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CABG in acute coronary syndrome
Published in K Sarat Chandra, AJ Swamy, Acute Coronary Syndromes, 2020
‘Factors that influence the choice of revascularization procedure include the extent and complexity of CAD; short-term risk and long-term durability of PCI; operative mortality, which can be estimated by the Society of Thoracic Surgeons (STS) score; diabetes mellitus (DM); chronic kidney disease (CKD); completeness of revascularisation; left ventricular (LV) systolic dysfunction; previous CABG; and the ability of the patient to tolerate and comply with dual anti-platelet therapy (DAPT). In general, the greater the extent and complexity of the multi-vessel disease, the more compelling the choice of CABG over multi-vessel PCI’ [3]. The ‘Heart Team’ approach, informed by calculation of the SYNTAX score, is strongly recommended. However, there is some evidence from the FREEDOM study lately that the SYNTAX score should not be used to guide the choice of coronary revascularisation in diabetics with complex multi-vessel CAD [4].. Even fractional flow reserve (FFR) needs validation [5].
Coronary angiography: Techniques and tools of the trade
Published in John Edward Boland, David W. M. Muller, Interventional Cardiology and Cardiac Catheterisation, 2019
Selective coronary angiography remains the standard for assessment of coronary artery anatomy. Ancillary imaging modalities such as IVUS and optical coherence tomography provide more detailed anatomical information on specific intravascular characteristics (dissection, stent apposition, extent of vessel calcification, virtual histology). These modalities, however, do not provide assessment of the functional significance of a coronary stenosis. Fractional flow reserve (FFR) and the instantaneous wave-free ratio (iFR) provide direct physiological assessment of the extent to which a coronary stenosis restricts epicardial myocardial blood flow and cause ischemia (see Chapter 26). FFR must be measured during maximal hyperemia, which is typically induced with administration of a potent intravenous or intracoronary vasodilator, such as adenosine. iFR is a pressure-derived index of stenosis severity that does not require administration of a vasodilator, thus making assessment of the functional significance of a stenosis faster, safer, and more cost-efficient. In two large, recent, multicentre, randomised, controlled, open-label clinical trials enrolling patients with stable angina or an acute coronary syndrome, an iFR-guided revascularisation strategy was non-inferior to an FFR-guided revascularisation strategy with respect to the rate of major adverse cardiac events at 12 months.7–8
Terumo OFDI system
Published in Hiram G. Bezerra, Guilherme F. Attizzani, Marco A. Costa, OCT Made Easy, 2017
Kenji Kaneko, Tetsuya Fusazaki, Takayuki Okamura
A 69-year-old male, who was on dialysis with effort angina, underwent PCI. CAG revealed a 75% calcified stenosis just proximal to the LAD (Figure 12.16a). The fractional flow reserve (FFR) was 0.76. A 7 Fr backup left 3.5 guiding catheter (Heartrail II) was inserted via the right femoral artery and guidewires were advanced to the LAD and left circumflex artery (LCx). As the pre-OFDI image demonstrated, the calcium was just proximal to the LAD, and rotational atherectomy with a 2.0 mm burr was used. After predilatation with a 3.5 mm noncompliant balloon at 18 atm, a 3.5–18 mm Nobori™ biolimus A9 eluting stent was deployed across the LCx (Figure 12.16b). A second wire was passed to the LCx through the jailing strut. 3D OFDI clearly demonstrated that the second wire passed through the far distal small cell (Figure 12.7a). It was considered a stent deformation after KBD. Second rewiring was attempted to recross more proximally. After confirmation of appropriate rewiring by 3D OFDI (Figure 12.7b), KBD commenced (Figure 12.16c). The final CAG and 3D OFDI revealed an acceptable SB opening without the residual struts at the SB orifice (Figures 12.16d and 12.17c).
