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The present study investigated the relationships between physiological indices and increased coronary flow during percutaneous coronary intervention (PCI) using a novel index of "anticipated maximum flow" [AMF; theoretical coronary flow of fractional flow reserve (FFR) = 1]. FFR-guided PCI aims to increase coronary flow, whereas recent studies have reported that PCI does not necessarily increase coronary flow despite improvement in FFR.This retrospective analysis was performed in 71 functionally significant lesions treated with elective PCI. AMF obtained by hyperemic average peak coronary flow velocity (h-APV) divided by FFR would not change after PCI given the constant microvascular resistance, which is the assumption of FFR as a surrogate of coronary flow. We evaluated the relationship between AMF and coronary flow during PCI.Post-PCI AMF was significantly different from pre-PCI AMF (p = 0.022), which impacted discordance between FFR improvement and change in coronary flow. Coronary flow increase50% was associated with smaller minimum lumen diameter (p = 0.010), greater diameter stenosis (p = 0.003), lower pre-PCI FFR (p0.001), lower pre-PCI coronary flow reserve (p = 0.001), higher pre-PCI hyperemic stenosis resistance (p0.001), lower pre-PCI h-APV (p = 0.001), and lower pre-PCI AMF (p = 0.031). Pre-PCI AMF provided significant incremental predictive capability for coronary flow increase50% when added to the clinical model including pre-PCI FFR.Pre-PCI AMF provided incremental ability to predict increased coronary flow after PCI and impacted the discordance between FFR improvement and increased coronary flow.

Introduction: The performances of contrast-enhanced ultrasound (CEUS) and digital subtraction angiography (DSA) were used to establish an efficient as well as non-invasive clinical technique for the diagnosis of extra-cranial internal carotid artery (ICA) stenosis. Materials and methods: Thirty-six successive patients (11 women and 25 men, mean age: 65.0 ± 9.2, range: 43–78 years) with internal carotid artery (ICA) stenosis were tested by CEUS and DSA. These tests were carried out by means of Hitachi Preirus ultrasound machine for CEUS and Allura Xper FD20 system (Philips Medical Systems, Nederland B.V.) for DSA. 1.2 ml Son- oVue (Bracco, Switzerland) was used a s contrast agent. Results: The results clearly indicated that there were no noteworthy variations among the distributions recorded by CEUS as well as DSA for the four tested groups. The percentage of diameter stenosis calculated by CEUS was clearly in accordance with the DSA images. CEUS showed accurate results with good specificity and sensitivity at 50%, 70%, and 100%. Also, CEUS per- formance was relatively better than DSA in the diagnosis of ICA and suitability of CEA. Conclusion: CEUS proved to be a precise non-invasive testing method for the diagnosis of carotid artery stenosis which is more feasible and well-tolerated in patients with various stages of carotid stenosis. Keywords: Carotid artery stenosis; CEUS; contrast-enhanced ultrasound; digital subtraction angiography.

Endothelial erosion of atherosclerotic plaques is the underlying cause of approximately 30% of acute coronary syndromes (ACS). As the vascular endothelium is profoundly affected by the haemodynamic environment to which it is exposed, we employed computational fluid dynamic (CFD) analysis of the luminal geometry from 17 patients with optical coherence tomography (OCT)-defined plaque erosion, to determine the flow environment permissive for plaque erosion. Our results demonstrate that 15 of the 17 cases analysed occurred on stenotic plaques with median 31% diameter stenosis (interquartile range 28–52%), where all but one of the adherent thrombi located proximal to, or within the region of maximum stenosis. Consequently, all flow metrics related to elevated flow were significantly increased (time averaged wall shear stress, maximum wall shear stress, time averaged wall shear stress gradient) with a reduction in relative residence time, compared to a non-diseased reference segment. We also identified two cases that did not exhibit an elevation of flow, but occurred in a region exposed to elevated oscillatory flow. Our study demonstrates that the majority of OCT-defined erosions occur where the endothelium is exposed to elevated flow, a haemodynamic environment known to evoke a distinctive phenotypic response in endothelial cells.

Background: Visual estimation (VE) of coronary stenoses is the first step during invasive coronary angiography. The aim of this study was to evaluate the accuracy of VE together with invasive functional assessment (IFA) in defining the functional significance (FS) of coronary stenoses based on the opinion of multiple operators. Methods: Fourteen independent operators visually evaluated 133 coronary lesions which had a previous FFR measurement, indicating the degree of stenosis (DS), FS and IFA intention. We determined the accuracy of FS prediction using several scenarios combining individual and group decision, considering IFA as deemed necessary by the operator or only in intermediate lesions. Results: The accuracy of VE in predicting FS was largely variable between operators (average 66.1%); it improved significantly when IFA was used either as per operator’s opinion (86.3%; p < 0.0001) or only in intermediate DS (82.9; p < 0.0001). There was no significant difference between using IFA per observer’s opinion or only in intermediate DS lesions (p = 0.166). The poorest accuracy of VE for FS was obtained in intermediate DS lesions (59.1%). Conclusions: There are significant inter-observer differences in reporting the degree of DS, while the accuracy of VE prediction of FS is also largely dependent on the operator, and the worst performance is obtained in the evaluation of intermediate DS.

