Abstract 18309: Integration of Quantitative Measures of Stenosis Severity With Morphologic Atherosclerotic Plaque Characteristics Improves Discrimination of Coronary Lesions that Cause Ischemia: Results from a Prospective Multicenter International Trial

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Hyung-Bok Park ◽  
Nakazato Ryo ◽  
Ran Heo ◽  
Iksung Cho ◽  
Heidi Gransar ◽  
...  
Keyword(s):  
Atherosclerotic Plaque ◽  
International Study ◽  
Computed Tomographic Angiography ◽  
Operating Characteristics ◽  
Plaque Volume ◽  
Fractional Flow ◽  
Luminal Diameter ◽  
Flow Reserve ◽  
Stenosis Severity ◽  
Coronary Lesions

Background: Beyond stenosis severity, coronary computed tomographic angiography (CCTA) enables morphologic evaluation of atherosclerotic plaque characteristics (APCs), including aggregate plaque volume, positive arterial remodeling (PR), low attenuation plaque (LAP) and spotty calcification (SC), features associated with global myocardial ischemia and acute coronary syndromes. We determined whether the combination of stenosis severity plus APCs would improve the discrimination of coronary lesions that cause ischemia. Method: 252 patients from 17 centers in 5 countries [mean age 63 years, 71% males] underwent CCTA and invasive angiography, with invasive fractional flow reserve (FFR) performed for 407 coronary lesions. Stenosis severity was determined by luminal diameter reduction (%DS). Aggregate plaque volume (APV) was defined as the plaque volume from ostium to distal end of the lesion, with APV percent (%APV) defined as APV divided by total vessel volume. Other APCs by CCTA were defined as: (1) PR, lesion diameter/reference diameter >1.10; (2) LAP, any voxel <30 HU; and (3) SC, nodular calcified plaque <3 mm. Lesion ischemia was defined by invasive FFR ≤0.8, which was employed as the reference standard. Results: Coronary stenosis severity and APCs demonstrated good discrimination for lesion ischemia: %DS, (Area under the receiver operating characteristics curve [AUC] of 0.72 (95% CI 0.68-0.77), APV (AUC 0.69, 95% CI 0.64-0.73), and %APV (0.75, 98% CI 0.70-0.79). Over %DS alone, the addition of %APV improved the discrimination of lesion-specific ischemia (0.79, 95% CI 0.75-0.83, p<0.001), with further improvement with increasing APC number (0.86, 95% CI 0.82-0.89, p<0.001) [Figure]. Conclusion: In this prospective multicenter international study, the combination of quantitative measures of stenosis severity with morphologic features of atherosclerotic plaque by CCTA resulted in improved discrimination of coronary lesion-specific ischemia.

Abstract 20015: Value of Quantitative Atherosclerotic Plaque Assessment Using CCTA to Predict Lesion-specific Ischemia, Data from 407 Coronary Lesions

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Ran Heo ◽  
Hyung-Bok Park ◽  
Nakazato Ryo ◽  
Iksung Cho ◽  
Heidi Gransar ◽  
...  
Keyword(s):  
Invasive Coronary Angiography ◽  
Computed Tomographic Angiography ◽  
Plaque Burden ◽  
Fractional Flow ◽  
Luminal Diameter ◽  
Computed Tomographic ◽  
Flow Reserve ◽  
Significant Difference ◽  
Coronary Lesions ◽  
Tomographic Angiography

Introduction: While coronary computed tomographic angiography (CCTA) demonstrates high diagnostic performance for identification and exclusion of high-grade anatomic stenosis, it is unable to effectively discriminate coronary lesions that causes ischemia. Hypothesis: To study whether quantitative assessment of CCTA offer incremental information for discrimination of lesion ischemia beyond stenosis measures. Methods: 252 consecutive patients with suspected or known coronary artery disease (CAD) from 17 centers in 5 countries were enrolled (mean age 63±9 years, 71% male). Patients underwent CCTA and invasive coronary angiography (ICA), with 407 coronary lesions interrogated by invasive fractional flow reserve (FFR) at the time of maximum hyperemia. For these coronary lesions, we evaluated % diameter stenosis (%DS), % area stenosis (%AS), minimal luminal diameter (MLD, mm), minimal luminal area (MLA, mm 2 ), and plaque burden at MLA by CCTA. Plaque burden (PB, %) was defined as (vessel area–lumen area)/vessel areaх100. Lesion-specific ischemia by FFR was defined as a value ≤0.8. Results: In quantitative analysis area under the receiver operating characteristic curves (AUC) value of %DS, %AS, MLD, MLA, and PB for prediction of ischemia were 0.72 (95% confidence interval (CI) 0.68-0.77, p<0.001), 0.73 (95% CI 0.68-0.77, p<0.001), 0.75 (95% CI 0.70-0.79, p<0.001), 0.75 (95% CI 0.70-0.79, p<0.001), and 0.77 (95% CI 0.73-0.81, p<0.001), respectively. PB showed significantly improved AUC when compared to % area stenosis (p=0.002). However, PB didn’t show incremental power over MLA (p=0.213). There also was no significant difference in AUC between MLA and % area stenosis (p=0.330) Conclusions: Quantitative plaque assessment using CCTA could predict lesion-specific ischemia with good discrimination. Plaque burden showed incremental value over % area stenosis for ischemia prediction.

