Physiology-Guided Management of Serial Coronary Artery Disease

Modi, Bhavik; Silva, Kalpa De; Rajani, Ronak; Curzen, Nick; Perera, Divaka

doi:10.1001/jamacardio.2018.0236

Cited by 27 publications

(33 citation statements)

References 33 publications

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“…A smaller spacing ratio induced a higher positive Q-value, i.e., a larger hemodynamic interference. This, in turn, causes larger errors in FFR measurements, which is consistent with current clinical speculation [11]. It is worth noting that the peak Q-values in the case of the spacing ratios of 1, 3, and 5 were located at the center of the second stenosis or further downstream, rather than the downstream of the first stenosis.…”

Section: Discussionsupporting

confidence: 83%

“…The instantaneous wave-free ratio (iFR) has been proposed recently as an adenosine-free alternative to FFR [8,9]. The iFR outputs the distal-to-proximal pressure ratio of an single stenosis at 75% of diastolic phase, which is 2 of 14 called the wave-free period [10,11]. The vessel resistance and the interference between serial stenoses at the diastole are expected to be significantly smaller than those under the hyperemic condition [12,13].…”

Section: Introductionmentioning

confidence: 99%

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Hemodynamic Interference of Serial Stenoses and Its Impact on FFR and iFR Measurements

2019

Applied Sciences

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The hemodynamic interference of serial stenoses poses challenges for identifying the functional severity using the fractional flow reserve (FFR) method. The instantaneous wave-free ratio (iFR), i.e., the distal-to-proximal pressure ratio at 75% of diastole, was recently proposed to overcome the disadvantages of the FFR. However, the underlying mechanism remained ambiguous due to the lack of quantitative definition of hemodynamic interference. The objective of this study is to quantitatively define the hemodynamic interference and then examine its role on the FFR and iFR measurements. Pressure distributions, velocity fields, and Q-criterion which identifies vortices, were obtained through the computational fluid dynamics (CFD) for five cases with spacing ratios at 1, 3, 5, 7, and 10. The hemodynamic interference was identified using vortex structures which were quantified by Q-criterion. Results have shown that a spacing ratio of 7 or larger was interference-free. Serial stenoses with a closer spacing ratio led to a larger hemodynamic interference, and thus, larger errors in the FFR measurements compared to the spacing ratio of 7. Moreover, the underestimation of the first stenosis lesion has been observed, even in interference-free cases due to the nature of hyperemia. However, the hemodynamic interference of the serial stenoses has a negligible impact on the iFR measurement, regardless of the spacing ratio. Our results demonstrated that the quantification of the hemodynamic interference in serial stenoses provided a better understanding of its role on the pressure measurements, which could be further exploited for the optimal treatment of serial stenoses.

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Section: Discussionsupporting

confidence: 83%

Section: Introductionmentioning

confidence: 99%

Hemodynamic Interference of Serial Stenoses and Its Impact on FFR and iFR Measurements

2019

Applied Sciences

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“…In contrast, the PCI planning tool is a completely new application leveraging the CTA‐derived anatomical model (for vessel and lesion dimensions and diameter stenosis) and FFRCT (for assessment of lesion‐specific ischemia) (Figure ). The assessment of complex anatomy, such as serial lesions or diffuse disease, is a common challenge due to difficulties assessing the impact of individual stenosis on FFRINV . In contrast to FFRINV, the PCI planning tool enables the operator to predict the physiological outcome of any combination of interventions, recalculate the residual FFRCT values, and remove uncertainty about the interaction between multiple stenoses.…”

Section: Noninvasive Approaches To Pci Planning Using Cta and Ffrctmentioning

confidence: 99%

Planning percutaneous coronary interventions using computed tomography angiography and fractional flow reserve‐derived from computed tomography: A state‐of‐the‐art review

