Invasive physiological indices to determine the functional significance of coronary stenosis

AL-Obaidi, Firas R.; Fearon, William F.; Yong, A.

doi:10.1016/j.ijcha.2018.02.003

Cited by 7 publications

(5 citation statements)

References 69 publications

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“…Overall, using invasive physiological coronary blood flow indices to assess lesion functional significance improves clinical outcomes in patients with MV CAD [ 25 ] and in patients with non-culprit coronary lesions during the acute phase [ 26 , 27 ]. FFR has been widely investigated, and after obtaining significant data regarding a reduction in the composite endpoint, which includes death, MI, and repeat revascularization, in the Fractional Flow Reserve versus Angiography for Multivessel Evaluation (FAME) study, evidence on the utility of FFR for the management of patients with ACS began to emerge [ 24 ].…”

Section: Discussionmentioning

confidence: 99%

Culprit versus Complete Revascularization during the Initial Intervention in Patients with Acute Coronary Syndrome Using a Virtual Treatment Planning Tool: Results of a Single-Center Pilot Study

et al. 2023

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Background and Objectives: The revascularization strategy for percutaneous coronary intervention (PCI) in patients with multivessel (MV) acute coronary syndrome (ACS) remains controversial. Certain gaps in the evidence are related to the optimal timing of non-culprit lesion revascularization and the utility of instantaneous wave-free ratio (iFR) in the management of MV ACS intervention. The major benefits of iFR utilization in MV ACS patients in one-stage complete revascularization are: (1) the possibility to virtually plan the PCI, both the location and the extension of the necessary stenting to achieve the prespecified final hemodynamic result; (2) the opportunity to validate the final hemodynamic result of the PCI, both in culprit artery and all non-culprit arteries and (3) the value of obliviating the uncomfortable, costly, time consuming and sometimes deleterious effects from Adenosine, as there is no requirement for administration. Thus, iFR use fosters the achievement of physiologically appropriate complete revascularization in MV ACS patients during acute hospitalization. Materials and Methods: This pilot study was aimed to test the feasibility of a randomized trial research protocol as well as to assess patient safety signals of co-registration iFR-guided one-stage complete revascularization compared with that of standard staged angiography-guided PCI in de novo patients with MV ACS. This was a single-center, prospective, randomized, open-label clinical trial consecutively screening patients with ACS for MV disease. The intervention strategy of interest was iFR-guided physiologically complete one-stage revascularization, in which the virtual PCI planning of non-culprit lesions and the intervention itself were performed in one stage directly following treatment of the culprit lesion and other critical stenosis of more than ninety percent. Seventeen patients were recruited and completed the 3-month follow-up. Results: Index PCI duration was significantly longer while the volume of contrast media delivered in index PCI was significantly greater in the iFR-guided group than in the angiography-guided group (119.4 ± 40.7 vs. 47 ± 15.5 min, p = 0.004; and 360 ± 97.9 vs. 192.5 ± 52.8 mL, p = 0.003). There were no significant differences in PCI-related major adverse cardiovascular events (MACE) between the groups during acute hospitalization and at 3-months follow-up. One-stage iFR-guided PCI requires fewer PCI attempts until complete revascularization than does angiography-guided staged PCI. Conclusions: Complete revascularization with the routine use of the virtual planning tool in one-stage iFR-guided PCI is a feasible practical strategy in an everyday Cath lab environment following the protocol designed for the study. No statistically significant safety signals were documented in the number of PCI related MACE during the 3-month follow-up.

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Section: Discussionmentioning

confidence: 99%

Culprit versus Complete Revascularization during the Initial Intervention in Patients with Acute Coronary Syndrome Using a Virtual Treatment Planning Tool: Results of a Single-Center Pilot Study

et al. 2023

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“…This is consistent with the previously reported diagnostic agreement between FFR and HSR in the general population of 78.7% ( 30 ). However, HSR is also dependent on an adequate hyperaemic response, and can be confounded by the presence of microvascular dysfunction ( 13 ). Previously, Kochiadakis et al indicated that irregularities in ventricular rhythm may be responsible of diminished CFR in AF ( 10 ), while a recent case report by Mills et al highlighted that changes in cardiac rhythm associated with AF may impact coronary physiological assessment ( 31 ).…”

Section: Discussionmentioning

confidence: 99%

“…Hemodynamic measurements were performed under basal conditions and under hyperaemia induced by intracoronary administration of adenosine (dose of 150 μg, increased progressively until attaining maximal hyperaemia). CFR is calculated as the ratio of maximum blood flow during hyperaemia (hAPV—hyperaemic average peak velocities) and resting coronary blood flow (bAPV—baseline average peak velocities), and reflects both the epicardial and the microcirculatory coronary status ( 13 ). Given the irregular RR interval in AF with potential impact on coronary flow, APV was calculated as the average instantaneous peak velocity over an interval of 5 beats.…”

