following indices: FFR, CFR, IMR, ABF, and AMR, using a pressure/temperature wire and an infusion catheter. One hundred and thirty-eight pairs of measurements were performed. Test-retest reliability was compared in 48 FFR, 18 CFR, 24 IMR, 24 ABF, and 24 AMR. Test-retest repeatability showed excellent reproducibility for FFR, ABF, and AMR; respectively 0.98 (0.97-0.99), 0.92 (0.81-0.97) and 0.91 (0.79-0.96) (P < 0.0001 for all). However, test-retest repeatability was weaker for IMR and poor for CFR; respectively 0.53 (0.16-0.77) (P = 0.006) and 0.27 (-0.26-0.67) (P = 0.30). CONCLUSIONS Using a coronary flow simulator, FFR and ABF with AMR had excellent test-retest reliability. IMR and CFR demonstrated weaker test-retest reliability.
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Affiliation(s)
- Fabien Picard
- Department of Cardiology, Hôpital Cochin, AP-HP, Paris, France.,Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| | - Omar Alansari
- Department of Cardiology, Hôpital Cochin, AP-HP, Paris, France
| | - Satoshi Mogi
- Department of Cardiology, Hôpital Cochin, AP-HP, Paris, France
| | - Marcel Van't Veer
- Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.,Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Olivier Varenne
- Department of Cardiology, Hôpital Cochin, AP-HP, Paris, France.,Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| | - Julien Adjedj
- Department of Cardiology, Hôpital Cochin, AP-HP, Paris, France.,Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
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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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Renard BM, Cami E, Jiddou-Patros MR, Said A, Kado H, Trivax J, Berman A, Gulati A, Rabah M, Timmis S, Shoukfeh M, Abbas AE, Hanzel G, Hanson I, Dixon S, Safian RD. Optimizing the Technique for Invasive Fractional Flow Reserve to Assess Lesion-Specific Ischemia. Circ Cardiovasc Interv 2019; 12:e007939. [DOI: 10.1161/circinterventions.119.007939] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Invasive fractional flow reserve (FFR
INV
) is the standard technique for assessing myocardial ischemia. Pressure distortions and measurement location may influence FFR
INV
interpretation. We report a technique for performing invasive fractional flow reserve (FFR
INV
) by minimizing pressure distortions and identifying the proper location to measure FFR
INV
.
Methods:
FFR
INV
recordings were obtained prospectively during manual hyperemic pullback in 100 normal and diseased coronary arteries with single stenosis, using 4 measurements from the terminal vessel, distal-to-the-lesion, proximal vessel, and guiding catheter. FFR
INV
profiles were developed by plotting FFR
INV
values (
y
-axis) and site of measurement (
x
-axis), stratified by stenosis severity. FFR
INV
≤0.8 was considered positive for lesion-specific ischemia.
Results:
Erroneous FFR
INV
values were observed in 10% of vessels because of aortic pressure distortion and in 21% because of distal pressure drift; these were corrected by disengagement of the guiding catheter and re-equalization of distal pressure/aortic pressure, respectively. There were significant declines in FFR
INV
from the proximal to the terminal vessel in normal and stenotic coronary arteries (
P
<0.001). The rate of positive FFR
INV
was 41% when measured from the terminal vessel and 20% when measured distal-to-the-lesion (
P
<0.001); 41.5% of positive terminal measurements were reclassified to negative when measured distal-to-the-lesion. Measuring FFR
INV
20 to 30 mm distal-to-the-lesion (rather than from the terminal vessel) can reduce errors in measurement and optimize the assessment of lesion-specific ischemia.
Conclusions:
Meticulous technique (disengagement of the guiding catheter, FFR
INV
pullback) is required to avoid erroneous FFR
INV
, which occur in 31% of vessels. Even with optimal technique, FFR
INV
values are influenced by stenosis severity and the site of pressure measurement. FFR
INV
values from the terminal vessel may overestimate lesion-specific ischemia, leading to unnecessary revascularization.
