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Fractional Flow Reserve Assessment of Coronary Artery Stenosis.

ABSTRACT: Objective proof of focal lesions is mandatory, and the best invasive method of physiological testing is fractional flow r eserve (FFR). The increased trans-stenotic gradient is measured via the guiding catheter and pressure transducer on a 0.014" coronary wire at maximal hyperaemia induced by adenosine. Patients with a FFR of less than 0.8 should undergo myocardial revascularisation by percutaneous coronary intervention or coronary artery bypass graft, particularly if the proximal and middle segments of the main coronary arteries and large side-branches are affected; there is no prognostic revascularisation benefit in patients with moderate stenoses and FFR greater than 0.80. FFR assessment of coronary lesions is superior to other invasive morphological studies, such as intracoronary ultrasound or optical coherence tomography. Its use in non-culprit vessels in acute coronary syndromes is currently under scrutiny. Recent advances in computed tomographic technique allow non-invasive assessment of FFR, but clinical validation has yet to be obtained.

SUBMITTER: Balanescu S

PROVIDER: S-EPMC6159406 | biostudies-other | 2016 Dec

REPOSITORIES: biostudies-other

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Fractional Flow Reserve Assessment of Coronary Artery Stenosis.

Balanescu Serban S

European cardiology 20161201 2

Objective proof of focal lesions is mandatory, and the best invasive method of physiological testing is fractional flow r eserve (FFR). The increased trans-stenotic gradient is measured via the guiding catheter and pressure transducer on a 0.014" coronary wire at maximal hyperaemia induced by adenosine. Patients with a FFR of less than 0.8 should undergo myocardial revascularisation by percutaneous coronary intervention or coronary artery bypass graft, particularly if the proximal and middle seg ...[more]

PMID: 30310451

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Project description:BackgroundUnderstanding of the risk conferred by functionally insignificant lesions in multiple coronary vessels is limited. We investigated the prognostic implications of coronary artery disease (CAD) based on 3-vessel fractional flow reserve (FFR).Methods and resultsA total of 1,136 patients underwent FFR measurement in the 3 major epicardial arteries. We defined vessels with "Moderate CAD" as vessels with FFR, 0.81 to 0.87. Patients were classified into Group 1: No apparent CAD (FFR>0.87 in all 3-vessels); Group 2: Single-vessel moderate CAD; Group 3: Multivessel moderate CAD; and Group 4: Functionally significant CAD (FFR≤0.80) in any vessel. The primary end point was 2-year major adverse cardiac events, a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization. Forty-three percent of patients had moderate CAD (Group 2: 403/1136, 35.5%; Group 3: 84/1136, 7.4%). The 2-year risk of major adverse cardiac events was not significantly different between patients with single-vessel moderate CAD and no apparent CAD (2.6 versus 2.6%; HR, 1.1; 95% confidence interval, 0.4%-2.8%; P=0.89). However, patients with multivessel moderate CAD were at significantly higher risk than Group 1 (7.4 versus 2.6%; hazard ratio, 3.3; 95% confidence interval, 1.1%-9.8%; P=0.03). The risk of major adverse cardiac events in patients with multivessel moderate CAD was comparable to that of patients with functionally significant CAD (hazard ratio, 1.2; 95% confidence interval, 0.5%-3.0%; P=0.67). In a multivariable regression model, multivessel moderate CAD was an independent predictor of greater risk of 2-year major adverse cardiac events.ConclusionsGlobal physiologic assessment with FFR measurement of 3 vessels can identify multivessel moderate CAD. The prognostic implication of multivessel moderate CAD appears comparable to that of functionally significant CAD.Clinical trial registrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT01621438.

Project description:Amongst patients with suspected obstructive coronary artery disease (CAD), less than a third of patients have obstructive disease on invasive coronary angiography (ICA) and fewer still have flow-limiting obstructive disease as determined by invasive fractional flow reserve (FFR). FFR is a powerful tool in guiding revascularization of flow-limiting lesions which in turn improves clinical outcome in those with haemodynamically significant obstructive disease. However FFR is infrequently performed due to the cost, time and patient discomfort the procedure entails. Further advances in non-invasive imaging has allowed FFR to be derived non-invasively by applying computational fluid dynamic (CFD) modeling to the coronary computed tomography angiography (CCTA) dataset without the need to induce hyperemia or modify the standard CCTA acquisition protocol. FFR derived from CCTA has been shown to have excellent correlation with invasive FFR and remains diagnostically robust in presence of reduced signal-to-noise ratio (SNR), coronary calcification and motion artifact. More recently, new data have emerged evaluating the clinical impact of fractional flow reserve computed tomography (FFRCT) on the assessment and management of patients with stable chest pain. One such study is the Prospective LongitudinAl trial of FFRCT: Outcome and Resource IMpacts (PLATFORM) study which showed an improved patient selection for ICA using CCTA-FFRCT approach by increasing the likelihood of identifying obstructive CAD at ICA amongst those intended for invasive testing. CCTA-FFRCT may therefore serve as efficacious gatekeeper to ICA that enriches the ICA population. The utility of FFRCT has also helped deepened our understanding of CAD. Through CFD modeling, it is now recognized that there are mechanistic forces of wall shear stress (WSS) and axial plaque force acting on coronary plaques. This has created further interest in exploring the possible interplay between these mechanistic forces on the development of coronary plaque and vulnerability of these plaques to rupture.

Dataset Information

Fractional Flow Reserve Assessment of Coronary Artery Stenosis.

Publications

Fractional Flow Reserve Assessment of Coronary Artery Stenosis.

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