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Coronary Physiology in Clinical Practice: Fractional Flow Reserve and Beyond

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (31 January 2020) | Viewed by 23449

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Special Issue Editor

Dr. Petr Kala

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Guest Editor

1. Department of Internal Medicine and Cardiology, University Hospital Brno, Jihlavska 20, 625 00 Brno, Czech Republic
2. Faculty of Medicine, Masaryk University, Jihlavska 20, 625 00 Brno, Czech Republic
Interests: interventional cardiology; coronary physiology; acute myocardial infarction; revascularization; TAVI; antithrombotic treatment; acute coronary syndrome; myocardial damage; FFR; iFR

Special Issue Information

Dear Colleagues,

Please let me start with an important question: What would you define as the gold standard in the assessment of coronary arteries and indication for coronary revascularization in 2019/2020? Is it still the coronary angiography alone? Should it be a combination of coronary angiography and non-invasive exercise stress tests or hybrid non-invasive imaging and perfusion techniques like positron-emission computed tomography (PET-CT), positron-emission magnetic resonance (PET-MR), and computed tomography-fractional flow reserve (CT_FFR)? Should it be a precise intracoronary invasive evaluation, optical coherent tomography (OCT), and/or intravascular ultrasound (IVUS)? Or should invasive coronary physiology assessment become the new gold standard providing additional value to coronary morphology?

The class IA ESC/EACTS Guidelines 2018 recommend FFR_myoand iFR (instantaneous wave-free ratio) for pressure-derived and lesion specific measurements before revascularization, which is based on numerous randomized clinical outcome trials. Beyond this, there are many more resting and hyperemic indexes, such as the coronary flow reserve (CFR) index of myocardial resistance (IMR), which may be relevant in different clinical situations.

In fact, to define a new gold standard in coronary assessment is rather difficult, but there is an emerging support for the idea that whole coronary circulation should be taken into account in the decision-making process, not only before but also during and after revascularization. Most probably, the combination of coronary physiology and morphology will become the new gold standard and provide deep insights into coronary, as well as some myocardial, pathologies.

In this Special Issue, we will focus on original and review articles dedicated to coronary physiology and combined techniques. We are interested in the coronary physiology not only of patients with coronary and myocardial pathologies but also of patients with a combination of coronary and other diseases, e.g., aortic valve stenosis or cardiomyopathies.

Welcome to the exciting world of coronary circulation and do not miss the possibility to become a part of this family!

Assoc. Prof. Dr. Petr Kala
Guest Editor

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Keywords

coronary physiology
FFR
CFR
IMR
iFR
myocardial infarction
revascularization

Published Papers (6 papers)

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Research

Jump to: Review

12 pages, 6287 KiB

Open AccessArticle

Comparison of Machine Learning Computed Tomography-Based Fractional Flow Reserve and Coronary CT Angiography-Derived Plaque Characteristics with Invasive Resting Full-Cycle Ratio

by Stefan Baumann, Markus Hirt, Christina Rott, Gökce H. Özdemir, Christian Tesche, Tobias Becher, Christel Weiss, Svetlana Hetjens, Ibrahim Akin, Stefan O. Schoenberg, Martin Borggrefe, Sonja Janssen, Daniel Overhoff and Dirk Lossnitzer

