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 233 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

A decision to perform coronary angioplasty on a constricted coronary artery should always be preceded by objective evidence of myocardial ischaemia in the flow region concerned. However, for patients with multi-vessel coronary disease it can be difficult to determine which of the several coronary stenoses present is responsible for the anginal complaints. Recently, special miniaturized sensor-equipped guide wires are introduced in the cardiac catheterisation laboratory. Therefore it is now possible to selectively evaluate coronary stenoses by means of haemodynamic parameters: fractional flow reserve (FFR, based on intracoronary derived pressure measurements) and coronary flow velocity reserve (CFVR, based on intracoronary derived Doppler flow velocity measurements). The diagnosis of coronary artery disease in the cardiac catheterisation laboratory has improved considerably due to the use of these intracoronary derived haemodynamic parameters. Several clinical studies have shown that it is safe to defer a coronary angioplasty based on an FFR > or = 0.75 or a CFVR > or = 2.0. In the case of an abnormal FFR or CFVR result, the appropriate treatment strategy can be implemented. Furthermore, these parameters can be used to evaluate the result of the therapy.
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PMID:[Fractional and coronary flow reserve: intracoronary diagnosis of coronary artery disease]]. 1158 40

Widely used non-invasive stress modalities, like exercise ECG, MPS and stress-echocardiography, are the tests of first choice for the diagnosis of CAD. It has been shown in numerous studies that non-invasive assessment of perfusion abnormalities is an adequate strategy for risk stratification. Moreover, non-invasive stress testing should be performed before a diagnostic cardiac catheterization to document the presence of myocardial ischemia, as a prerequisite for coronary revascularization. Coronary angiography is the gold standard for identifying CAD; however this technique is limited in assessing functional severity of coronary narrowings ('illusion of luminology'; see also Figure 5). The recently introduced i.c. hemodynamic parameters (CFVR and FFR) can identify functional severity of specific lesions and have shown a good agreement with the results of non-invasive stress test in validation studies. Furthermore, there is accumulating evidence that it is safe to defer a PTCA procedure, based on normal FFR and CFVR values. As these indices are derived during an invasive cardiac catheterization procedure, its use is recommended during a so called 'ad hoc' PTCA setting. Furthermore, they are particularly useful for clinical decision making in patients with documented multivessel CAD, as both indices allow selective evaluation of coronary narrowings in different arteries. Revascularization procedures are costly and always have a potential risk. It is important to be aware that, using above mentioned methods, unnecessary interventions (lacking potential benefit) may be avoided.
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PMID:Adequate patient selection for coronary revascularization: an overview of current methods used in daily clinical practice. 1213 22

The optimal revascularization strategy, percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG), for patients with multivessel coronary artery disease (MVD) remains controversial. The aim of the present study was to compare the long-term outcomes after selective PCI of only hemodynamically significant lesions (fractional flow reserve, or FFR < 0.75) to CABG of all stenoses in patients with MVD. In 150 patients with MVD referred for CABG, FFR was determined in 381 coronary arteries considered for bypass grafting. If the FFR was less than 0.75 in three vessels or in two vessels including the proximal left anterior descending (LAD) artery, CABG was performed (CABG group). If only one or two vessels were physiologically significant (not including the proximal LAD), PCI of those lesions was performed (PCI group). Of the 150 patients, 87 fulfilled the criteria for CABG and 63 for PCI. There were no significant differences in the angiographic or other baseline characteristics between the two groups. At 2-year follow-up, no differences were seen in adverse events, including repeat revascularization (event-free survival 74% in the CABG group and 72% in the PCI group). A similar number of patients were free from angina (84% in the CABG group and 82% in the PCI group). Importantly, the results in both groups were as good as the surgical groups in previous studies comparing PCI and CABG in MVD. In patients with multivessel disease, PCI in those with one or two hemodynamically significant lesions as identified by an FFR < 0.75 yields a similar favorable outcome as CABG in those with three or more culprit lesions despite a similar angiographic extent of disease.
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PMID:Percutaneous coronary intervention or bypass surgery in multivessel disease? A tailored approach based on coronary pressure measurement. 1539 Mar 44

To evaluate the accuracy of myocardial perfusion SPECT (MPI) in the detection and allocation of vessel specific perfusion defects (PD) using standard distribution territories in a routine clinical procedure of patients with multivessel disease (MVD). Combined quantitative coronary angiography and fractional flow reserve (QCA/FFR) measurements were used as invasive reference standard. 216 vessels in 72 MVD patients (67 +/- 10 years, 28 female) were investigated using MPI and QCA. FFR of 93 vessels with intermediate stenoses was determined. MPI detected significant stenoses according to QCA/FFR findings with a sensitivity of 85%. However, vessel-based evaluation using standard myocardial distribution territories delivered a sensitivity of only 62% (28 MPI+ out of 45 (QCA/FFR)+ findings), with specificity, PPV and NPV of 90, 62 and 90%. 7/17 false positive and 7/17 false negative findings (41%) could be attributed to incorrect allocation of reversible PD to their respective coronary arteries. 6/17 (35%) perfusion territories were classified as false negative when additional fixed PD were present. MPI had reasonable sensitivity for the detection of significant coronary artery disease in patients with multivessel disease. However, sensitivity decreased markedly, when the significance of each individual stenosis was evaluated using standard myocardial supplying territories. In this setting, 41% of false negative and false positive MPI findings resulted from incorrect allocation of reversible perfusion defects to their determining supplying vessel.
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PMID:Tc-99m sestamibi single photon emission computed tomography for guiding percutaneous coronary intervention in patients with multivessel disease: a comparison with quantitative coronary angiography and fractional flow reserve. 2003 85

