CT-Derived Fractional Flow Reserve (FFRCT): From Gatekeeping to Roadmapping
Alex L. HuangP. MaggioreRichard A. BrownMansi TuragaAnna ReidJacob MerkurPhilipp BlankeJonathon Leipsic
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Abstract:
Coronary computed tomography angiography (CCTA) has emerged as the preferred modality in the diagnosis of coronary artery disease, but it is limited by modest specificity. By applying principles of computational fluid dynamics, flow fraction reserve, a measure of lesion-specific ischemia that is used to guide revascularization, can be noninvasively derived from CCTA, the so-called computed tomography-derived flow fractional reserve (FFRCT). The accuracy of FFRCT in discriminating ischemia has been extensively validated, and it has been shown to improve the specificity of CCTA. Compared to other stress myocardial perfusion imaging, FFRCT has superior or comparable accuracy. Clinical studies have provided strong evidence that FFRCT has significant prognostic implications and informs clinical decisions for revascularization, serving as a gatekeeper to invasive coronary angiography. In addition, FFRCT-based tools can be used to simulate the physiological consequences of different revascularization strategies, thus providing the roadmap to achieve complete revascularization. Although challenges remain, ongoing research and randomized controlled trials are expected to address current limitations and better define its role in clinical practice.Keywords:
Fractional Flow Reserve
Objective To study and compare the diagnostic value in severe coronary artery disease (CAD) of 99 Tc m methoxyisobutylisonitrile (MIBI) electrocardiogram (ECG) gated early post exercise myocardial perfusion imaging (G MPI) with that of non ECG gated myocardial perfusion imaging (NG MPI). Methods Two hundred and fifteen suspected CAD patients had undergone G MPI and coronary artery angiography (CAG) within one month were enrolled and distributed into three vessel and non three vessel CAD groups according to CAG results (≥70%); the diagnostic values in severe CAD of G MPI and NG MPI were gained and compared to determine which one of the two protocols would be superior in identification of severe three vessel CAD. Results When the ≥70% diameter stenosis CAG was the diagnostic standard of severe CAD, the sensitivity of G MPI and NG MPI in the diagnosis of severe CAD were 95.3% (143/150) and 90.7% (136/150, χ 2=2.509, P =0 113), but when the comparison specifically pinpointed to severe three vessel CAD, there was significant difference between G MPI [100%(51/51)] and NG MPI [92.2% (47/51), χ 2=4.163, P =0.041]. Diagnostic specificity of G MPI was 80.0% and that of NG MPI was 72.3% ( χ 2=1.059, P =0.303). Conclusions The incremental diagnostic sensitivity of G MPI adding to the NG MPI in the diagnosis of severe CAD was mainly from the three vessel subgroup patients.Exercise stress G MPI has better diagnostic value in severe three vessel CAD patients than NG MPI.
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Objective To study the clinical value of adenosine triphosphate stress myocardial perfusion tomography imaging (ATP-MPI) in detection of coronary artery disease (CAD). Methods There were 278 patients underwent ATP-MPI, 51 patients of them also underwent coronary angiography (CAG). Seventy-three patients underwent stress-rest myocardial perfusion tomography imaging with multi-stage submaximal exercise test (ST-MPI) and CAG serving as control group. Results ①Side effects: there were 11 different symptoms and atrioventricular conduction block (10 patients), sinoatrial conduction block (2 patients) occurred during ATP stress. Allopathy or interruption of ATP stress did not happen. ②The sensitivity and specificity of ATP-MPI in detection of CAD were 97.1% and 82.4%, respectively, and those in detection of ≥50% narrowing coronary artery were 91.0% and 94.7%, respectively. ③In patients without myocardial infarction, the sensitivity and specificity of ATP-MPI in detection of myocardial ischemia were comparable to those of ST-MPI. Conclusion ATP-MPI is an accurate, safe modality and is comparable to ST-MPI in the detection of CAD.
Adenosine triphosphate
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Fractional Flow Reserve
Angiology
Medical Therapy
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Fractional flow reserve (FFR) is an accepted standard to detect the functional significance of coronary stenoses. Recent trials suggest that revascularization of moderate coronary stenoses can be safely deferred if the FFR is > or = 0.75 and FFR can be used to guide therapy in multivessel disease.In a cohort of patients with moderate angiographic coronary disease, we sought to examine the influence of FFR on lesion revascularization and the impact of multivessel FFR assessment on revascularization strategy.Patients with FFR measurements taken between April 2005 to October 2007 were included. Out of 300 cases performed in this time, 264 patients were included. Patients were 62 +/- 11 years and 1.3 +/- 0.54 vessels were examined per case. 92.7% of lesions with a FFR < 0.75 underwent revascularizati on an d 93% of lesions with a FFR > or = 0.75 had intervention deferred. FFR was 0.71 +/- 0.07 in the revascularization group (9 coronary artery bypass graft surgery, 64 percutaneous coronary interventions) and 0.86 +/- 0.06 in the deferred group (p < 0.001). Overall, 75% of patients avoided revascularization of at least one vessel on the basis of the FFR.Measurement of FFR is clinically useful with a high impact on clinical decision-making in the catheterization laboratory. FFR can be used to reclassify patients with multivessel stenoses, reducing the need for revascularization in the majority of cases.
