Influence of Variable Native Arterial Diameter and Vasculature Status on Coronary Diagnostic Parameters

2013 ◽  
Vol 135 (9) ◽  
Author(s):  
Ishan Goswami ◽  
Srikara V. Peelukhana ◽  
Marwan F. Al-Rjoub ◽  
Lloyd H. Back ◽  
Rupak K. Banerjee
Keyword(s):  
Pressure Drop ◽  
Clinical Decision Making ◽  
Dynamic Pressure ◽  
Clinical Intervention ◽  
Clinical Decision ◽  
Fractional Flow ◽  
Arterial Diameter ◽  
Diagnostic Parameters ◽  
Flow Reserve

In current practice, diagnostic parameters, such as fractional flow reserve (FFR) and coronary flow reserve (CFR), are used to determine the severity of a coronary artery stenosis. FFR is defined as the ratio of hyperemic pressures distal (p˜rh) and proximal (p˜ah) to a stenosis. CFR is the ratio of flow at hyperemic and basal condition. Another diagnostic parameter suggested by our group is the pressure drop coefficient (CDP). CDP is defined as the ratio of the pressure drop across the stenosis to the upstream dynamic pressure. These parameters are evaluated by invasively measuring flow (CFR), pressure (FFR), or both (CDP) in a diseased artery using guidewire tipped with a sensor. Pathologic state of artery is indicated by lower CFR (<2). Similarly, FFR lower than 0.75 leads to clinical intervention. Cutoff for CDP is under investigation. Diameter and vascular condition influence both flow and pressure drop, and thus, their effect on FFR and CDP was studied. In vitro experiment coupled with pressure-flow relationships from human clinical data was used to simulate pathophysiologic conditions in two representative arterial diameters, 2.5 mm (N1) and 3 mm (N2). With a 0.014 in. (0.35 mm) guidewire inserted, diagnostic parameters were evaluated for mild (∼64% area stenosis (AS)), intermediate (∼80% AS), and severe (∼90% AS) stenosis for both N1 and N2 arteries, and between two conditions, with and without myocardial infarction (MI). Arterial diameter did not influence FFR for clinically relevant cases of mild and intermediate stenosis (difference < 5%). Stenosis severity was underestimated due to higher FFR (mild: ∼9%, intermediate: ∼ 20%, severe: ∼ 30%) for MI condition because of lower pressure drops, and this may affect clinical decision making. CDP varied with diameter (mild: ∼20%, intermediate: ∼24%, severe: by 2.5 times), and vascular condition (mild: ∼35%, intermediate: ∼14%, severe: ∼ 9%). However, nonoverlapping range of CDP allowed better delineation of stenosis severities irrespective of diameter and vascular condition.

Diagnostic Uncertainties During Assessment of Serial Coronary Stenoses: An In Vitro Study

2014 ◽  
Vol 136 (2) ◽  
Author(s):  
Gavin A. D’Souza ◽  
Srikara V. Peelukhana ◽  
Rupak K. Banerjee
Keyword(s):  
Pressure Drop ◽  
Dynamic Pressure ◽  
Clinical Intervention ◽  
In Vitro Study ◽  
Gray Zone ◽  
Diagnostic Parameter ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Stenosis Severity

