Impact of hyperaemic microvascular resistance on fractional flow reserve measurements in patients with stable coronary artery disease: insights from combined stenosis and microvascular resistance assessment

Hoef, Tim P. van de; Nolte, Froukje; Echavarría‐Pinto, Mauro; Lavieren, Martijn A. van; Damman, Peter; Chamuleau, Steven A.J.; Voskuil, Michiel; Verberne, Hein J.; Henriques, José P.S.; Eck-Smit, Berthe L. F. van; Koch, Karel T.; Winter, Robbert J. de; Spaan, Jos A. E.; Siebes, Maria; Tijssen, Jan G.P.; Meuwissen, Martijn; Piek, Jan J.

doi:10.1136/heartjnl-2013-305124

Cited by 106 publications

(73 citation statements)

References 30 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…The relationship between angiographic stenosis severity and functional significance assessed by FFR and the mismatch between these 2 measures have been extensively investigated to optimize percutaneous coronary intervention (PCI) 16, 24, 25, 26. Clinical factors, including age, sex, angiographical lesion‐related factors, and physiological factors, have been reported to contribute to visual‐functional mismatch and reverse mismatch 15, 16, 26, 27, 28. Our results were in line with these previous studies and further suggested the importance of microvascular function in both mismatch and reverse mismatch.…”

Section: Discussionmentioning

confidence: 99%

“…Our results suggest that microvascular resistance independently and significantly influences visual‐functional mismatch and reverse mismatch in a large study population with intermediate epicardial coronary stenosis. Because FFR relies on a translesional hyperemic pressure gradient in a restricted model of coronary physiology, it is inevitably influenced by pharmacologically induced hyperemic coronary flow or by the individual's responsiveness to vasodilator drugs 15. The most important factor related to outcome in patients with coronary heart disease is the presence or absence of inducible myocardial ischemia and its extent.…”

Section: Discussionmentioning

confidence: 99%

“…However, several studies reported the evidence of serial changes in adenosine‐induced microvascular resistance before, after, and during follow‐up post‐PCI 13, 30, 31. van de Hoef et al also reported that identification of epicardial disease severity by FFR is partly obscured by microvascular resistance and that FFR increased with increasing hyperemic microvascular resistance to epicardial disease of equivalent severity 15. Our results shed light on the relationship between FFR and microvascular function and indicate that low hyperemic microvascular resistance most likely influences reverse visual‐unctional mismatch for intermediate epicardial stenoses, and that increased microvascular resistance affects visual‐functional mismatch.…”

Section: Discussionmentioning

confidence: 99%

“…Although such “visual‐functional mismatch” or “reverse visual‐functional mismatch” are not uncommon, the mechanism of these phenomena has not been fully elucidated. Recent studies further specifically suggest the relevance of microvascular function to FFR 13, 14, 15. Visual‐functional mismatch has important implications in overcoming limitations related to angiography‐guided decision‐making to reduce unnecessary revascularization and avoiding missed appropriate revascularization.…”

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Significance of Microvascular Function in Visual—Functional Mismatch Between Invasive Coronary Angiography and Fractional Flow Reserve

Yonetsu

Murai

Kanaji

et al. 2017

JAHA

View full text Add to dashboard Cite

BackgroundDespite a moderate correlation between angiographical stenosis and physiological significance, the mechanism of discordance has not been fully elucidated, particularly regarding the significance of microvascular function. This study sought to clarify whether microvascular function affects visual‐functional mismatch between quantitative coronary angiography (QCA) and fractional flow reserve (FFR).Methods and ResultsWe assessed QCA, FFR, coronary flow reserve, and the index of microcirculatory resistance in 849 non‐left‐main coronary lesions with visually estimated intermediate stenoses from 532 patients. Clinical and lesion‐specific characteristics and physiological parameters associated with mismatch and reverse mismatch were studied. Coronary flow reserve and index of microcirculatory resistance showed a weak, but significant, correlation with FFR (R=0.306, P<0.001 and R=0.158, P<0.001, respectively). Four hundred twenty‐two lesions were visually nonsignificant (diameter stenosis assessed by QCA [QCA‐DS] ≤50%) and 427 lesions were visually significant (QCA‐DS >50%). Among visually nonsignificant lesions, FFR ≤0.80 (reverse mismatch) was observed in 129 lesions (30.6%). Among visually significant lesions, FFR >0.80 (mismatch) were observed in 179 lesions (41.9%). The significant predictors of reverse mismatch were male sex, nonculprit lesions of acute coronary syndrome, left anterior descending artery location, smaller QCA reference diameter, greater QCA‐DS, lower coronary flow reserve, and lower index of microcirculatory resistance. Mismatch was associated with right coronary artery location, greater QCA reference diameter, smaller QCA‐DS, lesion length, higher coronary flow reserve, and higher index of microcirculatory resistance.ConclusionsThere was a high prevalence of visual‐functional mismatches between QCA and FFR. The discrepancy was related to clinical characteristics, lesion‐specific factors, and microvascular resistance that was undistinguishable by coronary angiography, thus suggesting the importance of physiological lesion assessment.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Significance of Microvascular Function in Visual—Functional Mismatch Between Invasive Coronary Angiography and Fractional Flow Reserve