espanolIntroduccion y objetivos: La estrategia de tratamiento percutaneo de los pacientes con enfermedad multivaso y oclusion total cronica (OTC) no esta bien definida. La importancia funcional de las lesiones localizadas en arterias donantes de colaterales no se ha abordado por completo. Nuestro objetivo fue evaluar mediante reserva fraccional de flujo (RFF) la cantidad de isquemia dependiente de una lesion angiografica intermedia en un vaso donante de colaterales antes y despues de la recanalizacion de la OTC, y valorar el cambio en la cantidad de isquemia por resonancia magnetica cardiaca (RMC) antes y 1 mes despues de la recanalizacion. Metodos: Estudio piloto prospectivo en 14 pacientes con angina estable y una OTC que recibia circulacion colateral de un vaso con una estenosis intermedia (50-70% por angiografia coronaria cuantitativa). Para indicar la revascularizacion, todos los pacientes presentaban viabilidad miocardica por RMC. Resultados: De los 14 pacientes, 7 (50%) evidenciaron una RFF ≤ 0,80 antes de la recanalizacion. Los valores medios de RFF de la arteria donante aumentaron significativamente tras la revascularizacion de la OTC (0,75 [0,73-0,78] frente a 0,83 [0,81-0,84]; p = 0,017). Solo 3 pacientes mostraron valores de RFF hemodinamicamente significativos despues de la recanalizacion de una OTC que requirio revascularizacion adicional. Hubo una tendencia hacia una reduccion del numero de segmentos isquemicos (2,5 [0-4] frente a 0 [0-0,25]; p = 0,066) evaluados por RMC antes y despues del intervencionismo. No se observaron eventos cardiacos adversos mayores durante el seguimiento de 2 anos. Conclusiones: Las mediciones de RFF en estenosis intermedias de vasos donantes de colaterales de una OTC pueden ser enganosas. En estos casos podria plantearse la estrategia de centrarse primero en la revascularizacion de la OTC y despues en la evaluacion de la lesion intermedia del vaso donante. EnglishIntroduction and objectives: The strategy of the percutaneous treatment of patients with multivessel disease associated with chronic total coronary occlusion (CTO) lesions is not well defined. Also, the functional significance of lesions located in the collateral donor artery has not been fully addressed. Using the fractional flow reserve (FFR) the objective was to evaluate the amount of ischemia related to the angiographically intermediate stenosis of collateral donor vessels before and immediately after successful percutaneous coronary intervention (PCI) of a CTO. Also, to assess any changes operated in the amount of ischemia using cardiovascular magnetic resonance imaging prior to the PCI and at 1-month follow-up. Methods: Prospective pilot study including 14 patients with stable angina and a CTO receiving collateral circulation from a blood vessel with intermediate stenosis (50%-70% diameter stenosis measured using quantitative angiography). In order to indicate recanalization by PCI all patients were referred for magnetic resonance assessment of the presence of myocardial viability. Results: Seven (50%) of the 14 patients included showed FFR values ≤ 0.80 before the PCI. FFR measures of the donor artery significantly increased after the revascularization of the CTO (0.75 [0.73-0.78] vs 0.83 [0.81-0.84]; P = .017). Eventually, only 3 patients showed hemodynamically significant FFR values after the recanalization of CTO requiring further revascularization. There was a tendency towards a reduction of the number of ischemic segments (2.5 [0-4] vs 0 [0-0.25]; P = .066) assessed using magnetic resonance imaging before and after the PCI. No major adverse cardiovascular events were reported at the 2-year follow-up. Conclusions: Our data suggest that FFR measurements in intermediate stenoses of collateral donor vessels of a CTO may be misleading. Therefore, the strategy of focusing primarily on the revascularization of the CTO and then on the assessment of the intermediate lesion in a collateral donor vessel may be recommended.

Objectives: B-type natriuretic peptide (BNP) has been extensively studied as a biomarker in heart failure. There is clear benefit of BNP in diagnosis and risk stratification of several cardiac diseases including acute coronary syndromes. Our aim was to evaluate diagnostic role of changes in BNP levels with exercise in coronary artery disease (CAD). Methods: Fifty-one patients underwent exercise stress testing (EST) for suspected CAD and consequently underwent coronary angiography (CA) were prospectively enrolled. Patients with and without at least one significant diameter stenosis in major epicardial arteries (CA+ and CA-) versus patients with and without evidence of myocardial ischemia during exercise stress testing (EST+ and EST-) were classified into 4 groups, respectively (Group 1, CA+/EST+; group 2, CA+/EST-; group 3, CA-/EST+; and group 4, CA-/EST-). All patients underwent EST. Blood was drawn from patients for determination of BNP levels 10 minutes prior to, 10 minutes after and 4 hours after EST. Results: EST parameters other than the parameters signifying myocardial ischemia didn’t differ significantly among groups (p > 0.05). Pre-exercise, post-exercise and 4h-post exercise BNP values were significantly higher in group 1 and group 2 compared to group 3 and group 4 (p < 0.05 for all comparisons between the groups for pre-exercise, post-exercise and 4h-post exercise BNP). Exercise-induced increases in BNP were higher in group 1 and group 2. Patients with significant CAD involving LAD demonstrated higher basal and exercise-induced BNP as well as BNP increases, irrespective of the EST result. Conclusions: Basal, maximal-exercise and post exercise BNP values predicted CAD, as well as CAD involving LAD irrespective of ischemic changes in EST. Our results point out potential role of BNP as an adjunct to EST in diagnosis and management of CAD.