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Affiliation(s)
- Brian M. Renard
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Elvis Cami
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | | | - Ahmad Said
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Herman Kado
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Justin Trivax
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Aaron Berman
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Akhil Gulati
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Maher Rabah
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Steven Timmis
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Mazen Shoukfeh
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Amr E. Abbas
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - George Hanzel
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Ivan Hanson
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Simon Dixon
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Robert D. Safian
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
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Xaplanteris P, Ntalianis A, De Bruyne B, Strisciuglio T, Pellicano M, Ciccarelli G, Milkas A, Barbato E. Coronary lesion progression as assessed by fractional flow reserve (FFR) and angiography. EUROINTERVENTION 2019; 14:907-914. [PMID: 29769166 DOI: 10.4244/eij-d-17-00872] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to explore the evolution of coronary lesions which had repeated physiologic evaluation by FFR as an endpoint, describe the clinical significance of longitudinal FFR change (ΔFFR=FFRfollow-up-FFRbaseline) and its correlation with angiographic indices, and identify predictors of FFRfollow-up. METHODS AND RESULTS A retrospective, single-centre analysis of 414 stenoses (331 patients) with consecutive FFR measurements at least six months apart was performed (median time interval: 24 [17, 37] months). The change in percent diameter stenosis was 2% (-5%, 11%). FFR values at baseline and follow-up were 0.86 (0.82, 0.90) and 0.83 (0.79, 0.90), respectively (<0.0001). The median ΔFFR was -0.007 (-0.028, 0.010) per year. Worsening FFR (ΔFFR <-0.05) was observed in 105 (25%) stenoses, stable FFR (-0.05 ≤ΔFFR ≤0.05) in 276 (67%) and improving FFR (ΔFFR >0.05) in 33 (8%) stenoses. The number of haemodynamically significant stenoses (FFR ≤0.80) was higher at follow-up compared to baseline (33% versus 17%, p<0.0001); ΔFFR correlated weakly with delta diameter stenosis (Δ%DS, ρ=-0.111, p=0.024). In mixed effects repeated measures analysis, only lesion location had an independent correlation with FFR values after adjusting for multiple confounders. In ROC analysis, FFRbaseline values predicted future clinically significant values (c-statistic: 0.736 [95% CI: 0.682-0.783]). CONCLUSIONS FFR values decrease slowly over a two-year follow-up. FFRbaseline, but not angiographic indices, is a predictor of significant functional atherosclerosis progression, predicting which stenoses will require revascularisation.
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42
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Changes in Resting Coronary Blood Flow During a Cardiac Catheterization Procedure - Implications for Use of Non-Hyperemic Pressure Ratios for Lesion Assessment. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:636-637. [DOI: 10.1016/j.carrev.2019.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 11/23/2022]
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Modi BN, Rahman H, Arri S, Ellis H, Mills MT, Williams R, Asrress K, Clapp B, Redwood S, Perera D. Resting Coronary Flow Varies With Normal Cardiac Catheter Laboratory Stimuli. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:669-673. [PMID: 30415969 DOI: 10.1016/j.carrev.2018.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/28/2018] [Accepted: 10/08/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Growing evidence supports physiology-guided revascularization, with Fractional Flow Reserve (FFR) the most commonly used invasive measure of coronary blood flow impairment at the time of diagnostic angiography. Recently, there has been growing interest in stenosis severity indices measured at rest, such as Instantaneous Wave Free Ratio (iFR) and the ratio of distal coronary to aortic pressure at rest (resting Pd/Pa). Their reliability may, theoretically, be more susceptible to changes in microvascular tone and coronary flow. This study aimed to assess variability of resting coronary flow with normal catheter laboratory stimuli. METHODS Simultaneous intracoronary pressure (Pd) and Doppler Average Peak Flow Velocity (APV) recordings were made at rest and following the verbal warning preceding an intravenous adenosine infusion. RESULTS 72 patients undergoing elective angiography were recruited (mean age 62 years, 52.7% male) with a wide range of coronary artery disease severity (FFR 0.86 ± 0.09). Average peak flow velocity varied significantly between measurements at rest and just prior to commencement of adenosine, with a mean variation of 10.2% (17.82 ± 9.41 cm/s vs. 19.63 ± 10.44 cm/s, p < 0.001) with an accompanying significant drop in microvascular resistance (6.27 ± 2.73 mm Hg·cm-1·s-1 vs. 5.8 ± 2.92 mm Hg·cm-1·s-1, p < 0.001). These changes occurred without significant change in systemic hemodynamic measures. Whilst there was a trend for an associated change in the resting indices, Pd/Pa and iFR, this was statistically and clinically not significant (0.92 ± 0.08 vs. 0.92 ± 0.08, p = 0.110; and 0.90 ± 0.11 vs. 0.89 ± 0.12, p = 0.073). CONCLUSION Resting coronary flow and microvascular resistance vary significantly with normal catheter laboratory stimuli, such as simple warnings. The clinical impact of these observed changes on indices of stenosis severity, particularly those measured at rest, needs further assessment within larger cohorts.