Yonetsu

Murai

Kanaji

et al. 2017

JAHA

View full text Add to dashboard Cite

show abstract

“…24 Identification of microvascular dysfunction, in addition to FFR, is essential to guide clinical management in a judicious manner. [25][26][27] Furthermore, impaired vasomotor function is a significant prognostic predictor, suggesting that myocardial perfusion is relevant despite the value of FFR. as the optimal cutoff value to detect hemodynamically significant CAD based on an FFR cutoff value of 0.80.…”

Section: Rfr Versus Ffrmentioning

confidence: 99%

Relative Flow Reserve Derived From Quantitative Perfusion Imaging May Not Outperform Stress Myocardial Blood Flow for Identification of Hemodynamically Significant Coronary Artery Disease

Stuijfzand

Uusitalo

Kero

et al. 2015

Circ: Cardiovascular Imaging

View full text Add to dashboard Cite

Background— Quantitative myocardial perfusion imaging is increasingly used for the diagnosis of coronary artery disease. Quantitative perfusion imaging allows to noninvasively calculate fractional flow reserve (FFR). This so-called relative flow reserve (RFR) is defined as the ratio of hyperemic myocardial blood flow (MBF) in a stenotic area to hyperemic MBF in a normal perfused area. The aim of this study was to assess the value of RFR in the detection of significant coronary artery disease. Methods and Results— From a clinical population of patients with suspected coronary artery disease who underwent oxygen-15–labeled water cardiac positron emission tomography and invasive coronary angiography, 92 patients with single- or 2-vessel disease were included. Intermediate lesions (diameter stenosis, 30%–90%; n=75) were interrogated by FFR. Thirty-eight (41%) vessels were deemed hemodynamically significant (>90% stenosis or FFR ≤0.80). Hyperemic MBF, coronary flow reserve, and RFR were lower for vessels with a hemodynamically significant lesion (2.01±0.78 versus 2.90±1.16 mL·min −1 ·g −1 ; P <0.001, 2.27±1.03 versus 3.10±1.29; P <0.001, and 0.67±0.23 versus 0.93±0.15; P <0.001, respectively). The correlation between RFR and FFR was moderate ( r =0.54; P <0.01). Receiver operator characteristic curve analysis showed an area under the curve of 0.82 for RFR, which was not significantly higher compared with that for hyperemic MBF and coronary flow reserve (0.76; P =0.32 and 0.72; P =0.08, respectively). Conclusions— Noninvasive estimation of FFR by quantitative perfusion positron emission tomography by calculating RFR is feasible, yet only a trend toward a slight improvement of diagnostic accuracy compared with hyperemic MBF assessment was determined.

show abstract

Variability of fractional flow reserve according to the methods of hyperemia induction

Lim

Koo

Nam

et al. 2014

Cathet Cardio Intervent

View full text Add to dashboard Cite

show abstract

Impact of hyperaemic microvascular resistance on fractional flow reserve measurements in patients with stable coronary artery disease: insights from combined stenosis and microvascular resistance assessment

Abstract: Identification of epicardial disease severity by FFR is partly obscured by the microvascular resistance, which illustrates the necessity of combined pressure and flow measurements in daily practice.

Cited by 106 publications

References 30 publications

Significance of Microvascular Function in Visual—Functional Mismatch Between Invasive Coronary Angiography and Fractional Flow Reserve

Significance of Microvascular Function in Visual—Functional Mismatch Between Invasive Coronary Angiography and Fractional Flow Reserve

Relative Flow Reserve Derived From Quantitative Perfusion Imaging May Not Outperform Stress Myocardial Blood Flow for Identification of Hemodynamically Significant Coronary Artery Disease

Variability of fractional flow reserve according to the methods of hyperemia induction

Contact Info

Product

Resources

About