A 71-year-old man with diabetes mellitus presented with effort angina. Computed tomography coronary angiogram showed a heavily calcified proximal left anterior descending coronary artery (LAD). Coronary angiogram showed discrete 75% diameter stenosis at the proximal LAD. Intravascular ultrasound

Edge restenosis has gained attention as a main cause of restenosis after first-generation drug-eluting stent (DES) implantation. The aim of this study was to assess the incidence of edge restenosis and identify the predictors of edge restenosis after second-generation DES implantation. Data were obtained from several postmarketing surveillance (PMS) studies on a cobalt-chromium everolimus-eluting stent (CoCr-EES; Xience V/PROMUS, Xience Prime, Xience Prime SV, and Xience Expedition SV), a second-generation DES, in Japan. Angiographic analysis was conducted at the baseline and after eight months on the following subsegments: in-stent region, proximal edge, and distal edge. Restenosis was defined as ≥ 50% diameter stenosis (DS) at follow-up. We used multivariate logistic regression (with lesions as a random effect) to compare the instances of restenosis between the proximal and the distal edges. Univariate and multivariate analyses of the risk factors for restenosis were performed for each subsegment. We analyzed 1,966 lesions in 1,687 patients. The restenosis rates at the in-stent region, proximal edge, and distal edge were 4.4%, 3.0%, and 1.1%, respectively. The risk of restenosis at the distal edge was significantly lower than that at the proximal edge, when adjusted for 13 variables. The predictors of restenosis were postprocedural % diameter stenosis (%DS), postprocedural reference diameter, ≥ 45° bending, stent overlap at the proximal edge, and postprocedural %DS at the distal edge. Our analysis of eight-month angiographic outcomes from CoCr-EES PMS demonstrated that postprocedural %DS is a major predictor of edge restenosis. Edge restenosis is more likely attributable to postprocedural angiographic results than to the patient's background.

Introduction: Myocardial bridge (MB) is a congenital anomaly in which a segment of a coronary artery is surrounded by myocardium. In our study, we want to use conventional coronary angiography (CCA) to describe morphologic characteristics of MB (unidentified or identified) in the patients with documented evidence of MB in coronary computed tomography angiography (CCTA). Methods: The present study was designed as cross-sectional and was conducted on 47 patients with documented evidence of MB in CCTA, who were referred to Nemazee and Faghihi hospitals for performing coronary angiography during a one year period. We compared the morphologic characteristics of tunneled segments, which were missed at CCA (unidentified), and the tunneled segments which were identified with CCA. Results: In sum, MB was found in 16 (34%) patients at CCA (identified), and it was not found in 31 (66%) patients (unidentified) based on compression sign. No significant correlation was found between the percentage of systolic compression and the length and depth of the tunneled segment in identified group (r=0.73, P = 0.18; r=1.09, P = 0.15; respectively). Degree of atherosclerotic plaque formation (diameter stenosis, percentage) (mean, 0.25 (25%) ±0.29; range, 0-0.98) of the tunneled segments in unidentified group was significantly more than the same degree (mean, 0.07 (7%) ±0.13; range, 0-0.41) of the identified group (P = 0.03). The measurement of the trapezoid area under the tunneled segment with this formula [(MB length+ intramyocardial segment) ×depth/2] had significant relation with systolic compression (r=0.304, P = 0.03) and defined the cut-off value of 250 mm2 as the value of significant difference in detecting myocardial bridging with CCA. Conclusion: Our results showed that in most of identified MBs in CCA the tunneled segment area was equal and more than 250 mm2. In addition, the degree of atherosclerotic plaque of the tunneled segments at CCA was significantly more in unidentified group.

Background An optimal system for interpreting fractional flow reserve (FFR) values derived from CT (FFRCT) is lacking. We sought to evaluate performance of three FFRCT measurements in detecting ischemia by comparing them with invasive FFR. Methods For 73 vessels in 50 patients who underwent coronary CT angiography (CCTA) and FFRCT analysis followed by invasive FFR, the greatest diameter stenosis on CCTA, FFRCT difference between distal and proximal to the stenosis (ΔFFRCT), FFRCT 2 cm distal to the stenosis (lesion-specific FFRCT), and the lowest FFRCT in distal vessel tip were calculated. Significant obstruction (≥50% diameter stenosis) and ischemia (lesion-specific FFRCT ≤0.80, the lowest FFRCT ≤0.80, or ΔFFRCT ≥0.12 based on the greatest Youden index) were compared with invasive FFR (≤0.80). Results Forty (55%) vessels demonstrated ischemia during invasive FFR. On multivariable generalized estimating equations, ΔFFRCT (odds ratio [OR] 10.2, p 0.05 for all). Area under the curve (AUC) of ΔFFRCT (0.86) was higher than CCTA (0.66), lesion-specific FFRCT (0.71), and the lowest FFRCT (0.65) (p Conclusions Compared with diameter stenosis, ΔFFRCT, lesion-specific FFRCT, and the lowest FFRCT improved ischemia discrimination and reclassification, with ΔFFRCT being superior in identifying and discriminating ischemia.