Fractional Flow Reserve
Cardiac catheterization
Target lesion
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Objective To explore diagnostic value of adenosine triphosphate stress myocardial perfusion imaging(ATP-MPI) to coronary artery disease(CAD).Methods ATP-MPI was made for 47 CAD patients and the contrast analysis was conducted among ATP-MPI,stress test myocardial perfusion imaging(STMPI) and coronary angiography(CAG).Results The detectable rate of ATP-MPI,ST-MPI and CAG were(78.7)%,(80.9)% and(85.1)%.There was no significant difference among them(χ~2=(0.638),P(0.05)).With CAG as the standard,the sensitivity and specificity of ATP-MPI and ST-MPI in CAD detection had no significance(P(0.05)).Conclusion Dignosis by ATP-MPI to CAD can replace ST-MPI as a routine examination.
Adenosine triphosphate
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Physiological assessment of intermediate coronary lesions to guide coronary revascularization is currently recommended by international guidelines. Vessel fractional flow reserve (vFFR) has emerged as a new approach to derive fractional flow reserve (FFR) from 3D-quantitative coronary angiography (3D-QCA) without the need for hyperemic agents or pressure wires. The FAST III is an investigator-initiated, open label, multicenter randomized trial comparing vFFR guided versus FFR guided coronary revascularization in approximately 2228 patients with intermediate coronary lesions (defined as 30%-80% stenosis by visual assessment or QCA). Intermediate lesions are physiologically assessed using on-line vFFR or FFR and treated if vFFR or FFR ≤0.80. The primary end point is a composite of all-cause death, any myocardial infarction, or any revascularization at 1-year post-randomization. Secondary end points include the individual components of the primary end point and cost-effectiveness will be investigated. FAST III is the first randomized trial to explore whether a vFFR guided revascularization strategy is non-inferior to an FFR guided strategy in terms of clinical outcomes at 1-year follow-up in patients with intermediate coronary artery lesions.
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The concept of significant lesions has substantially evolved over the last decade. With growing evidence for use of fractional flow reserve (FFR) as a determinant of lesion-specific ischemia and its superiority to angiography-guided revascularization and medical therapy, the field of percutaneous revascularization has shifted to rely exclusively on FFR instead of luminal stenosis alone in guiding revascularization. This transition to physiological assessment has not yet made it to the realm of surgical revascularization. FFR-guided therapy has been shown to be superior to angiography-guided therapy mainly by safe deferral of about 1/3rd of lesions, leading to less periprocedural events and better outcomes. Is it possible that utilization of FFR-guided CABG would lead to less complicated procedures, shorter operating times, more frequent off pump CABG procedures and more hybrid procedures? Can FFR-guided CABG improve the cardiovascular outcomes as compared to current standard of practice? In the following paragraphs we review the concept of FFR, the evidence behind FFR-guided therapy, the emerging data regarding use FFR-guided CABG and discuss where the revascularization field is headed.
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Recent advances in computed tomographic technology have contributed towards improving coronary computed tomography angiography (CCTA) in determining the severity of coronary artery disease anatomically. Although the viability of CCTA has most often been confined to anatomical assessment, recent development has enabled evaluation of the haemodynamic significance of coronary artery disease. In light of this, CCTA-derived fractional flow reserve (FFRCT), a novel imaging modality, now permits the physiological assessment of coronary artery disease. To date, several studies have documented the diagnostic performance of FFRCT, and more trials are being performed that will further substantiate this technique. The present paper provides an overview and discussion of the available evidence for FFRCT in the clinical setting as well as potential future directions of FFRCT.
Fractional Flow Reserve
Computed tomographic angiography
Computed Tomography Angiography
Stress testing (software)
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Coronary computed tomography (CT) is well established for the assessment of symptomatic patients with suspected but not yet confirmed coronary artery disease with high diagnostic accuracy and risk prediction. Until recently, coronary computed tomography angiography (CTA) has played a limited role in the management of complex coronary artery disease (CAD) and in planning revascularisation strategies. With the advent of FFRCT, enabling anatomy and physiology with a single study and the ability to adjudicate lesion specific pressure loss, the potential of combined coronary CT angiography (CCTA) and fractional flow reserve (FFR) computed from non-invasive CT angiography (FFRCT) to inform treatment decision-making and help guide revascularisation has been recognised. In this review, we highlight the evolving role of FFRCT in the management of complex CAD; the opportunities, the data and the unanswered questions.
Fractional Flow Reserve
Computed Tomography Angiography
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Introduction: Fractional flow reserve (FFR) derived from coronary computed tomography datasets (FFRCT) has excellent accuracy to diagnose hemodynamically significant coronary artery disease (CAD) compared to invasive FFR as the reference standard. The recent PLATFORM Trial demonstrated that the use of FFRCT resulted in the safe cancellation of 61% of invasive coronary angiograms (ICA). In the United States, the real world feasibility of a diagnostic strategy using FFRCT is unknown. Thus, we sought to determine whether the use of a coronary computed tomography angiogram (CT) plus FFRCT guided strategy as compared to CT alone will reduce the rate of unnecessary ICA without increasing the occurrence of major cardiac events. Hypothesis: A combined CT/FFRCT guided diagnostic strategy will safely reduce the number of ICA compared to CT alone. Methods: 138 consecutive patients with suspected CAD referred for CT / FFRCT over a 9-month period without known CAD at Loyola University Chicago were included in the anal...
Fractional Flow Reserve
Computed Tomography Angiography
Coronary arteries
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