Currently, the diagnosis of coronary stenosis is primarily based on the well-established functional diagnostic parameter, fractional flow reserve (FFR: ratio of pressures distal and proximal to a stenosis). The threshold of FFR has a “gray” zone of 0.75–0.80, below which further clinical intervention is recommended. An alternate diagnostic parameter, pressure drop coefficient (CDP: ratio of trans-stenotic pressure drop to the proximal dynamic pressure), developed based on fundamental fluid dynamics principles, has been suggested by our group. Additional serial stenosis, present downstream in a single vessel, reduces the hyperemic flow, Q˜h, and pressure drop, Δp˜, across an upstream stenosis. Such hemodynamic variations may alter the values of FFR and CDP of the upstream stenosis. Thus, in the presence of serial stenoses, there is a need to evaluate the possibility of misinterpretation of FFR and test the efficacy of CDP of individual stenoses. In-vitro experiments simulating physiologic conditions, along with human data, were used to evaluate nine combinations of serial stenoses. Different cases of upstream stenosis (mild: 64% area stenosis (AS) or 40% diameter stenosis (DS); intermediate: 80% AS or 55% DS; and severe: 90% AS or 68% DS) were tested under varying degrees of downstream stenosis (mild, intermediate, and severe). The pressure drop-flow rate characteristics of the serial stenoses combinations were evaluated for determining the effect of the downstream stenosis on the upstream stenosis. In general, Q˜h and Δp˜ across the upstream stenosis decreased when the downstream stenosis severity was increased. The FFR of the upstream mild, intermediate, and severe stenosis increased by a maximum of 3%, 13%, and 19%, respectively, when the downstream stenosis severity increased from mild to severe. The FFR of a stand-alone intermediate stenosis under a clinical setting is reported to be ∼0.72. In the presence of a downstream stenosis, the FFR values of the upstream intermediate stenosis were either within (0.77 for 80%–64% AS and 0.79 for 80%–80% AS) or above (0.88 for 80%–90% AS) the “gray” zone (0.75–0.80). This artificial increase in the FFR value within or above the “gray” zone for an upstream intermediate stenosis when in series with a clinically relevant downstream stenosis could lead to misinterpretation of functional stenosis severity. In contrast, a distinct range of CDP values was observed for each case of upstream stenosis (mild: 8–10; intermediate: 47–54; and severe: 130–155). The nonoverlapping range of CDP could better delineate the effect of the downstream stenosis from the upstream stenosis and allow for the accurate diagnosis of the functional severity of the upstream stenosis.

Assessment of Aortic Stenosis Severity Using Pressure Drop Coefficient: A Retrospective Study in Humans

2013 ◽  
Author(s):  
Anup K. Paul ◽  
Mohamed Effat ◽  
Jason J. Paquin ◽  
Rupak K. Banerjee
Keyword(s):  
Retrospective Study ◽  
Pressure Drop ◽  
Aortic Stenosis ◽  
Clinical Decision Making ◽  
Dynamic Pressure ◽  
Clinical Decision ◽  
Diagnostic Parameters ◽  
Stenosis Severity ◽  
Preliminary Study ◽  
A Prospective Study

Accurate assessment of the stenosis severity is critical in patients with aortic stenosis (AS). The ambiguities and reduced sensitivities of the current diagnostic parameters can result in sub-optimal clinical decision making. In this preliminary study, we investigate the functional diagnostic parameter CDP (ratio of the transvalvular pressure drop to the proximal dynamic pressure) for the assessment of AS severity by correlating with the current diagnostic parameters. CDP was calculated using diagnostic parameters obtained from retrospective chart reviews. CDP values were calculated independently from Doppler and catheterization measurements. CDP exhibited better correlation with transvalvular pressure drop and jet velocity simultaneously, than when correlated independently with the same diagnostic parameters. CDP increases with increasing AS severity, which is consistent with hydrodynamic principles. This retrospective study is a prelude to a prospective study to evaluate CDP for AS severity assessment.

Influence of Heart Rate and Contractility on Coronary Diagnostic Parameters With Normal Microvasculature in Porcine Model

2010 ◽  
Author(s):  
Kranthi K. Kolli ◽  
Mohamed Effat ◽  
Tarek Helmy ◽  
Massoud Leesar ◽  
Arif Imran ◽  
...  
Keyword(s):  
Heart Rate ◽  
Pressure Drop ◽  
Guide Wire ◽  
Dynamic Pressure ◽  
Fractional Flow ◽  
Diagnostic Parameters ◽  
In Vivo Experiments ◽  
Flow Reserve ◽  
Yorkshire Pigs

Invasive guide-wire measurements are used to assess coronary lesion severity under clinical settings. The objective of the present research is to determine the influence of heart rate (HR) and contractility (CY) on fractional flow reserve (FFR; the ratio of distal pressure to proximal pressure at a stenotic section) and pressure drop coefficient (CDPe; the ratio of trans-stenotic pressure drop to distal dynamic pressure). In-vivo experiments were performed on eight Yorkshire pigs, to evaluate the diagnostic parameters for the conditions “CY<1100 mmHg/sec” and “CY>1100 mmHg/sec,” and for the conditions “HR<110 bpm” and “HR>110 bpm”. It was found that in the presence of normal microvasculature the measured coronary diagnostic parameters (FFR and CDPe) have a significant mean difference for variation in contractility (0.59±0.04 to 0.89±0.045 for FFR and 121.63±18 to 23.53±18 for CDPe). The variation in HR has no significant effect on FFR and CDPe (0.72±0.048 to 0.74±0.048 and 54±20 to 53±20 respectively).

