Physiologic Stenosis Severity, Binary Thinking, Revascularization, and “Hidden Reality”

Gould, K. Lance; Johnson, Nils P.

doi:10.1161/circimaging.114.002970

Cited by 7 publications

(4 citation statements)

References 20 publications

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“…A formula from Ramanujan was used [8,9,13] which provides values closest to a mean from all other formulas. The area stenosis calculated based on elliptical assumptions provides much more physiological ostial area stenosis in better agreement with experimental observation on flow limitations caused from stenosis [16,17]. This is more important in less severe stenoses (< 70% area stenosis), where differences in areas are larger, while in more severe stenosis (> 70% area stenosis) the shape of the ostium does not seem to be so important and the values of area stenosis are more circular, no matter which formula is used.…”

Section: Discussionsupporting

confidence: 78%

Elliptical stretch as a cause of side branch ostial compromise after main vessel stenting in coronary bifurcations: New insights from numerical analysis

et al. 2013

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Background: The side branch (SB) compromise after main vessel (MV) stenting remains a significant problem in coronary bifurcation treatment. Currently the two major hypotheses for the mechanism of SB compromise are carina shift from MV into the SB and plaque shift into the ostium of side vessel. It is proposed herein, SB ostial deformation leading to reshaping of the ostium from circle to ellipse is a third possible mechanism. In the current study, the theoretical effects and correlation of ostial deformation with fractional flow reserve (FFR) is explored. Methods: Based on angiographic measurements and theoretical analysis formulas, three different SB ostial areas using circular ostial shape assumption and elliptical ostial shape assumption were calculated. Three different types of ostial areas with FFR values after MV stenting in 49 patients from the FIESTA registry were compared and analyzed. Results: It was found that there is significant overestimation of stenosis severity when estimated by the circle formula, than with the ellipse formula-ASc vs. ASds with 25% ± 13%, p < 0.001, ASc vs. ASmld with 9% ± 10%, p < 0.001. The elliptical shape assumptions provide more accurate ostial area stenosis, which correlates better with FFR. This finding is more significant in less severe stenosis (< 70% area stenosis) than in a more severe one. Conclusions: A third possible mechanism of SB compromise after MV stenting of coronary bifurcation stenosis is elliptical ostial deformation at the ostium of SBs. The ostial area, calculated based on elliptical assumption correlates better with FFR, than area stenosis calculated with the traditional circular formula.

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Section: Discussionsupporting

confidence: 78%

Elliptical stretch as a cause of side branch ostial compromise after main vessel stenting in coronary bifurcations: New insights from numerical analysis

et al. 2013

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“…With the emergence of novel tools that allow physicians to examine the heart in multiple aspects in terms of anatomy and function, the diagnosis and clinical management of coronary stenosis have rapidly evolved. Instead of simply observing the degree of arterial narrowing, physicians can now consider and integrate multiple functional parameters to achieve maximal benefit for the patient [ 30 ]. Among those parameters, MBF and the derived CFR have been widely used for evaluating ischemic severity.…”

Section: Discussionmentioning

confidence: 99%

Single-scan rest/stress imaging with 99mTc-Sestamibi and cadmium zinc telluride-based SPECT for hyperemic flow quantification: A feasibility study evaluated with cardiac magnetic resonance imaging

