Author + information
- Received March 9, 2020
- Revision received April 13, 2020
- Accepted April 21, 2020
- Published online July 20, 2020.
- Norihiro Kogame, MDa,b,
- Masafumi Ono, MDa,
- Hideyuki Kawashima, MDa,
- Mariusz Tomaniak, MDc,d,
- Hironori Hara, MDa,
- Jonathan Leipsic, MDe,
- Daniele Andreini, MD, PhDf,g,
- Carlos Collet, MDh,
- Manesh R. Patel, MDi,
- Shengxian Tu, PhDj,
- Bo Xu, MDk,
- Christos V. Bourantas, MD, PhDl,
- Amir Lerman, MDm,
- Jan J. Piek, MD, PhDa,
- Justin E. Davies, MD, PhDn,
- Javier Escaned, MD, PhDo,
- William Wijns, MD, PhDp,q,
- Yoshinobu Onuma, MD, PhDr and
- Patrick W. Serruys, MD, PhDr,s,∗ ()
- aAmsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- bDepartment of Cardiology, Toho University Medical Center, Ohashi Hospital, Tokyo, Japan
- cDepartment of Cardiology, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands
- dFirst Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
- eDepartment of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
- fCentro Cardiologico Monzino, IRCCS, Milan, Italy
- gDepartment of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- hCardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
- iDuke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
- jMed-X Research Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- kFu Wai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
- lDepartment of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
- mDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- nHammersmith Hospital, Imperial College NHS Trust, London, United Kingdom
- oHospital Clinico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
- pThe Lambe Institute for Translational Medicine and Curam, National University of Ireland Galway, Galway, Ireland
- qSaolta University Healthcare Group, University College Hospital Galway, Galway, Ireland
- rDepartment of Cardiology, National University of Ireland Galway, Galway, Ireland
- sFaculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- ↵∗Address for correspondence:
Prof. Patrick W. Serruys, National University of Ireland Galway, University Road, Galway H91 TK33, Ireland.
• Since the introduction of FFR, 10 more novel modalities for the assessment of coronary physiology have emerged.
• Physiological modalities should be appropriately selected according to their timing of use: outside the catheterization laboratory prior to the treatment decision and in the catheterization laboratory before and after PCI.
• The next challenge is to integrate the evaluation of microvascular circulation as part of daily practice.
• In the near future, invasive and noninvasive modalities of assessing coronary physiology may be integrated to stratify patients with history of anginal symptoms.
Physiological assessment of coronary artery disease (CAD) has become one of the cornerstones of decision making for myocardial revascularization, with a large body of evidence supporting the benefits of using fractional flow reserve and other pressure-based indexes for functional assessment of coronary stenoses. Furthermore, physiology allows the identification of specific vascular dysfunction mechanisms in patients without obstructive CAD. Currently, more than 10 modalities of functional coronary assessment are available, although the overall adoption of these physiological tools, of either intracoronary or image-based nature, is still low. In this paper the authors review these modalities of functional coronary assessment according to their timing of use: outside the catheterization laboratory, in the catheterization laboratory prior to the percutaneous coronary intervention (PCI), and in the catheterization laboratory during or after PCI. The authors discuss how the information obtained can be used in setting the indication for PCI, in planning and guiding the procedure, and in documenting the final functional result of the intervention. The advantages and limitations of each modality in each setting are discussed. Furthermore, the key value of intracoronary physiology in diagnosing mechanisms of microcirculatory dysfunction, which account for the presence of ischemia in many patients without obstructive CAD, is revisited. On the basis of the opportunities generated by the multiplicity of diagnostic tools described, the authors propose an algorithmic approach to physiological coronary investigations in clinical practice, with the key aims of: 1) avoiding unneeded revascularization procedures; 2) improving procedural PCI and long-term outcomes in patients with obstructive CAD; and 3) diagnosing vascular dysfunction mechanisms that can be effectively treated in patients with NOCAD. The authors believe that such structured approach may also contribute to the wider adoption of available technologies for functional assessment of patients with CAD.
- angiography-derived FFR
- computed tomography–derived fractional flow reserve
- coronary microvascular disease
- fractional flow reserve
- instantaneous wave-free ratio
- nonhyperemic pressure ratio
Dr. Collet has received research grants from Biosensor, HeartFlow, and Abbott Vascular; and has received consultancy fees from HeartFlow, Abbott Vascular, Opsens, Boston Scientific, and Philips Volcano. Dr. Tu has received research funding from Medis Medical Imaging Systems and Pulse Medical Imaging Technology. Dr. Piek has received personal fees from Philips/Volcano. Dr. Escaned is a consultant to Philips/Volcano. Dr. Wijns has received speaking fees from Biotronik and MicroPort; is a scientific advisor to Rede Optimus Research; and is a cofounder of Argonauts Partners, an innovation accelerator. Dr. Serruys has received personal fees from Sino Medical Sciences Technology, Philips/Volcano, and Xeltis. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Cardiovascular Interventions author instructions page.
- Received March 9, 2020.
- Revision received April 13, 2020.
- Accepted April 21, 2020.
- 2020 American College of Cardiology Foundation
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