In-Vivo Evaluation of Severity of Microvascular Impairments and Epicardial Coronary Stenoses Using Fundamental Fluid Dynamics Endpoints

2008 ◽  
Author(s):  
Koustubh D. Ashtekar ◽  
Edward Kim ◽  
Abhijit S. Roy ◽  
Tarek A. Helmy ◽  
Mohamed A. Effat ◽  
...  
Keyword(s):  
Clinical Decision Making ◽  
Clinical Decision ◽  
Fractional Flow ◽  
In Vivo Evaluation ◽  
Flow Reserve ◽  
Coronary Stenoses ◽  
Decision Making Processes ◽  
Epicardial Stenosis ◽  
Treatment Procedures

Coronary circulation is mainly regulated by two serial resistances, namely, epicardial stenosis and microvascular impairments, both causing abnormal coronary blood circulation [1]. Delineation of the true severities of these diseases is important to guide clinical decision-making processes for the selection of appropriate treatment procedures [2]. The presently used diagnostic parameters: FFR (fractional flow reserve defined as the ratio of distal to proximal hyperemic pressure) and CFR (coronary flow reserve defined as ratio of basal to hyperemic flow) [1], for the evaluation of severity of epicardial coronary stenosis are well established in clinical practice. On the other hand, current methods to evaluate the microcirculatory status are limited [3].

Functional and Anatomical Diagnosis of Coronary Artery Stenoses: A Retrospective Study in Humans

2012 ◽  
Author(s):  
Kranthi K. Kolli ◽  
Mohamed Effat ◽  
Imran Arif ◽  
Tarek Helmy ◽  
Massoud Leesar ◽  
...  
Keyword(s):  
Pressure Drop ◽  
Dynamic Pressure ◽  
Microvascular Disease ◽  
Flow Coefficient ◽  
Fractional Flow ◽  
Throat Region ◽  
Flow Reserve ◽  
Stenosis Severity ◽  
Lesion Flow Coefficient ◽  
Hemodynamic Information

Fractional flow reserve (FFR: ratio of distal to proximal pressure of a stenotic section) is used to evaluate hemodynamic significance of epicardial stenosis. However, FFR and coronary flow reserve (CFR: ratio of hyperemic blood velocity to that of resting condition) are used in conjunction to evaluate combination of both epicardial and microvascular disease. It has been proposed that optimization of cutoff values for diagnostic parameters in determining stenosis severity depends on coupling functional (pressure and velocity) and anatomical data (% area stenosis). We hypothesize that, pressure drop coefficient (CDP: the ratio of trans-stenotic pressure drop to distal dynamic pressure) which has the functional information of pressure and velocity in its formulation correlates significantly with FFR and CFR, and lesion flow coefficient (LFC: ratio of % area stenoses to CDP at throat region) which combines both functional and anatomical (% area stenoses) information in its formulation correlates significantly with FFR, CFR and % area stenosis. We retrospectively analyzed the hemodynamic information from Meuwissen et al [3] to test this hypothesis. It was observed that, CDP, a functional index based on pressure drop and velocity, correlated linearly and significantly with FFR and CFR. And, LFC (combined functional and anatomic parameter) also correlated significantly with FFR, CFR (both hemodynamic endpoints) and % area stenosis (anatomic endpoint).

scholarly journals Numerical Investigation of the Effect of Stenosis Geometry on the Coronary Diagnostic Parameters