J. Clin. Med. 2020, 9(3), 714; https://doi.org/10.3390/jcm9030714 - 06 Mar 2020

Cited by 5 | Viewed by 3051

Abstract

Background: The aim is to compare the machine learning-based coronary-computed tomography fractional flow reserve (CT-FFR_ML) and coronary-computed tomographic morphological plaque characteristics with the resting full-cycle ratio (RFR^TM) as a novel invasive resting pressure-wire index for detecting hemodynamically significant coronary artery stenosis. Methods: In our single center study, patients with coronary artery disease (CAD) who had a clinically indicated coronary computed tomography angiography (cCTA) and subsequent invasive coronary angiography (ICA) with pressure wire-measurement were included. On-site prototype CT-FFR_ML software and on-site CT-plaque software were used to calculate the hemodynamic relevance of coronary stenosis. Results: We enrolled 33 patients (70% male, mean age 68 ± 12 years). On a per-lesion basis, the area under the receiver operating characteristic curve (AUC) of CT-FFR_ML (0.90) was higher than the AUCs of the morphological plaque characteristics length/minimal luminal diameter⁴ (LL/MLD⁴; 0.80), minimal luminal diameter (MLD; 0.77), remodeling index (RI; 0.76), degree of luminal diameter stenosis (0.75), and minimal luminal area (MLA; 0.75). Conclusion: CT-FFR_ML and morphological plaque characteristics show a significant correlation to detected hemodynamically significant coronary stenosis. Whole CT-FFR_ML had the best discriminatory power, using RFR^TM as the reference standard. Full article

(This article belongs to the Special Issue Coronary Physiology in Clinical Practice: Fractional Flow Reserve and Beyond)

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16 pages, 1099 KiB

Open AccessArticle

Additional Value of Machine-Learning Computed Tomographic Angiography-Based Fractional Flow Reserve Compared to Standard Computed Tomographic Angiography

by Dirk Lossnitzer, Leonard Chandra, Marlon Rutsch, Tobias Becher, Daniel Overhoff, Sonja Janssen, Christel Weiss, Martin Borggrefe, Ibrahim Akin, Stefan Pfleger and Stefan Baumann

J. Clin. Med. 2020, 9(3), 676; https://doi.org/10.3390/jcm9030676 - 03 Mar 2020

Cited by 11 | Viewed by 3593

Abstract

Background: Machine-learning-based computed-tomography-derived fractional flow reserve (CT-FFR_ML) obtains a hemodynamic index in coronary arteries. We examined whether it could reduce the number of invasive coronary angiographies (ICA) showing no obstructive lesions. We further compared CT-FFR_ML-derived measurements to clinical and CT-derived scores. Methods: We retrospectively selected 88 patients (63 ± 11years, 74% male) with chronic coronary syndrome (CCS) who underwent clinically indicated coronary computed tomography angiography (cCTA) and ICA. cCTA image data were processed with an on-site prototype CT-FFR_ML software. Results: CT-FFR_ML revealed an index of >0.80 in coronary vessels of 48 (55%) patients. This finding was corroborated in 45 (94%) patients by ICA, yet three (6%) received revascularization. In patients with an index ≤ 0.80, three (8%) of 40 were identified as false positive. A total of 48 (55%) patients could have been retained from ICA. CT-FFR_ML (AUC = 0.96, p ≤ 0.0001) demonstrated a higher diagnostic accuracy compared to the pretest probability or CT-derived scores and showed an excellent sensitivity (93%), specificity (94%), positive predictive value (PPV; 93%) and negative predictive value (NPV; 94%). Conclusion: CT-FFR_ML could be beneficial for clinical practice, as it may identify patients with CAD without hemodynamical significant stenosis, and may thus reduce the rate of ICA without necessity for coronary intervention. Full article

(This article belongs to the Special Issue Coronary Physiology in Clinical Practice: Fractional Flow Reserve and Beyond)

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15 pages, 2864 KiB

Open AccessArticle

Fractional Flow Reserve Derived from Coronary Computed Tomography Angiography Safely Defers Invasive Coronary Angiography in Patients with Stable Coronary Artery Disease

by Mark Rabbat, Jonathon Leipsic, Jeroen Bax, Brian Kauh, Rina Verma, Demetrios Doukas, Sorcha Allen, Gianluca Pontone, David Wilber, Verghese Mathew, Campbell Rogers and John Lopez