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Affiliation(s)
- Bhavik N Modi
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Haseeb Rahman
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Satpal Arri
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Howard Ellis
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Mark T Mills
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Rupert Williams
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Kaleab Asrress
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Brian Clapp
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Simon Redwood
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Divaka Perera
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom.
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44
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Current Evidence in Cardiothoracic Imaging: Computed Tomography-derived Fractional Flow Reserve in Stable Chest Pain. J Thorac Imaging 2019; 34:12-17. [PMID: 30376481 DOI: 10.1097/rti.0000000000000369] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
High-accuracy diagnostic imaging is needed to diagnose and manage coronary artery disease as well as to allow risk stratification for future events. Advancements in multidetector computed tomography and image postprocessing allow for routine computed tomography coronary angiography to provide anatomic luminal assessment similar to invasive coronary angiography, and, similarly, computational fractional flow reserve derived from computed tomography facilitates determination of hemodynamically relevant stenosis comparable to invasive fractional flow reserve. In this review article, we describe the diagnostic performance and the potential impact of fractional flow reserve derived from computed tomography in clinical practice.
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45
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Evaluation of fractional flow reserve in patients with stable angina: can CT compete with angiography? Eur Radiol 2019; 29:3669-3677. [DOI: 10.1007/s00330-019-06023-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/20/2018] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
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46
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47
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van Zandvoort LJ, Masdjedi K, Witberg K, Ligthart J, Tovar Forero MN, Diletti R, Lemmert ME, Wilschut J, de Jaegere PP, Boersma E, Zijlstra F, Van Mieghem NM, Daemen J. Explanation of Postprocedural Fractional Flow Reserve Below 0.85. Circ Cardiovasc Interv 2019; 12:e007030. [DOI: 10.1161/circinterventions.118.007030] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
| | - Kaneshka Masdjedi
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Karen Witberg
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jurgen Ligthart
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Roberto Diletti
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Miguel E. Lemmert
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jeroen Wilschut
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Peter P.T. de Jaegere
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Nicolas M. Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
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48
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Modi BN, Sankaran S, Kim HJ, Ellis H, Rogers C, Taylor CA, Rajani R, Perera D. Predicting the Physiological Effect of Revascularization in Serially Diseased Coronary Arteries. Circ Cardiovasc Interv 2019; 12:e007577. [PMID: 30722688 PMCID: PMC6794156 DOI: 10.1161/circinterventions.118.007577] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/19/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR) is commonly used to assess the functional significance of coronary artery disease but is theoretically limited in evaluating individual stenoses in serially diseased vessels. We sought to characterize the accuracy of assessing individual stenoses in serial disease using invasive FFR pullback and the noninvasive equivalent, fractional flow reserve by computed tomography (FFRCT). We subsequently describe and test the accuracy of a novel noninvasive FFRCT-derived percutaneous coronary intervention (PCI) planning tool (FFRCT-P) in predicting the true significance of individual stenoses. METHODS AND RESULTS Patients with angiographic serial coronary artery disease scheduled for PCI were enrolled and underwent prospective coronary CT angiography with conventional FFRCT-derived post hoc for each vessel and stenosis (FFRCT). Before PCI, the invasive hyperemic pressure-wire pullback was performed to derive the apparent FFR contribution of each stenosis (FFRpullback). The true FFR attributable to individual lesions (FFRtrue) was then measured following PCI of one of the lesions. The predictive accuracy of FFRpullback, FFRCT, and the novel technique (FFRCT-P) was then assessed against FFRtrue. From the 24 patients undergoing the protocol, 19 vessels had post hoc FFRCT and FFRCT-P calculation. When assessing the distal effect of all lesions, FFRCT correlated moderately well with invasive FFR ( R=0.71; P<0.001). For lesion-specific assessment, there was significant underestimation of FFRtrue using FFRpullback (mean discrepancy, 0.06±0.05; P<0.001, representing a 42% error) and conventional trans-lesional FFRCT (0.05±0.06; P<0.001, 37% error). Using FFRCT-P, stenosis underestimation was significantly reduced to a 7% error (0.01±0.05; P<0.001). CONCLUSIONS FFR pullback and conventional FFRCT significantly underestimate true stenosis contribution in serial coronary artery disease. A novel noninvasive FFRCT-based PCI planner tool more accurately predicts the true FFR contribution of each stenosis in serial coronary artery disease.