Fang

Liu

et al. 2017

PLoS ONE

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IntroductionWe aimed to evaluate whether the hyperemic myocardial blood flow (MBF) can be estimated using cadmium zinc telluride (CZT)-based single-photon emission computed tomography (SPECT) cameras with a single, rapid rest/stress dynamic scan. Dynamic contrast-enhanced (DCE) cardiac magnetic resonance imaging (MRI) was used as a reference modality for flow measurement.Materials and methodsThe proposed protocol included both the rest and stress acquisitions within a 24-min scan. Patients were first injected with 99mTc-Sestamibi at the resting state. Sixty minutes after the first injection, the subject was positioned via scintigraphy, after which the list-mode data acquisition was initiated and continued for 24 minutes. Five minutes after data acquisition was initiated, a stressed state was induced via dipyridamole infusion, after which a second dose of 99mTc-Sestamibi was injected. Dynamic SPECT images were reconstructed for all subjects, who also underwent T1-weighted cardiac DCE-MRI performed on days other than those of the SPECT studies. MBF values were estimated for the rest and stress MRI studies, and for the stress portion of the SPECT study. The SPECT-measured hyperemic MBF was compared with the MR-measured hyperemic MBF and coronary flow reserve (CFR), based on the regions of interest.ResultsA total of 30 subjects were included in this study. The hyperemic MBF estimated from SPECT showed a strong correlation with the MR-measured hyperemic MBF (r2 = 0.76) and a modest correlation with the MR-measured CFR (r2 = 0.56). Using MR-measured CFR <1.3 as a cutoff for coronary stenosis, we found that the SPECT-measured hyperemic MBF served as a useful clinical index with 94% sensitivity, 90% specificity, and 93% accuracy.ConclusionsHyperemic MBF can be measured with a rapid, single-scan rest/stress study with CZT-based SPECT cameras.

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“…4,5,[10][11][12][13] Quantitative PET for CFR shows a high risk of MACE for global CFR of 1.5 or less indicating severe diffuse CAD 10 that may be moderated by coronary bypass surgery, 11 whereas revascularization for less severe disease provided no benefit. Thus, quantitative severity of focal and diffuse CAD is necessary to guide management and revascularization for reduced hard endpoints, not just diagnosis and prognosis.…”

Section: Qualitative Diagnosis Vs Quantitative Physiologic Severity Omentioning

confidence: 99%

“…4,5,[10][11][12][13] Since significant stenosis is usually associated with diffuse disease, the residual diffuse disease may contravene the potential benefit by PCI of stenosis, as also evidenced by a significant risk of residual FFR after successful PCI. 9 For PCI to reduce MI or mortality, a stenosis has to be severe enough to pose a greater cumulative risk than that from residual diffuse disease plus the revascularization procedure itself.…”

Section: Critical Balance Between Quantitative Severity Of Stenosis Amentioning

confidence: 99%

Exercise PET: More insight or more complex?

Gould

Johnson

2015

Journal of Nuclear Cardiology

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In this issue of the journal, Aggarwal et al 1 report on 265 patients undergoing diagnostic treadmill stress myocardial perfusion imaging by PET using N-13 ammonia and rotating rod attenuation correction. 194 patients were obese (74%) with average treadmill capacity significantly less than non-obese patients as reflected by significantly lower exercise duration, functional aerobic capacity, METs achieved, and pressurerate product. Coronary angiograms were done in 43 (16% of 265) patients of whom 36 (14% of 265) had significant CAD by visual assessment. Diagnostic sensitivity was 86% and specificity 74%, with no difference between obese and non-obese patients. The authors conclude that treadmill stress perfusion PET is ''feasible and useful clinically with higher rate of good image quality, greater spatial, temporal, and contrast resolution, robust attenuation correction, high-count statistics, and less hepatobiliary tracer uptake of PET compared to SPECT.''The authors deserve credit for a large series of patients using a treadmill exercise PET perfusion imaging protocol. Due to the short half-life of cyclotron-produced N-13 ammonia, simply timing and coordinating the exercise stress with producing N-13 ammonia for injection at peak exercise and moving patients into the scanner gantry for adequate count images are a singular achievement. The effort to get good relative perfusion images is worthwhile given the attenuation artifacts of SPECT and its lack of management impact in the literature.2,3

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Physiologic Stenosis Severity, Binary Thinking, Revascularization, and “Hidden Reality”

Cited by 7 publications

References 20 publications

Elliptical stretch as a cause of side branch ostial compromise after main vessel stenting in coronary bifurcations: New insights from numerical analysis

Elliptical stretch as a cause of side branch ostial compromise after main vessel stenting in coronary bifurcations: New insights from numerical analysis

Single-scan rest/stress imaging with 99mTc-Sestamibi and cadmium zinc telluride-based SPECT for hyperemic flow quantification: A feasibility study evaluated with cardiac magnetic resonance imaging

Exercise PET: More insight or more complex?

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