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This study was performed to determine whether three-dimensional intravascular ultrasound (3D IVUS) could predict the physiologic significance of coronary lesions. Seventeen lesions were evaluated by means of 3D IVUS, pressure measurements, and quantitative coronary angiography. Physiologic parameters were calculated from the 3D IVUS measures using established equations and compared to values measured by pressure guidewire. IVUS minimum lumen area (MLA) correlated with fractional flow reserve (FFR; R2 = 0.55, P = 0.003) and pressure gradient (R2 = 0.52, P = 0.003). Lesion length (L) had a positive correlation with pressure gradient (R2 = 0.45, P = 0.007). By multivariate analysis, the only significant independent determinant of FFR was MLA/L measured by IVUS. The IVUS-predicted pressure gradient and FFR were well correlated with values measured directly (R2) = 0.88, P < 0.001; R2 = 0.90, P < 0.001, respectively). The physiologic severity of coronary lesions is primarily influenced by lumen area and lesion length and can be established by 3D IVUS.
Catheter Cardiovasc Interv 2001 May
PMID:Prediction of the physiologic severity of coronary lesions using 3D IVUS: validation by direct coronary pressure measurements. 1132 18

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.
Int J Cardiovasc Imaging 2002 Feb
PMID:Adequate patient selection for coronary revascularization: an overview of current methods used in daily clinical practice. 1213 22

A patient with distal slow-flow after stenting in the old vein graft intervention was reported. This case is a first in whom guidewire-based serial measurement of pressure-derived fractional flow reserve (FFR(myo)) and thermodilution-based coronary flow reserve (CFR(thermo)) clearly demonstrated the serial change of microvascular circulation. During slow-flow, CFR(thermo) remained in low value despite significant improvement of FFR(myo) from 0.61 to 0.90. After thrombus aspiration and nicorandil injection, coronary flow reestablished immediately. CFR(thermo) improved significantly from 1.3 during slow-flow to 3.6 after restoration of flow.
Catheter Cardiovasc Interv 2003 Nov
PMID:Myocardial perfusion during transient slow-flow in the patient with old vein graft intervention: assessment by serial measurement of pressure-derived fractional flow reserve and thermodilution-derived coronary flow reserve. 1457 93

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.
Catheter Cardiovasc Interv 2004 Oct
PMID:Percutaneous coronary intervention or bypass surgery in multivessel disease? A tailored approach based on coronary pressure measurement. 1539 Mar 44

Insights into intracellular calcium regulation and contractile state can be accomplished by changing pacing rate. Steady-state increases in heart rate (HR) (force-frequency relationship, FFR), and introduction of extrasystoles (ES) (force-interval relationship, FIR) have been used to investigate this relationship. This study focused on the recirculation fraction (RF) and potentiation ratio (PR), obtained from the recovery of the FFR and FIR. These parameters may provide insight on intracellular Ca(2+) regulation. Left ventricular (LV) pressures and HR were assessed in anesthetized canines (n = 7). Intrinsic data were collected prior to and following HR increases to 150, 180, and 200 bpm, as well as following delivery of an ES at 280 ms. The RF was calculated as the slope of dP/dt(max(n + 1)) vs. dP/dt(max(n)), where n = beat number. The PR was calculated by normalizing dP/dt(max) from the first beat following the ES (or the last paced beat) to the steady-state dP/dt(max). The RF due to an ES was not significantly different than that from a HR of 200 bpm. The PR from an ES was not significantly different than from a HR of 150 bpm. The impact of an ES delivered at an interval of 280 ms produces a PR similar to that from a HR of 150 bpm; yet, it recovers similarly to the termination of pacing at 200 bpm, eliciting a similar RF value. The method of measuring RF by an ES versus an increased HR may provide a safer and more feasible approach to collecting diagnostic information.
Cardiovasc Eng 2007 Mar
PMID:Novel means to monitor cardiac performance: the impact of the force-frequency and force-interval relationships on recirculation fraction and potentiation ratio. 1731 31