Induced myocardial ischemia in candidates to liver transplantation without evidence of heart disease
Published in Annals of Medicine, 2023
Luca Mircoli, Niccolò Bacà, Barbara Antonelli, Lucio Caccamo, Emanuele Cattaneo, Federico Colombo, Clara Dibenedetto, Livia Diehl, Maria Francesca Donato, Andrea Faggiano, Massimo Alberto Iavarone, Pietro Lampertico, Cristina Marenghi, Federico Polli, Edoardo Quarenghi, Fabiola B. Sozzi, Cristina Spaziani, Giulia Tosetti, Carlo Valsecchi, Pierluigi Vicardi, Marco Vicenzi, Arianna Zefelippo, Massimiliano Ruscica, Stefano Carugo
According to the proposed protocol, the additional use of CCTA (as a non-invasive approach) was justified by the known high sensitivity. Specifically, CCTA sensitivity and the NPV were very high, whereas specificity and PPVs were relatively low. CCTA does not clearly discriminate the extent (critical or non-critical) of the CAD, but identifies the absence of coronary atherosclerosis [1,32]. According to the CAT-CAD trial (computed tomography as the first-choice diagnostics in high pre-test probability of coronary artery disease), CCTA might reduce the number of non-actionable coronary angiographies in patients with indications to CAG. According to this trial, CCTA resulted to be an effective and safe, non-invasive, outpatient-based and cost-effective alternative to CAG for patients with a high clinical odds of obstructive CAD [33–35]. Furthermore, in the case of intermediate lesions, CCTA-derived fractional flow reserve can assess flow limitation across coronary stenosis with high diagnostic accuracy and good correlation to invasive fractional flow reserve [36,37]. Based on this finding, the assessment of the fractional flow reserve by CCTA may represent an add-on value in the evaluation of CV risk in patients selected to LT.
FFR pressure wire comparative study: piezoresistive versus optical sensor
Published in Acta Cardiologica, 2022
Daan Cottens, Joren Maeremans, Mathias Vrolix, Johan Van Lierde, Jo Dens, Bert Ferdinande
Pressure derived fractional flow reserve measurement (FFR) is an objective and quantitative assessment of the functional severity of a coronary artery stenosis during cardiac catheterisation. The concept was first described by Pijls et al. [1]. In the following decades, the DEFER, FAME 1 and FAME 2 studies provided strong evidence that systematical use of FFR evaluation of angiographically intermediate lesions to guide revascularization improves outcome and is desirable from economical point of view [2–5]. It is safe to defer treatment with an FFR value >0.80 with an excellent long-term prognosis reflected in a low rate of death and myocardial infarction (MI) of 0,6%/year [2–4]. The recent results of the Define-Flair and Swede-Heart studies [6,7] only add up the amount of evidence in favour of using the physiological assessment of an intermediate coronary stenosis. Since 2010, it has a Class Ia recommendation of the European society of Cardiology for the assessment of intermediate coronary lesions.
Risk prediction of in-stent restenosis among patients with coronary drug-eluting stents: current clinical approaches and challenges
Published in Expert Review of Cardiovascular Therapy, 2021
Atsushi Sakamoto, Yu Sato, Rika Kawakami, Anne Cornelissen, Masayuki Mori, Kenji Kawai, Raquel Fernandez, Daniela Fuller, Neel Gadhoke, Liang Guo, Maria E. Romero, Frank D. Kolodgie, Renu Virmani, Aloke V. Finn
There are two definitions of ISR; i.e. an angiographic and a clinical definition. A stenosis of ≥50% of the vessel diameter by coronary angiography allows determination of ISR [17]. This cutoff is estimated by animal studies and human clinical correlations that demonstrate functional ischemic significance with the anatomic presence of a 50% diameter stenosis [18]. Clinical ISR definition was proposed by the Academic Research Consortium. This definition requires both angiographic diameter stenosis ≥50% and one of the following patient’s clinical context; 1) the positive history of recurrent angina, 2) ischemic sign of electrocardiogram changes at rest or during exercise test, 3) abnormal results of any invasive functional diagnostic test (e.g. fractional flow reserve <0.80), and 4) intravascular ultrasonography (IVUS) findings including minimal cross-sectional area <4 mm2 (6 mm2 for left main), or restenosis with ≥70% reduction in lumen diameter even without clinical symptoms or signs [19,20]. The criteria of cross-sectional area by IVUS has been established by correlation with abnormal fractional flow reserve and need for subsequent target lesion revasculalization [21,22].