2014 ◽  
Vol 2014 ◽  
pp. 1-7 ◽  
Author(s):  
Sarfaraz Kamangar ◽  
Govindaraju Kalimuthu ◽  
Irfan Anjum Badruddin ◽  
A. Badarudin ◽  
N. J. Salman Ahmed ◽  
...  
Keyword(s):  
Pressure Drop ◽  
Computational Simulation ◽  
Fractional Flow ◽  
Diagnostic Parameters ◽  
Flow Reserve ◽  
Geometrical Shapes ◽  
Elliptical Model ◽  
Different Shapes ◽  
Triangular Model ◽  
The Relationship

The present study deals with the functional severity of a coronary artery stenosis assessed by the fractional flow reserve (FFR). The effects of different geometrical shapes of lesion on the diagnostic parameters are unknown. In this study, 3D computational simulation of blood flow in three different geometrical shapes of stenosis (triangular, elliptical, and trapezium) is considered in steady and transient conditions for 70% (moderate), 80% (intermediate), and 90% (severe) area stenosis (AS). For a given percentage AS, the variation of diagnostic parameters which are derived from pressure drop across the stenosis was found in three different geometrical shapes of stenosis and it was observed that FFR is higher in triangular shape and lower in trapezium shape. The pressure drop coefficient (CDP) was higher in trapezium shape and lower in triangular model whereas the LFC shows opposite trend. From the clinical perspective, the relationship between percentage AS and FFR is linear and inversely related in all the three models. A cut-off value of 0.75 for FFR was observed at 76.5% AS in trapezium model, 79.5% in elliptical model, and 82.7% AS for the triangular shaped model. The misinterpretation of the functional severity of the stenosis is in the region of 76.5%-82.7 % AS from different shapes of stenosis models.

scholarly journals The FAME Trials: Impact on Clinical Decision Making

2016 ◽  
Vol 11 (2) ◽  
pp. 116 ◽  
Author(s):  
Guy R Heyndrickx ◽  
Gábor G Tóth ◽  
◽  
Keyword(s):  
Medical Treatment ◽  
Fractional Flow Reserve ◽  
Clinical Decision Making ◽  
Stable Coronary Artery Disease ◽  
Coronary Intervention ◽  
Clinical Decision ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Stenosis Severity ◽  
Artery Disease

Careful and stepwise evaluation of the fractional flow reserve (FFR) index has been performed over the years, culminating in the landmark Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) and Fractional Flow Reserve-Guided Percutaneous Coronary Intervention Plus Optimal Medical Treatment Versus Optimal Medical Treatment Alone in Patients with Stable Coronary Artery Disease (FAME II) trials. Findings from these studies demonstrated unequivocally the overall inadequacy of angiography versus FFR to correctly assess stenosis severity. Thus, proof of concept and clinical applicability was established beyond debate and will be discussed here.

scholarly journals Case Report of First Angiography-Based On-Line FFR Assessment during Coronary Catheterization

2017 ◽  
Vol 2017 ◽  
pp. 1-4 ◽  
Author(s):  
Ran Kornowski ◽  
Hana Vaknin-Assa
Keyword(s):  
Decision Making ◽  
Case Report ◽  
Clinical Decision Making ◽  
Guide Wire ◽  
Coronary Revascularization ◽  
Three Dimensional ◽  
Clinical Decision ◽  
Fractional Flow ◽  
Flow Reserve ◽  
On Line

Fractional flow reserve (FFR), an index of the hemodynamic severity of coronary stenoses, is derived from hyperemic pressure measurements and requires a pressure-monitoring guide wire and hyperemic stimulus. Although it has become the standard of reference for decision-making regarding coronary revascularization, the procedure remains underutilized due to its invasive nature. FFRangio is a novel technology that uses the patient’s hemodynamic data and routine angiograms to generate a complete three-dimensional coronary tree, with color-coded display of the FFR values at each point along the vessels. After being proven to be as accurate as invasive FFR measurements in an off-line study, this case report presents the first on-line application of the system in the catheterization lab. Here too, a high concordance between FFRangio and invasive FFR was observed. In light of the demonstrated capabilities of the FFRangio system, it should emerge as an important tool for clinical decision-making regarding revascularization in patients with coronary artery disease.

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