This study explored the potential of hemodynamic disturbances and geometric features to predict long-term carotid restenosis after carotid endarterectomy (CEA). Thirteen CEA for carotid diameter stenosis > 70% were performed with patch graft (PG) angioplasty in nine cases, and primary closure (PC) in four cases. MRI acquisitions within one month after CEA were used for hemodynamic and geometric characterization. Personalized computational hemodynamic simulations quantified the exposure to low and oscillatory wall shear stress (WSS). Geometry was characterized in terms of flare (the expansion at the bulb) and tortuosity. At 60 months after CEA, Doppler ultrasound (DUS) was applied for restenosis detection and intima-media thickness determination. Larger flares were associated to larger exposure to low WSS (Pearson R2 values up to 0.38, P 50% at 60 months. Linear regressions revealed associations of DUS observations of thickening with flare variables (up to R2 = 0.84, P

Identification of obstructive coronary artery disease (OCAD) in patients with chest pain is a clinical challenge. The value of corrected QT interval (QTc) for the prediction of OCAD has yet to be established. We consecutively enrolled 1741 patients with suspected angina. The presence of obstructive OCAD was defined as ≥ 50% diameter stenosis by coronary angiography. The pre-test probability was evaluated by combining QTc prolongation with the CAD Consortium clinical score (CAD2) and the updated Diamond-Forrester (UDF) score. OCAD was detected in 661 patients (38.0%). QTc was longer in patients with OCAD compared with those without OCAD (444 ± 34 vs. 429 ± 28 ms, p

OBJECTIVES This study sought to identify culprit lesion (CL) precursors among acute coronary syndrome (ACS) patients based on qualitative and quantitative computed tomography-based plaque characteristics.BACKGROUND Coronary computed tomography angiography (CTA) has been validated for patient-level prediction of ACS. However, the applicability of coronary CTA to CL assessment is not known.METHODS Utilizing the ICONIC (Incident COroNary Syndromes Identified by Computed Tomography) study, a nested casecontrol study of 468 patients with baseline coronary CTA, the study included ACS patients with invasive coronary angiography-adjudicated CLs that could be aligned to CL precursors on baseline coronary CTA. Separate blinded core laboratories adjudicated CLs and performed atherosclerotic plaque evaluation. Thereafter, the study used a boosted ensemble algorithm (XGBoost) to develop a predictive model of CLs. Data were randomly split into a training set (80%) and a test set (20%). The area under the receiver-operating characteristic curve of thismodel was compared with that of diameter stenosis (model 1), high-risk plaque features (model 2), and lesion-level features of CL precursors from the ICONIC study (model 3). Thereafter, the machine learning (ML) model was applied to 234 non-ACS patients with 864 lesions to determine model performance for CL exclusion.RESULTS CL precursors were identified by both coronary angiography and baseline coronary CTA in 124 of 234 (53.0%) patients, with a total of 582 lesions (containing 124 CLs) included in the analysis. The ML model demonstrated significantly higher area under the receiver-operating characteristic curve for discriminating CL precursors (0.774; 95% confidence interval [CI]: 0.758 to 0.790) compared with model 1 (0.599; 95% CI: 0.599 to 0.599; p < 0.01), model 2 (0.532; 95% CI: 0.501 to 0.563; p < 0.01), and model 3 (0.672; 95% CI: 0.662 to 0.682; p < 0.01). When applied to the non-ACS cohort, the ML model had a specificity of 89.3% for excluding CLs.CONCLUSIONS In a high-risk cohort, a boosted ensemble algorithm can be used to predict CL from non-CL precursors on coronary CTA. (c) 2020 by the American College of Cardiology Foundation.

Background Patients with type 2 diabetes are under substantially higher risk of in-stent restenosis (ISR) after coronary stent implantation. We sought to investigate whether visit-to-visit HbA1c variability is a potential predictor of ISR in diabetic patients after stent implantation. Methods We consecutively enrolled type 2 diabetic patients who underwent successful elective percutaneous coronary intervention and performed follow-up coronary angiography after around 12 months. The incidence of ISR and its relationship with visit-to-visit HbA1c variability, expressed as coefficient of variation (CV), standard deviation (SD) and variability independent of the mean (VIM), were studied. Multivariable Cox proportional hazards models were constructed to analyze the predictive value of HbA1c variability for ISR. Results From September 2014 to July 2018 in Ruijin Hospital, a total of 420 diabetic patients (688 lesions) after stent implantation were included in the final analysis. During a mean follow-up of 12.8 ± 1.3 months, the incidence of ISR was 8.6%, which was significantly increased in patients with higher CV of HbA1c (P = 0.001). The mean diameter stenosis (DS), net luminal loss and net luminal gain were 22.9 ± 16.8%, 0.42 ± 0.88 mm and 1.66 ± 0.83 mm, respectively. Greater DS was observed in subjects with higher tertiles of CV of HbA1c (P 1c ≤ 7%) in the baseline. In multivariate analysis, HbA1c variability was independently associated with incidence of ISR after adjustment for traditional risk factors and mean HbA1c (HR: 3.00 [95% CI 1.14–7.92] for highest vs. lowest tertile). Inclusion of CV of HbA1c led to a better risk stratification accuracy. Assessing HbA1c variability by SD or VIM yielded similar findings. Conclusions This study suggests that visit-to-visit HbA1c variability is an independent predictor of incidence of ISR in patients with type 2 diabetes after stent implantation. Trial registration NCT02089360: NCT