J. Clin. Med. 2020, 9(2), 604; https://doi.org/10.3390/jcm9020604 - 24 Feb 2020

Cited by 30 | Viewed by 5085

Abstract

Objectives: In the United States, the real-world feasibility and outcome of using fractional flow reserve from coronary computed tomography angiography (FFR_CT) is unknown. We sought to determine whether a strategy that combined coronary computed tomography angiography (CTA) and FFR_CT could safely reduce the need for invasive coronary angiography (ICA), as compared to coronary CTA alone. Methods: The study included 387 consecutive patients with suspected CAD referred for coronary CTA with selective FFR_CT and 44 control patients who underwent CTA alone. Lesions with 30–90% diameter stenoses were considered of indeterminate hemodynamic significance and underwent FFR_CT. Nadir FFR_CT ≤ 0.80 was positive. The rate of patients having ICA, revascularization and major adverse cardiac events were recorded. Results: Using coronary CTA and selective FFR_CT, 121 patients (32%) had at least one vessel with ≥50% diameter stenosis; 67/121 (55%) patients had at least one vessel with FFR_CT ≤ 0.80; 55/121 (45%) underwent ICA; and 34 were revascularized. The proportion of ICA patients undergoing revascularization was 62% (34 of 55). The number of patients with vessels with 30–50% diameter of stenosis was 90 (23%); 28/90 (31%) patients had at least one vessel with FFR_CT ≤ 0.80; 8/90 (9%) underwent ICA; and five were revascularized. In our institutional practice, compared to coronary CTA alone, coronary CTA with selective FFR_CT reduced the rates of ICA (45% vs. 80%) for those with obstructive CAD. Using coronary CTA with selective FFR_CT, no major adverse cardiac events occurred over a mean follow-up of 440 days. Conclusion: FFR_CT safely deferred ICA in patients with CAD of indeterminate hemodynamic significance. A high proportion of those who underwent ICA were revascularized. Full article

(This article belongs to the Special Issue Coronary Physiology in Clinical Practice: Fractional Flow Reserve and Beyond)

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13 pages, 2243 KiB

Open AccessArticle

QFR Predicts the Incidence of Long-Term Adverse Events in Patients with Suspected CAD: Feasibility and Reproducibility of the Method

by Andrea Buono, Annika Mühlenhaus, Tabitha Schäfer, Ann-Kristin Trieb, Julian Schmeißer, Franziska Koppe, Thomas Münzel, Remzi Anadol and Tommaso Gori

J. Clin. Med. 2020, 9(1), 220; https://doi.org/10.3390/jcm9010220 - 14 Jan 2020

Cited by 12 | Viewed by 3865

Abstract

AIMS: We evaluate feasibility and reproducibility of post hoc quantitative flow ratio (QFR) measurements and their prognostic predictive power during long-term follow-up. METHODS AND RESULTS: Between 2010 and 2012, 167 patients without angiographic evidence of significant stenoses were enrolled in a prospective registry. Of these patients, 96% presented 7 years follow-up data. QFR was measured post hoc by three certified investigators. QFR analysis was feasible in 71% of left anterior descending (LAD), 72% of left circumflex (LCX), and 61% of right (RCA) coronaries for a total of 350 measurements repeated in triplicate. Coefficients of variation were 2.1% for RCA and LCX, and 2.8% for the LAD (quartile coefficients of dispersion respectively 1.5, 1.4, and 1.3). QFR ≤0.80 was recorded in 25 patients (27 vessels, in 74% of the cases LAD). A total of 86 major adverse cardiovascular and cerebrovascular events were observed in 76 patients. QFR ≤0.80 in at least one of the three vessels was the strongest predictor of events (HR 3.14, 95%CI 1.78–5.54, p = 0.0001). This association was maintained in several sensitivity analyses. CONCLUSIONS: QFR reproducibility is acceptable, even when analysis is performed post hoc. A pathological QFR is not rare in patients without angiographic evidence of significant stenosis and is a predictor of incident events during long-term follow-up. Condensed Abstract: In a post hoc analysis of 167 patients without evidence of angiographic significant stenosis, the presence of QFR value ≤0.80 in at least one of the three coronary vessels showed to be the strongest predictor of major adverse cardiovascular and cerebrovascular events during long-term follow-up. QFR reproducibility have been shown to be acceptable among experienced operators. Full article