The aim of this study was the determination of the pressure-derived collateral fractional flow reserve (FFR(coll)) in patients with three vessel disease and chronic occlusion of the right coronary artery undergoing surgical complete revascularization with the off-pump technique. The angiograms of eight patients were preoperatively analysed to quantify collaterality. FFR(coll) was determined before any revascularization (FFR(coll) 0), and after revascularization of the left coronary arteries, (FFR(coll) 1). FFR(coll) 0 was compared to the Rentrop grade, to the left ventricular ejection fraction (LVEF), and to FFR(coll) 1. No correlation was demonstrated between preoperative Rentrop grade and FFR(coll) 0. There was a linear statistically significant correlation between FFR(coll) 0 and LVEF (P;ie0.001). No significant variation of the FFR(coll) index was observed after performing left coronary artery bypass grafts. Collaterality observed on the coronary angiogram cannot be used as an estimation of the functional collaterality, which can be better appreciated with the LVEF. The absence of variation of FFRcoll before and after left coronary artery revascularization suggests that grafting of the occluded right coronary artery remains justified.
Interact Cardiovasc Thorac Surg 2005 Feb
PMID:Collateral flow reserve and right coronary occlusion: evaluation during off-pump revascularization. 1767 Mar 48

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.
Int J Cardiovasc Imaging 2010 Feb
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

Conversations in Cardiology is a new use of modern email communication to facilitate transfer of medical knowledge. In this Conversation in Cardiology, Dr. Barry Uretsky of Little Rock Arkansas asked a question about a patient with left main narrowing and the assessment by FFR and IVUS and several well known expert interventionalists address the clinical dilemma. Their answers and rebuttals are reflective of areas of agreement and disagreement and demonstrate the educational value of this format from expert opinion on problems not readily addressed by reference books or formal data studies.
Catheter Cardiovasc Interv 2012 Sep 01
PMID:Conversations in cardiology: using new media to transmit timely medical knowledge. How do you assess the left main stenosis with FFR and IVUS in a patient with multivessel CAD? 2241 7

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.
J Cardiovasc Transl Res 2013 Oct
PMID:Computed fractional flow reserve (FFTCT) derived from coronary CT angiography. 2427 9

Percutaneous coronary intervention (PCI) based on fractional flow reserve (FFRcath) measurement during invasive coronary angiography (CAG) results in improved patient outcome and reduced healthcare costs. FFR can now be computed non-invasively from standard coronary CT angiography (cCTA) scans (FFRCT). The purpose of this study is to determine the potential impact of non-invasive FFRCT on costs and clinical outcomes of patients with suspected coronary artery disease in Japan. Clinical data from 254 patients in the HeartFlowNXT trial, costs of goods and services in Japan, and clinical outcome data from the literature were used to estimate the costs and outcomes of 4 clinical pathways: (1) CAG-visual guided PCI, (2) CAG-FFRcath guided PCI, (3) cCTA followed by CAG-visual guided PCI, (4) cCTA-FFRCT guided PCI. The CAG-visual strategy demonstrated the highest projected cost ($10,360) and highest projected 1-year death/myocardial infarction rate (2.4 %). An assumed price for FFRCT of US $2,000 produced equivalent clinical outcomes (death/MI rate: 1.9 %) and healthcare costs ($7,222) for the cCTA-FFRCT strategy and the CAG-FFRcath guided PCI strategy. Use of the cCTA-FFRCT strategy to select patients for PCI would result in 32 % lower costs and 19 % fewer cardiac events at 1 year compared to the most commonly used CAG-visual strategy. Use of cCTA-FFRCT to select patients for CAG and PCI may reduce costs and improve clinical outcome in patients with suspected coronary artery disease in Japan.
Cardiovasc Interv Ther 2015 Jan
PMID:Cost analysis of non-invasive fractional flow reserve derived from coronary computed tomographic angiography in Japan. 2503 Jan 80


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