Epicardial coronary stenosis severity and myocardial perfusion

2020 ◽  
pp. 12-16
Keyword(s):  
Myocardial Perfusion ◽  
Myocardial Ischemia ◽  
Coronary Disease ◽  
Myocardial Perfusion Reserve ◽  
Pharmacological Intervention ◽  
Fractional Flow ◽  
Perfusion Reserve ◽  
Flow Reserve ◽  
Stenosis Severity ◽  
Microvascular Resistance

Patients suspected of having epicardial coronary disease are often investigated with noninvasive myocardial ischemia tests to establish a diagnosis and guide management. However, the relationship between myocardial ischemia and coronary stenoses is affected by multiple factors, and there is marked biological variation between patients. The ischemic cascade represents the temporal sequence of pathophysiological events that occur after interruption of myocardial oxygen delivery. The earliest part of the cascade is examined via perfusion imaging, and fractional flow reserve (FFR) is a corresponding index which is specific to the coronary artery. Whereas FFR has come to be regarded a clinical reference standard against which other newer invasive and noninvasive tests are validated, the diagnostic FFR threshold for detecting ischemia was established against a combination of noninvasive ischemia tests that assessed different stages of the ischemic cascade. Moreover, the validity of invasive pressure-derived indices of stenosis severity are contingent on the assumption that pressure is proportional to flow if microvascular resistance is constant, a condition induced by pharmacological intervention or by examining specific segments of the cardiac cycle. Furthermore, myocardial perfusion reserve depends on dynamic modulation of microvascular resistance, and dysfunction of the microvasculature can lead to ischemia even in the absence of epicardial coronary disease.

Prognostic implication of CT-FFR based functional SYNTAX score in patients with de novo three-vessel disease

2020 ◽  
Author(s):  
Hong Yan Qiao ◽  
Jian Hua Li ◽  
U Joseph Schoepf ◽  
Richard R Bayer ◽  
Fiona C Tinnefeld ◽  
...  
Keyword(s):  
De Novo ◽  
Predictive Accuracy ◽  
Computed Tomographic Angiography ◽  
Syntax Score ◽  
Cardiac Events ◽  
Fractional Flow ◽  
Computed Tomographic ◽  
Flow Reserve ◽  
The Difference ◽  
Functional Syntax

Abstract Aims This study was aimed at investigating whether a machine learning (ML)-based coronary computed tomographic angiography (CCTA) derived fractional flow reserve (CT-FFR) SYNTAX score (SS), ‘Functional SYNTAX score’ (FSSCTA), would predict clinical outcome in patients with three-vessel coronary artery disease (CAD). Methods and results The SS based on CCTA (SSCTA) and ICA (SSICA) were retrospectively collected in 227 consecutive patients with three-vessel CAD. FSSCTA was calculated by combining the anatomical data with functional data derived from a ML-based CT-FFR assessment. The ability of each score system to predict major adverse cardiac events (MACE) was compared. The difference between revascularization strategies directed by the anatomical SS and FSSCTA was also assessed. Two hundred and twenty-seven patients were divided into two groups according to the SSCTA cut-off value of 22. After determining FSSCTA for each patient, 22.9% of patients (52/227) were reclassified to a low-risk group (FSSCTA ≤ 22). In the low- vs. intermediate-to-high (&gt;22) FSSCTA group, MACE occurred in 3.2% (4/125) vs. 34.3% (35/102), respectively (P &lt; 0.001). The independent predictors of MACE were FSSCTA (OR = 1.21, P = 0.001) and diabetes (OR = 2.35, P = 0.048). FSSCTA demonstrated a better predictive accuracy for MACE compared with SSCTA (AUC: 0.81 vs. 0.75, P = 0.01) and SSICA (0.81 vs. 0.75, P &lt; 0.001). After FSSCTA was revealed, 52 patients initially referred for CABG based on SSCTA would have been changed to PCI. Conclusion Recalculating SS by incorporating lesion-specific ischaemia as determined by ML-based CT-FFR is a better predictor of MACE in patients with three-vessel CAD. Additionally, the use of FSSCTA may alter selected revascularization strategies in these patients.

