Comparison of fractional flow reserve, instantaneous wave-free ratio and a novel technique for assessing coronary arteries with serial lesions.
- 作者列表："Modi BN","Rahman H","Ryan M","Ellis H","Pavlidis A","Redwood S","Clapp B","Chowienczyk P","Perera D
AIMS:Physiological indices such as fractional flow reserve (FFR), instantaneous wave-free ratio (iFR) and resting distal coronary to aortic pressure (Pd/Pa) are increasingly used to guide revascularisation. However, reliable assessment of individual stenoses in serial coronary disease remains an unmet need. This study aimed to compare conventional pressure-based indices, a reference Doppler-based resistance index (hyperaemic stenosis resistance [hSR]) and a recently described mathematical correction model to predict the contribution of individual stenoses in serial disease. METHODS AND RESULTS:Resting and hyperaemic pressure wire pullbacks were performed in 54 patients with serial disease. For each stenosis, FFR, iFR, and Pd/Pa were measured by the translesional gradient in each index and the predicted FFR (FFRpred) derived mathematically from hyperaemic pullback data. "True" stenosis significance by each index was assessed following PCI of the accompanying stenosis or measurements made in a large disease-free branch. In 27 patients, Doppler average peak flow velocity (APV) was also measured to calculate hSR (hSR=∆P/APV, where ∆P=translesional pressure gradient). FFR underestimated individual stenosis severity, inversely proportional to cumulative FFR (r=0.5, p<0.001). Mean errors for FFR, iFR and Pd/Pa were 33%, 20% and 24%, respectively, and 14% for FFRpred (p<0.001). Stenosis misclassification rates based on FFR 0.80, iFR 0.89 and Pd/Pa 0.91 thresholds were not significantly different (17%, 24% and 20%, respectively) but were higher than FFRpred (11%, p<0.001). Apparent and true hSR correlated strongly (r=0.87, p<0.001, mean error 0.19±0.3), with only 7% of stenoses misclassified. CONCLUSIONS:Individual stenosis severity is significantly underestimated in the presence of serial disease, using both hyperaemic and resting pressure-based indices. hSR is less prone to error but challenges in optimising Doppler signals limit clinical utility. A mathematical correction model, using data from hyperaemic pressure wire pullback, produces similar accuracy to hSR and is superior to conventional pressure-based indices.
目的: 生理指标如血流储备分数 (FFR) 、瞬时无波比 (iFR) 和静息远端冠状动脉与主动脉压力 (Pd/Pa) 越来越多地用于指导血运重建。然而，连续冠状动脉疾病中个体狭窄的可靠评估仍然是未满足的需要。本研究旨在比较传统的基于压力的指数、基于参考多普勒的阻力指数 (充血狭窄阻力 [hSR]) 和最近描述的数学校正模型，以预测个体狭窄在系列疾病中的贡献。 方法和结果: 54例连续疾病患者进行了静息和充血压力导丝回缩。对于每个狭窄，FFR、iFR和Pd/Pa通过每个指数中的横向梯度和从高血回撤数据数学导出的预测FFR (FFRpred) 来测量。在伴随狭窄的PCI或在无疾病的大分支中进行测量后，评估每个指标的 “真” 狭窄显著性。在27例患者中，还测量多普勒平均峰值流速 (APV) 以计算hSR (hSR = △ p/APV，其中 △ p = 横向压力梯度)。FFR低估了个体狭窄程度，与累积FFR成反比 (r = 0.5，p<0.001)。FFR、iFR和Pd/Pa的平均误差分别为33% 、20% 和24%，FFRpred为14% (p<0.001)。基于FFR 0.80、iFR 0.89和Pd/Pa 0.91阈值的狭窄误分类率无显著差异 (分别为17% 、24% 和20%)，但高于FFRpred (11%，p<0.001)。明显的和真实的hSR强烈相关 (r = 0.87，p<0.001，平均误差0.19 ± 0.3)，只有7% 的狭窄分类错误。 结论: 使用基于充血和静息压力的指数，在存在连续疾病的情况下，个体狭窄的严重程度被显著低估。hSR不太容易出错，但优化多普勒信号的挑战限制了临床应用。使用来自充血压力线回拉的数据的数学校正模型产生与hSR相似的精度，并且优于传统的基于压力的指数。
METHODS::We present the case of a 61-year-old woman with a large tumoral infiltration extending from the pelvis throughout the inferior vena cava inferior to the right atrium, protruding into the right ventricle and right ventricular outflow tract. She had been treated 10 years before for low-grade endometrial stromal sarcoma by hysterectomy and adnexectomy followed by hormone- and radio-therapy. Due to cancer recurrence, she underwent peritonectomy, appendectomy, and resection of terminal ileum.
METHODS:AIMS:Significant platelet activation after long stented coronary segments has been associated with periprocedural microvascular impairment and myonecrosis. In long lesions treated either with an everolimus-eluting bioresorbable vascular scaffold (BVS) or an everolimus-eluting stent (EES), we aimed to investigate (a) procedure-related microvascular impairment, and (b) the relationship of platelet activation with microvascular function and related myonecrosis. METHODS AND RESULTS:Patients (n=66) undergoing elective percutaneous coronary intervention (PCI) in long lesions were randomised 1:1 to either BVS or EES. The primary endpoint was the difference between groups in changes of pressure-derived corrected index of microvascular resistance (cIMR) after PCI. Periprocedural myonecrosis was assessed by high-sensitivity cardiac troponin T (hs-cTnT), platelet reactivity by high-sensitivity adenosine diphosphate (hs-ADP)-induced platelet reactivity with the Multiplate Analyzer. Post-dilatation was more frequent in the BVS group, with consequent longer procedure time. A significant difference was observed between the two groups in the primary endpoint of ΔcIMR (p=0.04). hs-ADP was not different between the groups at different time points. hs-cTnT significantly increased after PCI, without difference between the groups. CONCLUSIONS:In long lesions, BVS implantation is associated with significant acute reduction in IMR as compared with EES, with no significant interaction with platelet reactivity or periprocedural myonecrosis.
METHODS:BACKGROUND:Aortopulmonary window is an uncommon congenital heart disease, with untreated cases not surviving beyond childhood. However, very rarely it can present in adult patients with features of pulmonary hypertension. Clinically these patients cannot be differentiated from other more common conditions with left to right shunt. Transthoracic echocardiography if performed meticulously, can depict the defect in aortopulmonary septum. RESULTS:We report a case of large unrepaired aortopulmonary window in a 23 years old patient, diagnosed on transthoracic echocardiography.