Over the last 15 years, the use of invasive coronary physiology in the catheterization laboratory has demonstrated favorable outcomes for decision making in patients with intermediate single-vessel stenoses, complex bifurcation and ostial branch stenoses, multivessel coronary artery disease, and left main stenoses. A recent large multicenter study (FAME [FFR versus Angiography for Multivessel Evaluation]) found that a physiologically-guided approach was superior to the standard angiographically-guided approach for percutaneous revascularization in patients with multivessel coronary artery disease. This review addresses selected pertinent concepts and studies supporting the integration of coronary physiology in the catheterization laboratory for optimal patient outcomes.
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PMID:Current concepts of integrated coronary physiology in the catheterization laboratory. 2011 97

In a recent manuscript in the Journal of the American College of Cardiology, the newly introduced "functional SYNTAX score" (FSS) was found to be a better tool to assess the extent and severity of coronary artery disease than the SYNTAX score (SS) and has reclassified 1/3 of the studied cohort into lower-risk categories. Besides being more invasive, costly, and time consuming, FSS still suffers from inherent deficiencies of its own. Like SS, FSS does not incorporate clinical risk predictors and consequently is a suboptimal tool for predicting PCI risk. FSS is not supported by a wealth of contemporary outcome data in a wide range of patient and lesions subsets. Key unanswered questions are whether PCI of hemodynamically significant lesions (FFR <0.80) is superior to optimal medical therapy (OMT) and whether complete revascularization yields considerably better outcomes than partial revascularization. Since partial revascularization is still an option, operational FSS (taking into account only the FSS of lesions subject to PCI) combined with a clinical risk score will probably better predict the procedural risk of the planned PCI.
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PMID:The functional SYNTAX score - a huge step forward or research in motion? 2268 88

Functional imaging in patients with suspected or known coronary artery disease (CAD) is crucial for the identification of patients who could benefit from coronary revascularization. Several studies demonstrated the high diagnostic accuracy of Single-photon-emission computed tomography myocardial perfusion imaging, stress perfusion magnetic resonance imaging, and of invasive FFR measurements for the detection of hemodynamic relevant stenosis. Cardiac computed tomography (CT) used to be limited to coronary angiography (CTA); current guidelines recommend CTA only for the exclusion of CAD. Technological advances now offer the possibility to assess myocardial perfusion by computed tomography (CT-MPI). Though different acquisition protocols and post-processing algorithms still have to be evaluated, initial clinical studies could already show a diagnostic accuracy comparable to the established imaging modalities. Thus, cardiac CT may offer a combined approach of anatomical and functional imaging. Beside the need for further studies, especially on the prognostic value of CT-MPI to stratify future cardiovascular events, the comparatively high radiation exposure and additional administration of contrast agent has to be taken in account.
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PMID:CT imaging of myocardial perfusion: possibilities and perspectives. 2347 67

Cornerstones in the treatment of coronary artery disease (CAD) are medical therapy and coronary revascularization. In acute settings (ST-elevation myocardial infarction and non-ST-elevation myocardial infarction), percutaneous coronary intervention (PCI) has proven to improve prognosis. The optimal treatment of stable CAD is subject to great controversy. By using fractional flow reserve to guide PCI, it is possible to stent only those lesions that induce myocardial ischemia. This review aims to reflect on the use of FFR-guided PCI in stable CAD.
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PMID:Recent insights into the treatment of stable CAD : FFR-guided PCI vs. medical therapy. 2615 25

Decision to revascularize a patient with stable coronary artery disease should be based on the detection of myocardial ischemia. If this decision can be straightforward with significant stenosis or in non-significant stenosis, the decision with intermediate stenosis is far more difficult and require invasive measures of functional impact of coronary stenosis on maximal blood (flow fractional flow reserve=FFR). A recent computer based method has been developed and is able to measure FFR with data acquired during a standard coronary CT-scan (FFRcT). Two recent clinical studies (DeFACTO and DISCOVER-FLOW) show that diagnostic performance of FFRcT was associated with improved diagnostic accuracy versus standard coronary CT-scan for the detection of myocardial ischemia although FFRcT need further development.
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PMID:[Diagnosis of stable coronary artery disease with non-invasive FFR: myth or reality?]. 2378 81

Recent advances in image-based modeling and computational fluid dynamics permit the calculation of coronary artery pressure and flow from typically acquired coronary computed tomography (CT) scans. Computed fractional flow reserve is the ratio of mean coronary artery pressure divided by mean aortic pressure under conditions of simulated maximal coronary hyperemia, thus providing a noninvasive estimate of fractional flow reserve (FFRCT) at every point in the coronary tree. Prospective multicenter clinical trials have shown that computed FFRCT improves diagnostic accuracy and discrimination compared to CT stenosis alone for the diagnosis of hemodynamically significant coronary artery disease (CAD), when compared to invasive FFR as the reference gold standard. This promising new technology provides a combined anatomic and physiologic assessment of CAD in a single noninvasive test that can help select patients for invasive angiography and revascularization or best medical therapy. Further evaluation of the clinical effectiveness and economic implications of noninvasive FFRCT are now being explored.
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PMID:Computed fractional flow reserve (FFTCT) derived from coronary CT angiography. 2427 9


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