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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, King’s College London (B.N.M., H.E., R.R., D.P.)
| | | | - Hyun Jin Kim
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Howard Ellis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
| | - Campbell Rogers
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Charles A. Taylor
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Ronak Rajani
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
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49
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Fossan FE, Sturdy J, Müller LO, Strand A, Bråten AT, Jørgensen A, Wiseth R, Hellevik LR. Uncertainty Quantification and Sensitivity Analysis for Computational FFR Estimation in Stable Coronary Artery Disease. Cardiovasc Eng Technol 2018; 9:597-622. [PMID: 30382522 DOI: 10.1007/s13239-018-00388-w] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/12/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE The main objectives of this study are to validate a reduced-order model for the estimation of the fractional flow reserve (FFR) index based on blood flow simulations that incorporate clinical imaging and patient-specific characteristics, and to assess the uncertainty of FFR predictions with respect to input data on a per patient basis. METHODS We consider 13 patients with symptoms of stable coronary artery disease for which 24 invasive FFR measurements are available. We perform an extensive sensitivity analysis on the parameters related to the construction of a reduced-order (hybrid 1D-0D) model for FFR predictions. Next we define an optimal setting by comparing reduced-order model predictions with solutions based on the 3D incompressible Navier-Stokes equations. Finally, we characterize prediction uncertainty with respect to input data and identify the most influential inputs by means of sensitivity analysis. RESULTS Agreement between FFR computed by the reduced-order model and by the full 3D model was satisfactory, with a bias ([Formula: see text]) of [Formula: see text] at the 24 measured locations. Moreover, the uncertainty related to the factor by which peripheral resistance is reduced from baseline to hyperemic conditions proved to be the most influential parameter for FFR predictions, whereas uncertainty in stenosis geometry had greater effect in cases with low FFR. CONCLUSION Model errors related to solving a simplified reduced-order model rather than a full 3D problem were small compared with uncertainty related to input data. Improved measurement of coronary blood flow has the potential to reduce uncertainty in computational FFR predictions significantly.
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Affiliation(s)
- Fredrik E Fossan
- Department of Structural Engineering, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Jacob Sturdy
- Department of Structural Engineering, Norwegian University of Science and Technology, Trondheim, Norway
| | - Lucas O Müller
- Department of Structural Engineering, Norwegian University of Science and Technology, Trondheim, Norway
| | - Andreas Strand
- Department of Structural Engineering, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anders T Bråten
- Clinic of Cardiology, St. Olavs Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arve Jørgensen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim, Norway
| | - Rune Wiseth
- Clinic of Cardiology, St. Olavs Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Leif R Hellevik
- Department of Structural Engineering, Norwegian University of Science and Technology, Trondheim, Norway
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50
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Sciola MI, Morris PD, Gosling R, Lawford PV, Hose DR, Gunn JP. The impact of Objective Mathematical Analysis during Fractional Flow Reserve measurement: results from the OMA-FFR study. EUROINTERVENTION 2018; 14:935-941. [PMID: 29437033 DOI: 10.4244/eij-d-17-00826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIMS Fractional flow reserve (FFR), the reference standard for guiding coronary revascularisation, is most commonly acquired during intravenous adenosine infusion. Results may be sensitive to system- and operator-dependent variability in how pressure data are analysed and interpreted. To quantify FFR objectively, we developed a computational protocol to process the recorded pressure signals in a consistent manner. We studied the impact on lesion (re)classification and compared this with the operator-selected FFR obtained during cardiac catheterisation. METHODS AND RESULTS The algorithm used a moving average and Fourier transformation to identify the Pd/Pa ratio at its nadir (FFRmin) and during the stable hyperaemic period (FFRstable) in <2 s with 100% repeatability, in 163 coronary stenoses (93 patients). The mean operator-selected FFR (FFRCL) was higher than FFRmin and lower than FFRstable (0.779 vs. 0.762 vs. 0.806, p=<0.01). Compared with FFRmin, FFRstable resulted in 16.5% of all lesions being reclassified, all from significant to non-significant (p<0.01). FFRCL classified lesion significance differently from both FFRstable and FFRmin (11.7% and 6.1% lesions reclassified, respectively, p<0.01). CONCLUSIONS Subtle differences in how pressure data are analysed and interpreted by the operator during adenosine infusion result in significant differences in the classification of physiological lesion significance. An algorithmic analysis may be helpful in standardising FFR analysis, providing an objective and repeatable result.
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Affiliation(s)
- Martina I Sciola
- Mathematical Modelling in Medicine Group, Department of Infection, Immunity and Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom
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