RESUMEN
Fractional flow reserve is the current invasive gold standard for assessing the ischemic potential of an angiographically intermediate coronary stenosis. Procedural cost and time, the need for coronary vessel instrumentation, and the need to administer adenosine to achieve maximal hyperemia remain integral components of invasive fractional flow reserve. The number of new alternatives to fractional flow reserve has proliferated over the last ten years using techniques ranging from alternative pressure wire metrics to anatomic simulation via angiography or intravascular imaging. This review article provides a critical description of the currently available or under-development alternatives to fractional flow reserve with a special focus on the available evidence, pros, and cons for each with a view towards their clinical application in the near future for the functional assessment of coronary artery disease.
Asunto(s)
Cateterismo Cardíaco , Técnicas de Imagen Cardíaca , Enfermedad de la Arteria Coronaria/diagnóstico , Vasos Coronarios/diagnóstico por imagen , Reserva del Flujo Fraccional Miocárdico , Cateterismo Cardíaco/instrumentación , Catéteres Cardíacos , Enfermedad de la Arteria Coronaria/fisiopatología , Vasos Coronarios/fisiopatología , Humanos , Valor Predictivo de las Pruebas , Pronóstico , Reproducibilidad de los Resultados , Transductores de PresiónRESUMEN
AIMS: Atherosclerotic plaques develop at low shear stress locations in the arterial tree. However, at a certain moment, plaques encroach into the lumen causing local wall shear stress (WSS) increase. Minimal information is available on the relationship between WSS and plaque composition. We investigated in human coronary arteries in vivo the frequency with which the necrotic core and necrotic core in contact with the lumen are located at either low or high WSS regions in early and advanced plaques. METHODS AND RESULTS: We combined a 3-D reconstruction technique of coronary arteries based on angiography and intravascular ultrasound with IVUS-virtual histology (IVUS-VH) data. With IVUS-VH the necrotic core was determined. The lumen of these 3-D reconstructions served as input for the computational fluid dynamics. Per cross-section the WSS at the regions with major necrotic core and necrotic core in contact with the lumen were compared to the median WSS in the cross-section. Ten human coronary arteries were studied. Only cross-sections with average wall thickness >0.5 mm were included in the analysis. In early plaques (plaque burden <40%), the necrotic core was most frequently located at WSS smaller than the median (61%) contrasting the advanced plaques (plaque burden >40%), being located at WSS higher than the median (60%, p<0.05 Mann-Whitney U test). Necrotic core in contact with the lumen was most often exposed to high WSS, being most pronounced in advanced disease (61%, p<0.05). CONCLUSIONS: With the advancement of disease, necrotic core is less often located at low WSS regions, but exposed to high WSS, which is probably the result of lumen narrowing. Necrotic core in contact with the lumen was most frequently exposed to high WSS.