Objectives: The PRISON-IV trial showed inferior outcome in patients with chronic total occlusions (CTOs) treated with the ultrathin-struts (60 μm for stent diameter ≤3 mm, 81μm >3 mm) hybrid-sirolimus eluting stents (SES) compared with everolimus eluting stents (EES, 81 μm). The aim of this study is to investigate if the use of smaller stents (≤3 mm) was responsible for the inferior outcome reported in the trial. Methods: In the PRISON-IV trial 330 patients with CTO lesion were randomized 1:1 to receive either hybrid-SES or EES. The hybrid-SES failed to reach the non-inferiority primary endpoint of in-segment late lumen loss (LLL) at 9-month angiographic follow-up. In this sub-analysis, we divided the population according to the different size of stents implanted in those receiving only stents with diameter ≤3 mm (Group-A, 178 patients), only stents >3 mm (Group-B, 59 patients), and those receiving stents of both sizes (Group-C, 93 patients). Results: Baseline and procedural characteristics were comparable in the three groups. At angiographic follow-up, most of the adverse outcomes occurred in Group A, with higher incidence of binary restenosis in the Hybrid-SES versus EES (10.3% vs 1.3%, P = 0.03) and augmented in-stent diameter stenosis (26.04 ± 18.59% vs 21.24 ± 12.84, P = 0.06). Similarly, optical coherence tomography (OCT), which was performed in 60 patients at follow-up, documented a mild trend toward lower values of minimum in stent area in Hybrid-SES arm of Group A (4.4 ± 1.02mm2 vs 5.0 ± 1.28mm2, respectively, P = 0.16). Conclusions: The present analysis suggests that the inferior performance of the ultra-thin hybrid-SES in CTO-PCI is particularly pronounced when smaller stent (≤3 mm diameter) are adopted, if compared with EES.

The relationship between the features of morphologically unstable plaque and physiological lesion severity remains elusive. We aimed to investigate this relationship using optical coherence tomography (OCT)-derived high-risk plaque characteristics and fractional flow reserve (FFR) as the degree of anatomical and physiological stenosis severity.Methods and Results:We investigated 286 de novo intermediate and severe coronary lesions in 248 patients who underwent OCT and FFR examinations. Lesions were divided into tertiles based on either FFR or quantitative coronary angiographic diameter stenosis (QCA-%DS). The OCT findings were compared among the tertiles of FFR and QCA-%DS. FFR and QCA tertiles were defined as follows: FFR-T1 (FFR0.74), FFR-T2 (0.74≤FFR≤0.81), and FFR-T3 (FFR0.81); and QCA-T1 (%DS ≥61%), QCA-T2 (51%≤%DS61%), and QCA-T3 (%DS51%). The prevalence of thin-cap fibroatheroma (TCFA) was significantly greater in FFR-T1 (20.0%) than in FFR-T2 and FFR-T3 (7.0%, P=0.03 and 7.7%, P=0.04, respectively), although no significant differences were observed among the QCA tertiles.Physiological severity of coronary stenosis evaluated by FFR correlated with plaque instability in terms of TCFA. Preferable clinical outcomes for lesions with negative FFR based on the existing clinical evidence might be attributable to less likelihood of TCFA.

To determine the potential of a non-invasive acoustic device (CADScor®System) to reclassify patients with intermediate pre-test probability (PTP) and clinically suspected stable coronary artery disease (CAD) into a low probability group thereby ruling out significant CAD. Audio recordings and clinical data from three studies were collected in a single database. In all studies, patients with a coronary CT angiography indicating CAD were referred to coronary angiography. Audio recordings of heart sounds were processed to construct a CAD-score. PTP was calculated using the updated Diamond-Forrester score and patients were classified according to the current ESC guidelines for stable CAD: low 85% PTP. Intermediate PTP patients were re-classified to low probability if the CAD-score was ≤ 20. Of 2245 patients, 212 (9.4%) had significant CAD confirmed by coronary angiography ( ≥ 50% diameter stenosis). The average CAD-score was higher in patients with significant CAD (38.4 ± 13.9) compared to the remaining patients (25.1 ± 13.8; p