Section: Methodsmentioning

confidence: 99%

“…HSR is a combined pressure- and flow-based index defined as the ratio of hyperaemic stenosis pressure gradient (Pa-Pd) and hAPV. A previous study has shown superior diagnostic accuracy of HSR compared to FFR or CFR for assessing the functional significance of epicardial coronary lesions in the general population ( 13 ), although is not currently implemented in day-to-day practice. Analogous to HSR, BSR is a combined pressure- and flow-based index that evaluates the epicardial coronary stenosis under basal conditions, being defined as the ratio of resting pressure gradient (Pa-Pd) and bAPV.…”

Section: Methodsmentioning

confidence: 99%

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Particularities of coronary physiology in patients with atrial fibrillation: insights from combined pressure and flow indices measurements

Pintea Bentea,

Berdaoui,

Samyn

et al. 2023

Front. Cardiovasc. Med.

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BackgroundSymptoms suggestive of myocardial ischemia are frequently encountered in patients with atrial fibrillation (AF) even in the absence of obstructive coronary artery disease. Nevertheless, an in-depth characterisation of coronary physiology in patients with AF is currently lacking.ObjectivesWe aim to provide an insight into the characteristics of coronary physiology in AF, by performing simultaneous invasive measurements of coronary flow- and pressure- indices in a real-life population of patients with AF and indication of coronary angiography.MethodsThis is a prospective open label study including patients with permanent or persistent AF and indication of coronary angiography showing intermediate coronary stenosis requiring routine physiological assessment (n = 18 vessels from 14 patients). We measured FFR (fractional flow reserve), and Doppler-derived coronary flow indices, including CFR (coronary flow reserve) and HMR (hyperaemic microvascular resistance).ResultsFrom the analysed vessels, 18/18 vessels (100%) presented a pathological CFR (<2.5), indicative of coronary microvascular dysfunction (CMD), and 3/18 (17%) demonstrated obstructive epicardial coronary disease (FFR ≤ 0.8). A large proportion of vessels (15/18; 83%) showed discordant FFR/CFR with preserved FFR and low CFR. 47% of the coronary arteries in patients with AF and non-obstructive epicardial coronary disease presented structural CMD (HMR ≥ 2.5 mmHg/cm/s), and were associated with high BMR and an impaired response to adenosine. Conversely, vessels from patients with AF and non-obstructive epicardial coronary disease with functional CMD (HMR < 2.5 mmHg/cm/s) showed higher bAPV. The permanent AF subpopulation presented increased values of HMR and BMR compared to persistent AF, while structural CMD was more often associated with persistent symptoms at 3 months, taking into account the limited sample size of our study.ConclusionOur findings highlight a systematically impaired CFR in patients with AF even in the absence of obstructive epicardial coronary disease, indicative of CMD. In addition, patients with AF presented more prevalent structural CMD (HMR ≥ 2.5 mmHg/cm/s), characterized by reduced hyperaemic responses to adenosine, possibly interfering with the FFR assessment.

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“…This clinical diagnostic score system may help to prescreen for coronary artery spasm in patients with acute chest pain. Additionally, several invasive and non-invasive strategies are currently used to assess the functional significance of coronary lesions [46], [47] and coronary CT angiography is a widely used strategy to detect significant coronary lesions non-invasively [48], [49].…”

Section: Coronary Artery Disease and Myocardial Infarctionmentioning

confidence: 99%

Highlights from the International Journal of Cardiology Heart & Vasculature: Heart failure, atrial fibrillation, coronary artery disease and myocardial infarction

Linz

Ammirati

Dan

et al. 2019

IJC Heart & Vasculature

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Invasive physiological indices to determine the functional significance of coronary stenosis

Cited by 7 publications

References 69 publications

Culprit versus Complete Revascularization during the Initial Intervention in Patients with Acute Coronary Syndrome Using a Virtual Treatment Planning Tool: Results of a Single-Center Pilot Study

Culprit versus Complete Revascularization during the Initial Intervention in Patients with Acute Coronary Syndrome Using a Virtual Treatment Planning Tool: Results of a Single-Center Pilot Study

Particularities of coronary physiology in patients with atrial fibrillation: insights from combined pressure and flow indices measurements

Highlights from the International Journal of Cardiology Heart & Vasculature: Heart failure, atrial fibrillation, coronary artery disease and myocardial infarction

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