Incremental Value of Subtended Myocardial Mass for Identifying FFR-Verified Ischemia Using Quantitative CT Angiography

Yang, Dong Hyun; Kang, Soo–Jin; Koo, Hyun Jung; Kweon, Jihoon; Kang, Joon‐Won; Lim, Tae‐Hwan; Jung, Joonho; Kim, Namkug; Lee, June-Goo; Han, Seungbong; Ahn, Jung‐Min; Park, Duk‐Woo; Lee, Seung-Whan; Lee, Cheol Whan; Park, Seong-Wook; Park, Seung‐Jung; Mintz, Gary S.; Kim, Young‐Hak

doi:10.1016/j.jcmg.2017.10.027

Cited by 29 publications

(26 citation statements)

References 34 publications

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“…Pressure loss across a stenosis is a function of resistance, whose components include morphologic factors (including stenosis entrance angle, orifice configuration, length of stenosis, exit angles) as well as physiologic factors such as flow and associated myocardial supply area (28). Recently, the incremental value of also considering the subtended myocardial mass for identifying FFR-verified ischemia was confirmed using quantitative CT angiography (29). Furthermore, as explicitly formulated in an editorial, the question arises "which of the two instruments for gauging stenosis, FFR or angiography, is at fault" (30).…”

Section: Discussionmentioning

confidence: 99%

Fractional Flow Reserve Evaluated as Metric of Coronary Stenosis — A Mathematical Model Study

Faes

Meer

Heyndrickx³

et al. 2020

Front. Cardiovasc. Med.

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Introduction: Coronary arterial stenosis may impair myocardial perfusion with myocardial ischemia and associated morbidity and mortality as result. The myocardial fractional flow reserve (FFR) is clinically used as a stenosis-specific index. Aim: This study aims to identify the relation between the FFR and the degree of coronary arterial stenosis using a simple mathematical model of the coronary circulation. Methods: A mathematical model of the coronary circulation, including an arterial stenosis of variable degree, was developed. The relation between the FFR and the degree of stenosis (defined as the fractional cross sectional area narrowing) was investigated, including the influence of the aortic and venous pressures and the capillary resistance. An additional study concerning 22 patients with coronary artery disease permits comparison of clinical data and in silico findings. Results: The FFR shows an S-shaped relationship with the stenosis index. We found a marked influence of venous and aortic pressure and capillary resistance. The FFR is accompanied by a clinically relevant co-metric (FFR C), defined by the Pythagorean sum of the two pressures in the definition formula for FFR. In the patient group the FFR C is strongly related to the post-stenotic pressure (R = 0.91). The FFR C requires establishment of a validated cutoff point using future trials. Conclusion: The S-shaped dependence of FFR on the severity of the stenosis makes the FFR a measure of the ordinal scale. The marked influences of the aortic and venous pressures and the capillary resistance on the FFR will be interpreted as significant variations in intra-and inter-individual clinical findings. These fluctuations are partly connected to the neglect of considering the FFR C. At otherwise identical conditions the FFR as measured at baseline differs from the value obtained during hyperemic conditions. This expected observation requires further investigation, as the current hyperemia based evaluation fails to take advantage of available baseline data.

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Section: Discussionmentioning

confidence: 99%

Fractional Flow Reserve Evaluated as Metric of Coronary Stenosis — A Mathematical Model Study

Faes

Meer

Heyndrickx³

et al. 2020

Front. Cardiovasc. Med.

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“…On the other hand, functional assessment can be made using angiograms, including CTA measurements of FFR (FFR CT ), quantitative coronary angiogram FFR (FFR QCA ), quantitative flow ratio (QFR), and stenosis flow reserve (SFR). CT-FFR chiefly reflects the degree of stenosis but is also affected by the size of the coronary arteries 94 as well as the mass of ventricular myocardium subtended by the stenosis bearing vessel 95 and both these parameters can be accounted for by CT, which may make this parameter more meaningful.…”