OBJECTIVES This study sought to investigate the performance of various cardiac computed tomography (CT)-derived atherosclerotic plaque metrics for predicting provocable myocardial ischemia.BACKGROUND The association of coronary arterial diameter stenosis with myocardial ischemia is only modest, but cardiac CT provides several other, readily available atherosclerosis metrics, which may have incremental value.METHODS The study analyzed 873 nonstented coronary arteries and their myocardial perfusion territories in 356 patients (mean 62 years of age) enrolled in the CORE320 (Coronary Artery Evaluation using 320-row Multidetector Computed Tomography Angiography and Myocardial Perfusion) study. Myocardial perfusion defects in static CT perfusion imaging were graded at rest and after adenosine in 13 myocardial segments using a 4-point scale. The summed difference score was calculated by subtracting the summed rest score from the summed stress score. Reversible ischemia was defined as summed difference score >= 1. In a sensitivity analysis, results were also provided using single-photon emission computed tomography (SPECT) as the reference standard. Vessel based predictor variables included maximum percent diameter stenosis, lesion length, coronary calcium score, maximum cross-sectional calcium arc, percent atheroma volume (PAV), low-attenuation atheroma volume, positive (external) vascular remodeling, and subjective impression of "vulnerable plaque." The study used logistic regression models to assess the association of plaque metrics with myocardial ischemia.RESULTS In univariate analysis, all plaque metrics were associated with reversible ischemia. In the adjusted logistic model, only maximum percent diameter stenosis (1.26; 95% confidence interval: 1.15 to 1.38) remained an independent predictor. With SPECT as outcome variable, PAV and "vulnerable" plaque remained predictive after adjustment. In vessels with intermediate stenosis (40% to 70%), no single metric had clinically meaningful incremental value.CONCLUSIONS Various plaque metrics obtained by cardiac CT predict provocable myocardial ischemia by CT perfusion imaging through their association with maximum percent stenosis, while none had significant incremental value. With SPECT as reference standard, PAV and "vulnerable plaque" remained predictors of ischemia after adjustment but the predictive value added to stenosis assessment alone was small. (C) 2019 by the American College of Cardiology Foundation.

Background Quantitative flow ratio ( QFR ) has a high diagnostic accuracy in assessing functional stenoses relevance, as judged by fractional flow reserve ( FFR ). However, its diagnostic performance has not been thoroughly evaluated using instantaneous wave‐free ratio ( iFR ) or coronary flow reserve as the reference standard. This study sought to evaluate the diagnostic performance of QFR using other reference standards beyond FFR . Methods and Results We analyzed 182 patients (253 vessels) with stable ischemic heart disease and 82 patients (105 nonculprit vessels) with acute myocardial infarction in whom coronary stenoses were assessed with FFR , iFR, and coronary flow reserve. Contrast QFR analysis of interrogated vessels was performed in blinded fashion by a core laboratory, and its diagnostic performance was evaluated with respect to the other invasive physiological indices. Mean percentage diameter stenosis, FFR , iFR , coronary flow reserve, and QFR were 53.1±19.0%, 0.80±0.13, 0.88±0.12, 3.14±1.30, and 0.81±0.14, respectively. QFR showed higher correlation ( r =0.863 with FFR versus 0.740 with iFR , P P P FFR was used as a reference standard than when iFR was used as the reference standard. However, when coronary flow reserve was used as an independent reference standard, FFR , iFR , and QFR showed modest discriminant function (area under the curve=0.682, 0.765, and 0.677, respectively) and there were no significant differences in diagnostic accuracy among FFR , iFR , and QFR (65.4%, 70.6%, and 64.9%; all P values in pairwise comparisons >0.05, overall comparison P =0.061). Conclusions QFR has a high correlation and agreement with respect to both FFR and iFR , although it is better when FFR is used as the comparator. As a pressure‐derived index not depending on wire or adenosine, QFR might be a promising tool for improving the adoption rate of physiology‐based revascularization in clinical practice.

Patients undergoing coronary angiography for suspected coronary heart disease who are found to have coronary atherosclerotic disease with

Significant left main coronary artery (LMCA) stenosis, which is defined as a 50% diameter stenosis that corresponds to a 75% area stenosis of the LMCA, is found in approximately 5–10% of all coronary angiograms performed for symptomatic coronary artery disease (1,2). Data obtained before the modern age of pharmacotherapy of coronary artery disease suggested that significant LMCA stenosis has a very grim prognosis when treated medically, with a mortality rate of 50% within 3 years of diagnosis (3,4).

Aims: We investigated the relationship between coronary artery calcium score (CACS) and coronary artery disease (CAD) on coronary computed tomography angiography (CCTA), and measures of left ventricular diastolic function (DD). Methods: We included 429 consecutive patients (39% women; mean age 49 ± 12 years) without known CAD, who underwent CCTA and transthoracic echocardiography (TTE) within 1-month. Evaluation of CCTA was per vessel, and per segment basis for intraluminal diameter stenosis. We also used the 16-segment model to determine overall coronary plaque burden with segment involvement score (SIS). DD on TTE was assessed using mitral inflow E wave-to-A wave ratio (EAR) and tissue Doppler early mitral annual tissue velocity axial excursion. Results: A total of 293 (68.4%) patients had DD, 15.4% had more than stage 2 DD. The presence of DD was associated with increasing CACS (P < 0.001). Similarly, there was a statistically significant correlation between EAR and CCS (r = −0.147, P = 0.004) and SIS (r = 0.536, P < 0.001). The prevalence of more than stage 2 DD was associated with higher prevalence of obstructive CAD (26.2% vs. 11.7%, P < 0.0001). In multivariable analyses, the independent predictors of more than stage 1 DD are the age (P < 0.001), and diabetes (P = 0.010), while the CACS and SIS were not independently associated with DD. Conclusion: Our analysis suggests that CACS, as well as CAD by CCTA, are not independently associated with measures of DD on echocardiography.