Feldmann

Cami

Safian

2018

Cathet Cardio Intervent

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Fractional flow reserve derived by coronary computed tomography angiography (CTA; FFRCT) is an accurate noninvasive method for identifying coronary artery disease (CAD) and detecting hemodynamically significant stenosis. Although initially proposed as noninvasive tools to "rule out" significant CAD in low-risk patients, CTA and FFRCT are now utilized in higher-risk patients. Furthermore, new applications of CTA and FFRCT include a planning tool for percutaneous coronary intervention (PCI), which allows the cardiologist to assess lesion-specific ischemia, plan stent locations and sizes, and use virtual remodeling of the lumen (virtual stenting) to assess the functional impact of PCI. The purpose of this review is to discuss the principles of CTA and FFRCT acquisition, and their application for PCI planning, even before invasive angiography is performed.computed tomography angiography, coronary artery disease, fractional flow reserve, percutaneous coronary intervention

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“…The data supporting physiology-guided revascularisation are largely derived from studies that only included vessels with single discrete lesions. The reality, particularly within elderly and diabetic populations, is that serial and diffuse CAD is common 5,85,86 . Serial CAD is important and likely to affect physiological assessment of an individual stenosis: any additional resistance proximal or distal to a stenosis will affect the trans-lesional pressure gradient at any point, with the problem further compounded by complex fluid dynamics.…”

Section: Introductionmentioning

confidence: 99%

“…Serial CAD is important and likely to affect physiological assessment of an individual stenosis: any additional resistance proximal or distal to a stenosis will affect the trans-lesional pressure gradient at any point, with the problem further compounded by complex fluid dynamics. 30,86 .…”

Section: Introductionmentioning

confidence: 99%

3 Optimising physiology guided management of serial coronary artery disease

Modi

Perera

2018

Abstracts

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BackgroundPhysiology-guided coronary revascularisation is associated with better outcomes however it is unclear if pressure-derived indices, such as FFR, can reliably assess individual lesions in serial disease.Methods3D printed serial disease phantoms were assessed in vitro. FFR of a lesion was predicted from the size of step up on pressure-wire pullback in the presence of serial lesions (FFR app ) and compared to phantoms with no accompanying lesion (FFR true ). Mathematical models to minimise error in predicting FFR true were developed in 32 phantoms and validated in 15 patients and another 20 phantoms. In 43 serial disease patients we compared how different indices (FFR, iFR, Pd/Pa) predict true values, after isolation by PCI or disease-free sidebranch. In a subset of 21 we measured flow to calculate Hyperaemic Stenosis Resistance (hSR).ResultsFFR app underestimated FFR true in 85% of phantoms, with discrepancy proportional to total FFR. 4.5% of lesions were misclassified (FFR <0.8 threshold); with mathematical models this fell to 1.5% (figure 1). Clinically, FFR, iFR and Pd/Pa significantly underestimated true values; hSR is least affected (p<0.01).Abstract 3 Figure 1Scatterplots of difference between FFRapp of a stenosis in presence of accompanying lesion and FFRtrue, when stenosis present in isolation. Within the validation cohort, discrepancy was 5% (0.036±0.048), which improved to 0.6% (0.005±0.037) and 0.8% (0.006±0.023) using empirical and theoretical solutions respectively (P<0.01). In the clinical cohort, discrepancy was 6.6% (0.041±0.03), which improved to 2.2% (0.019±0.026) and 2.0% (0.016±0.023) (P<0.01)ConclusionPressure-derived indices underestimate stenosis significance in serial disease. Pressure pullback data can be mathematically analysed to minimise this. Pressure-flow based resistance indices are less prone to this error.

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Physiology-Guided Management of Serial Coronary Artery Disease

Cited by 27 publications

References 33 publications

Hemodynamic Interference of Serial Stenoses and Its Impact on FFR and iFR Measurements

Hemodynamic Interference of Serial Stenoses and Its Impact on FFR and iFR Measurements

Planning percutaneous coronary interventions using computed tomography angiography and fractional flow reserve‐derived from computed tomography: A state‐of‐the‐art review

3 Optimising physiology guided management of serial coronary artery disease

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