(This article belongs to the Special Issue Coronary Physiology in Clinical Practice: Fractional Flow Reserve and Beyond)

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10 pages, 1436 KiB

Open AccessArticle

Reliability of Instantaneous Wave-Free Ratio (iFR) for the Evaluation of Left Main Coronary Artery Lesions

by Salvatore De Rosa, Alberto Polimeni, Giovanni De Velli, Micaela Conte, Sabato Sorrentino, Carmen Spaccarotella, Annalisa Mongiardo, Jolanda Sabatino, Marco Contarini, Daniel Todaro and Ciro Indolfi

J. Clin. Med. 2019, 8(8), 1143; https://doi.org/10.3390/jcm8081143 - 31 Jul 2019

Cited by 13 | Viewed by 3426

Abstract

The assessment of the left main coronary artery (LMCA) by coronary angiography has several limitations. The fractional flow reserve (FFR) is useful for the functional evaluation of LMCA stenoses. The instantaneous wave-free ratio (iFR), a resting index, was developed to simplify functional coronary assessment. However, its performance for LMCA stenoses has yet to be explored. The iFR was measured at rest, and the FFR was measured under maximal hyperemia. We calculated that a sample size of 90 lesions would have provided 90% power at a 5% significance level to detect an Area Under the Curve (AUC) < 0.7 for the iFR to identify FFR-positive stenoses. A total of 91 measurements were performed on angiographically intermediate LMCA stenoses at three centers. The comparison between the iFR and the FFR showed a significant correlation (r = 0.67, p < 0.001). At receiver operating characteristic (ROC) analysis, the iFR revealed a good diagnostic performance when compared to the FFR (AUC = 0.84; p < 0.001). A classification agreement between the iFR and the FFR was recorded in 81% of cases. The left ventricular ejection fraction (LVEF) was an independent predictor of the discrepancy between the FFR and iFR values (p = 0.040). The present study is the first demonstrating that the assessment of LMCA stenoses with the instantaneous wave-free ratio is a reliable adenosine-free alternative to classic fractional flow reserve. If confirmed in larger populations, these findings could be of relevance for real world daily practice. Full article

(This article belongs to the Special Issue Coronary Physiology in Clinical Practice: Fractional Flow Reserve and Beyond)

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Review

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23 pages, 1628 KiB

Open AccessReview

Determining the Significance of Coronary Plaque Lesions: Physiological Stenosis Severity and Plaque Characteristics

by John-Ross D. Clarke, Freddy Duarte Lau and Stuart W. Zarich

J. Clin. Med. 2020, 9(3), 665; https://doi.org/10.3390/jcm9030665 - 02 Mar 2020

Cited by 3 | Viewed by 3942

Abstract

The evaluation of coronary lesions has evolved in recent years. Physiologic-guided revascularization (particularly with pressure-derived fractional flow reserve (FFR)) has led to superior outcomes compared to traditional angiographic assessment. A greater importance, therefore, has been placed on the functional significance of an epicardial lesion. Despite the improvements in the limitations of angiography, insights into the relationship between hemodynamic significance and plaque morphology at the lesion level has shown that determining the implications of epicardial lesions is rather complex. Investigators have sought greater understanding by correlating ischemia quantified by FFR with plaque characteristics determined on invasive and non-invasive modalities. We review the background of the use of these diagnostic tools in coronary artery disease and discuss the implications of analyzing physiological stenosis severity and plaque characteristics concurrently. Full article

(This article belongs to the Special Issue Coronary Physiology in Clinical Practice: Fractional Flow Reserve and Beyond)

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