PURPOSE: The efficacy of intravascular ultrasound (IVUS) in diagnosing obstructive venous lesions has been established in the Western countries; however, its beneficial role in the Asian population is seldom reported. Because IVUS is still not widely used in China, we, therefore, investigated whether the salutary effect of IVUS on the diagnosis and treatment of iliac venous outflow obstructions could also be extended to the Chinese population. MATERIALS AND METHODS: This was a prospective single-center study. Patients with nonthrombotic iliac venous obstructions were consecutively enrolled from September 2017 to September 2019. IVUS and venography were performed for every participant. The anatomic characteristics of the venous lesions were measured by these two imaging modalities and then compared with each other. Venous lesions were divided into the collateral and noncollateral group according to the presence of collaterals on venographic images, and comparison was performed between the two groups. The difference of lesion diameter or area at the most compression site was also observed after the endovascular intervention. RESULTS: A total of 50 patients with 59 limbs were eligible (males, 25; females, 25; mean age 63.46 ± 8.07). The clinical-etiology-anatomy-pathophysiology classification was C4: 43 (72.88%), C5: 6 (10.17%), and C6: 10 (16.95%). Compared with IVUS, the diameter and area stenosis calculated by traditional venography were dramatically lower than that measured by IVUS (diameter stenosis, 38.56% ± 17.76% vs. 64.55% ± 15.96%, P < 0.001; area stenosis: 51.14% ± 19.50% vs. 60.11% ± 13.86%, P = 0.003). Based on a previously reported 50% stenosis threshold (significant stenosis), traditional venography displayed a low sensitivity of 23.91% and an acceptable specificity of 84.62% in detecting significant lesions. The overall intermodality agreement was extraordinarily low between venography and IVUS (κ = 0.045). With no major difference in the baseline characteristics, the area stenosis measured by IVUS was not significantly different between the collateral and noncollateral group (61.31% ± 15.29% vs. 57.94% ± 10.79%, P = 0.376). IVUS also confirmed a significant increase of the compressed vein lumen after the endovascular intervention. CONCLUSIONS: Compared with IVUS, traditional venography underestimates the degree of stenosis and misses significant iliac venous obstructive lesions. The collaterals presented by venography is not a reliable indicator in distinguishing significant lesions. IVUS is a valuable and effective imaging modality in the diagnosis and treatment of nonthrombotic iliac venous obstructions in the Chinese population.

Coronary arterial imaging and the assessment of the severity of arterial stenoses can be achieved with several modalities classified mainly according to their invasive or noninvasive nature. These modalities can be further utilized for the 3-dimensional (3D) reconstruction of the arterial geometry. This study aims to determine the prediction performance of atherosclerotic disease progression using reconstructed arteries from three reconstruction methodologies: Quantitative Coronary Analysis (QCA), Virtual Histology Intravascular Ultrasound (VH)-IVUS-Angiography fusion method and Coronary Computed Tomography Angiography (CCTA). The accuracy of the reconstruction methods is assessed using several metrics such as Minimum lumen diameter (MLD), Reference vessel diameter (RVD), Lesion length (LL), Diameter stenosis (DS%) and the Mean wall shear stress (WSS). Five patients in a retrospective study who underwent X-ray angiography, VH-IVUS and CCTA are used for the method evaluation.

The present study aimed to evaluate the clinical significance of color Doppler sonography (CDS) in the diagnosis of spontaneous isolated superior mesenteric artery dissection (SISMAD). The ultrasonographic images of 19 patients with SISMAD confirmed by computed tomography angiography (CTA) were retrospectively analyzed and the ultrasonographic features were summarized. The paired t-test was used to statistically analyze the differences in parameters determined by CTA vs. CDS, including the minimal inner diameter (MID), cross-sectional area (CSA), diameter and area stenosis rate, and flow rate of the true lumen. Of the 19 patients, 18 (94.7%) were diagnosed with SISMAD with correct classification by CDS. There was no significant difference between CTA and CDS with regard to minimal ID, CSA, diameter stenosis and area stenosis rate, and flow rate of the true lumen (all P>0.05). CDS was indicated to be an effective imaging modality for the diagnosis of SISMAD.