Section: Plaque Characterizationmentioning

confidence: 99%

SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography

Narula

Chandrashekhar

Ahmadi

et al. 2021

Journal of Cardiovascular Computed Tomography

190

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2.1.2. Diagnostic performance of functional imaging and CTA compared to >50% diameter stenosis by ICA The National Cardiovascular Data Registry 9 suggested that functional testing is suboptimal for detecting significant coronary stenoses. Of the 661,063 patients undergoing elective catheterization, 64% had testing before the invasive coronary angiogram (ICA); of those, only 51.9% were abnormal. The percentages of patients with <50% DS on subsequent ICA ranged from 55 to 56% after an abnormal exercise treadmill test (ETT), stress echocardiography (SE), single photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI); for resting CTA, the percentage was 30%. In the oldest report, Fleischmann et al. evaluated 5874 patients in 41 studies from 1990 to 1997, and reported sensitivity and specificity of 85% and 77% for SE and 87% and 64% for SPECT, with 52% and 71% for exercise ECG. 10 DeJong et al. (Table 2A), in a meta-analysis of 5088 patients in 51 studies from 2000 to 2011 evaluated MRI, SE and SPECT with >50%DS by ICA as reference. 11 MRI was the most sensitive and specific (91% and 80%), with SE (87% and 72%) and SPECT (83% and 77%) roughly similar. Jaarsma et al. (Table 2B), reported on SPECT, MRI and positron emission tomography (PET) in 141 per-patient studies and 70 per-vessel studies. 12 Per-patient diagnostic odds ratio (DOR) was highest for PET (36.47) followed by MRI (26.42) and SPECT (16.31). In pervessel analysis, PET and MRI were equal (24.74 and 24.11), while SPECT was lowest (11.75). In a meta-analysis limited to 26 studies in which CTA was compared to either ETT or SPECT in the same group of patients, Nielsen et al. 13 (Table 2C) reported CTA sensitivities of 95e99%, specificities of 68e93% and DOR of 128e728. Corresponding ranges for ETT were 65e70%, 24e60% and 0.7e4 and for SPECT were 67e73%, 48e52% and 2e4. It is important to understand that available meta-analyses are also challenged by the small numbers of patients in some of the individual reports, potential referral bias, and often include a mixture of newer and older technology (e.g., planar and SPECT imaging). Finally, in a paper published too recently for meta-analysis inclusion, 391 symptomatic patients, 52% with intermediate and 46% with high risk pre-test probability, who were scheduled for ICA, underwent both CTA and SPECT with >50%DS by ICA as reference. 14 Sensitivity, specificity, positive and negative predictive values were 0.92, 0.75, 0.84 and 0.87 for CTA and 0.62, 0.68, 0.74 and 0.55 for SPECT. AUC was significantly higher for CTA (0.91 versus 0.69, p < 0.001.

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“…A potential reason for this fining may by the difference in subtended myocardial mass between the LAD and non‐LAD. In the previous studies using cardiac computed tomography, the LAD had a greater supplied myocardial mass than the non‐LAD, and the amount of subtended myocardial mass was an important factor to predict FFR ≤0.80 . In the territory of the LAD, the degree of vascular resistance decrease might be greater than the increase in the blood flow volume, owing to the smaller diameter of the artery.…”

Section: Discussionmentioning

confidence: 94%

Differential influence of lesion length on fractional flow reserve in intermediate coronary lesions between each coronary artery

Shibutani

Fujii

Matsumura

et al. 2019

Cathet Cardio Intervent

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Objectives: This study evaluated whether the influence of lesion length on functional significance is similar between each target artery.Background: In the presence of a similar moderate degree of stenosis, the fractional flow reserve (FFR) in the left anterior descending coronary artery (LAD) is more often <0.80 than in the other arteries. Methods: A total of 221 lesions with intermediate stenosis on coronary angiography that underwent FFR measurement for the evaluation of myocardial ischemia were enrolled. Quantitative coronary angiographic analysis including percent diameter stenosis and lesion length was performed. The area under the receiver operating characteristics (ROC) curve was estimated for the best cutoff value as a predictor of FFR value of ≤0.80 for each coronary artery.Results: Although lesion length was similar among the lesions with an FFR >0.80 at different locations, the mean lesion length was significantly longer for lesions in the right coronary artery (RCA) with an FFR ≤0.80 than for those in the LAD and left circumflex artery (13.4 ± 3.4 vs. 8.6 ± 3.1 vs. 12.0 ± 3.7 mm, p < .001). ROC analysis demonstrated that the optimal cutoff value of lesion length for predicting an FFR ≤0.80 was 10.0 mm in the LAD (0.56 area under the curve [AUC], 48% sensitivity, and 76% specificity), whereas 13.1 mm in the RCA (0.84 AUC, 67% sensitivity, and 93% specificity). Conclusions:The impact of lesion length on myocardial ischemia is different for each coronary artery. A longer lesion length is required in the RCA than in the LAD to achieve an FFR ≤0.80. K E Y W O R D S catheterization, coronary angiography, fractional flow reserve

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Incremental Value of Subtended Myocardial Mass for Identifying FFR-Verified Ischemia Using Quantitative CT Angiography

Cited by 29 publications

References 34 publications

Fractional Flow Reserve Evaluated as Metric of Coronary Stenosis — A Mathematical Model Study

Fractional Flow Reserve Evaluated as Metric of Coronary Stenosis — A Mathematical Model Study

SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography

Differential influence of lesion length on fractional flow reserve in intermediate coronary lesions between each coronary artery

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