Functional assessment of myocardial ischemia by intracoronary electrocardiogram

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M.R Bigler ◽  
F Praz ◽  
G.C.M Siontis ◽  
M Stoller ◽  
R Grossenbacher ◽  
...  
Keyword(s):  
Myocardial Ischemia ◽  
Primary Study ◽  
Coronary Perfusion ◽  
Funding Source ◽  
Maximal Heart Rate ◽  
Fractional Flow ◽  
Coronary Syndrome ◽  
Flow Reserve ◽  
St Segment ◽  
Coronary Lesions

Abstract Background In patients with chronic coronary syndrome (CCS), percutaneous coronary intervention (PCI) targets hemodynamically significant stenoses, i.e., those thought to cause ischemia. The hemodynamic severity of a coronary stenosis increases with its tightness and with the myocardial mass of viable myocardium downstream of the stenosis. Besides the structural angiographic approach, assessment of functional relevance by pressure measurements (fractional flow reserve, FFR; instantaneous wave-free ratio, iFR) is recommended. However, visual angiographic assessment continues to dominate the treatment decisions for intermediate coronary lesions. Conversely, intracoronary ECG (icECG) potentially provides an inexpensive, sensitive and direct measure of myocardial ischemia. Purpose The goal of this study was to test the accuracy of intracoronary ECG during pharmacologic inotropic stress to determine coronary lesion severity in comparison to established physiologic indices (FFR/iFR) as well as with quantitatively determined percent diameter stenosis (%S) using biplane coronary angiography. Method This was a prospective, open-label study in patients with CCS. The primary study end point was the maximal change in icECG ST-segment shift during pharmacologic inotropic stress induced by dobutamine plus atropine obtained within 1 minute after the point of maximal heart rate (estimated by the formula 220 - age). IcECG was acquired by attaching an alligator clamp to the angioplasty guidewire positioned downstream of a stenosis. For the pressure-derived ratios, i.e. FFR and iFR, the coronary perfusion pressure downstream of a lesion as well as the aortic pressure were continuously recorded. Results One hundred patients were included in the study. Pearson-Correlation coefficient was significant between icECG and all three comparators (%S p&lt;0.001, iFR p&lt;0.001, FFR p&lt;0.001). Using the FFR threshold of 0.80 defining coronary hemodynamic significance, ROC-analysis of the absolute icECG ST-segment shift showed an area under the curve (AUC) of 0.708±0.053 (p=0.0001, n=100, FFR&lt;0.80 n=41). AUC for iFR was 0.919±0.030 (p&lt;0.0001), for percent diameter stenosis it was 0.867±0.036 (p&lt;0.0001). Conclusions During pharmacologic inotropic stress, intracoronary ECG ST-segment shift provides specific evidence for regional myocardial ischemia irrespective of the etiology and thus, provides an additional (patho-)physiologic information for decision making in borderline coronary lesions. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Swiss Heart Foundation

Additional value of deep learning computed tomographic angiography-based fractional flow reserve in detecting coronary stenosis and predicting outcomes

2021 ◽  
pp. 028418512098397
Author(s):  
Yang Li ◽  
Hong Qiu ◽  
Zhihui Hou ◽  
Jianfeng Zheng ◽  
Jianan Li ◽  
...  
Keyword(s):  
Deep Learning ◽  
Unstable Angina ◽  
Fractional Flow Reserve ◽  
Predictive Value ◽  
Computed Tomographic Angiography ◽  
Fractional Flow ◽  
Computed Tomographic ◽  
Flow Reserve ◽  
Sensitivity Specificity ◽  
Tomographic Angiography

Background Deep learning (DL) has achieved great success in medical imaging and could be utilized for the non-invasive calculation of fractional flow reserve (FFR) from coronary computed tomographic angiography (CCTA) (CT-FFR). Purpose To examine the ability of a DL-based CT-FFR in detecting hemodynamic changes of stenosis. Material and Methods This study included 73 patients (85 vessels) who were suspected of coronary artery disease (CAD) and received CCTA followed by invasive FFR measurements within 90 days. The diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristics curve (AUC) were compared between CT-FFR and CCTA. Thirty-nine patients who received drug therapy instead of revascularization were followed for up to 31 months. Major adverse cardiac events (MACE), unstable angina, and rehospitalization were evaluated and compared between the study groups. Results At the patient level, CT-FFR achieved 90.4%, 93.6%, 88.1%, 85.3%, and 94.9% in accuracy, sensitivity, specificity, PPV, and NPV, respectively. At the vessel level, CT-FFR achieved 91.8%, 93.9%, 90.4%, 86.1%, and 95.9%, respectively. CT-FFR exceeded CCTA in these measurements at both levels. The vessel-level AUC for CT-FFR also outperformed that for CCTA (0.957 vs. 0.599, P < 0.0001). Patients with CT-FFR ≤0.8 had higher rates of rehospitalization (hazard ratio [HR] 4.51, 95% confidence interval [CI] 1.08–18.9) and MACE (HR 7.26, 95% CI 0.88–59.8), as well as a lower rate of unstable angina (HR 0.46, 95% CI 0.07–2.91). Conclusion CT-FFR is superior to conventional CCTA in differentiating functional myocardial ischemia. In addition, it has the potential to differentiate prognoses of patients with CAD.

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