Aims Recent study suggests that algorithms such as the Duke Clinical score (DCS) may overestimate the pretest probability. The Agatston score representing the grade of coronary artery calcification can be simply calculated from low-radiation exposure ECG-gated plain CT. In this study, we investigated whether or not more superior diagnostic performance for obstructive coronary artery disease (CAD) can be obtained by combining DCS with the Agatston score. Methods and results Of 3939 consecutive patients suspected of having stable angina without known CAD who underwent Coronary Computed Tomography Angiography (CCTA) as well as calculation of the DCS and Agatston score at our hospital, 3688 patients were selected as subjects. Obstructive CAD was defined as >50% diameter stenosis on CCTA; we investigated the diagnostic performance based on the area under the curve (AUC) of a receiver operating characteristic (ROC) curve, Net Reclassification Improvement (NRI), and Integrated Discrimination Improvement (IDI). The AUCs of ROCs prepared using the DCS alone and combination of the DCS and Agatston score were 0.7137 and 0.8057, respectively, showing that the diagnostic performance of the combination was significantly superior to DCS alone ( P < 0.001). NRI was 0.8132 and IDI was 0.1374, showing that the diagnostic performance was improved by the combination of the DCS and Agatston score compared with DCS alone ( P < 0.001). NRI (0.3522) and IDI (0.0287) were improved compared with those of the Agatston score alone ( P < 0.001). Conclusion The combination of the DCS and Agatston score improved the diagnostic performance for obstructive CAD compared with DCS alone and Agatston score.

We thank Drs Jin-Shan and Xue-Bin for their interest and thoughtful questions on our work.1 First, they asked the indication of fractional flow reserve (FFR) measurement. American practice guideline suggests that FFR measurement is reasonable to assess angiographic intermediate coronary stenosis (50%–70% diameter stenosis). A more recent consensus document has extended FFR use up to 90% diameter stenosis because ≈20% of coronary stenoses with 70% to 90% diameter stenosis are functionally insignificant.2 In addition, although diameter stenosis is

Stenotic flow reserve (SFR) derived from quantitative coronary angiography (QCA) has been correlated with myocardial ischaemia as determined by pharmacological stress echocardiography. However, the diagnostic accuracy of SFR in predicting functionally significant coronary stenosis as assessed by the gold standard, fractional flow reserve (FFR), has not been previously characterised.Patients who underwent coronary angiography and FFR assessment between January 2010 and February 2012 in a single tertiary centre were retrospectively assessed. QCA parameters such as minimal lumen diameter (MLD), lesion length, diameter stenosis (DS), SFR, turbulent resistance (TR) and Poiseuille resistance (PR) were assessed. Significant FFR was defined as FFR ≤0.8. The diagnostic accuracy of QCA parameters to predict significant FFR was assessed by independent t-test and receiver operator characteristic (ROC) curve. Statistical significance was defined as P value of0.05.The study included 272 patients (age: 64±11, 70% males) and 415 vessels. There were 180 (43%) vessels which were FFR significant. The mean FFR value for all vessels was 0.81±0.11. On comparison of AUC for predicting significant FFR, SFR (AUC =0.76) had the highest diagnostic accuracy compared to PR (AUC =0.75), % DS (AUC =0.73), TR (AUC =0.69), MLD (AUC =0.71) and DS50% (AUC =0.64). Using a retrospectively determined optimal cut-off value of 3.51, the sensitivity of stenotic-flow-reserve was modest at 56% with good specificity of 81%. DS50% had a sensitivity of 47% and specificity of 82% in predicting significant FFR. There was incremental predictive value when SFR was added to DS50% on integrated discrimination improvement index (IDI =0.103, P0.001) and net reclassification index (NRI =0.72, P0.001).SFR has modest diagnostic accuracy for predicting significant FFR but adds incremental predictive value to DS50% for predicting significant FFR.

The aim of the study was to assess the effect of coronary lesion length (LL) on fractional flow reserve (FFR) in coronary arteries with intermediate diameter stenosis (DS; 30– 60%). Eighty-three patients (89 lesions) with coronary artery disease underwent FFR measurement using a Radi or Volcano pressure wire. Diameter stenosis and LL were determined by quantitative coronary angiography, and the relationship between DS, LL, and FFR was assessed by regression analysis. Seventy-nine lesions had DS between 30 and 60% and were entered into the retrospective analysis. Mean DS and LL were 41.6 (+6.77%) and 9.2 (+6 mm), respectively. Fractional flow reserve ranged from 0.5 to 1.0. Pearson correlation coefficient for FFR vs. LL was 0.42 (P , 0.001). Using FFR ¼ 0.8 as a cut-off point, there was no difference in mean DS between the two subgroups (42 vs. 41.5%, P ¼ NS), while there was a significant difference in the LL (12.39 vs. 7.83 mm, P ¼ 0.002). In intermediate coronary artery lesion, there is a strong inverse correlation between FFR and LL.

We eagerly read the report by Lee et al. [(1)][1] that found slower rate of total and noncalcified percentage of atheroma volume (PAV) progression and a faster progression of calcified PAV in statin-taking patients without history of coronary artery disease who underwent coronary computed

A 54-year-old man with a history of hypertension, diabetes, and tobacco use was admitted for unstable angina. Angiography revealed a 90% diameter stenosis in the proximal left anterior descending coronary artery. Stenting with Magmaris 3.0 × 25 mm and 3.5 × 15 mm bioresorbable scaffolds (

Optimal endpoint of balloon angioplasty for femoropopliteal lesion remains unknown. We measured fractional flow reserve (FFR) after balloon angioplasty for femoropopliteal lesion and evaluated its predictive ability for future restenosis compared to angiographic dissection and diameter stenosis