russjcardiolРоссийский кардиологический журналRussian Journal of Cardiology1560-40712618-7620«SILICEA-POLIGRAF» LLC10.15829/1560-4071-2023-5548ZEECSTrussjcardiol-5548Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИORIGINAL ARTICLESВиртуальное стентирование и корегистрация показателя мгновенного резерва кровотока для прогнозирования физиологического эффекта чрескожного коронарного вмешательства у пациентов с многоуровневым поражением коронарных артерийVirtual stenting and coregistration of instantaneous wave-free ratio to predict the physiological effect of percutaneous coronary intervention in patients with multilevel coronary artery diseasehttps://orcid.org/0000-0002-3370-0295ПетросянК. В.PetrosyanK. V.

д.м.н., зав. отделением

Москва

Moscow

dr.petrosian@gmail.comhttps://orcid.org/0000-0003-0038-5193ГончароваЕ. С.AbrosimovA. V.

к. м. н., н. с.,

Москва

Moscow

katrin15687@gmail.comhttps://orcid.org/0000-0001-5907-9508АбросимовА. В.GoncharovaE. S.

м.н.с.

Москва

Moscow

drabrosimov@gmail.comhttps://orcid.org/0000-0002-5091-0518БулаеваН. И.BulaevaN. I.

к.б.н., с.н.с.

Москва

Moscow

nibulaeva@bakulev.ruhttps://orcid.org/0000-0001-7717-4971БердибековБ. Ш.BerdibekovB. Sh.

м.н.с.

Москва

Moscow

bsberdibekov@bakulev.ruhttps://orcid.org/0000-0002-6252-0322ГолуховаЕ. З.GolukhovaE. Z.

Директор НМИЦ ССХ им. А. Н. Бакулева, академик РАН.

Москва

Moscow

egolukhova@bakulev.ruФГБУ Национальный медицинский исследовательский центр сердечнососудистой хирургии им. А.Н. Бакулева Минздрава РоссииРоссияBakulev National Medical Research Center of Cardiovascular SurgeryRussian Federation202328122023284SОбразование55485548Copyright © Петросян К.В., Гончарова Е.С., Абросимов А.В., Булаева Н.И., Бердибеков Б.Ш., Голухова Е.З., 20232023Петросян К.В., Гончарова Е.С., Абросимов А.В., Булаева Н.И., Бердибеков Б.Ш., Голухова Е.З.Petrosyan K.V., Abrosimov A.V., Goncharova E.S., Bulaeva N.I., Berdibekov B.S., Golukhova E.Z.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://russjcardiol.elpub.ru/jour/article/view/5548Цель

Цель. Оценить точность технологии виртуального стентирования в отношении прогнозирования физиологического эффекта чрескожного коронарного вмешательства (ЧКВ) при многоуровневом поражении коронарных артерий.

Материал и методы

Материал и методы. 34 пациентам с многоуровневым поражением коронарных артерий с целью планирования тактики ЧКВ выполнена оценка мгновенного резерва кровотока (МРК) с протяжкой датчика и картированием показателя МРК путем его наложения на ангиографическое изображение. Используя функцию виртуального стентирования, были получены значения прогнозируемого МРК (МРКпр). После имплантации стента проводилась повторная оценка фактически полученного МРК (МРКф). Расхождение показателей МРКпр и МРКф на 0,03 единицы определялось в качестве порогового уровня значимой разницы и критерия "плохой согласованности" между измерениями.

Результаты

Результаты. Среднее значение МРК до ЧКВ составило 0,77±0,11, после проведения ЧКВ данный показатель статистически значимо увеличился и составил 0,94±0,04 (р<0,001). При сопоставлении значений прогнозируемого и фактического МРК разность измерений существенно не зависела от величины показателя (rxy=-0,183; р=0,300), а значение средней разности между измерениями составило 0,013 (стандартное отклонение разности составило ±0,019), что свидетельствует об отсутствии систематического расхождения данных и хорошей сопоставимости исследуемых методов. Также по результатам корреляционного анализа между МРКф и МРКпр была выявлена статистически значимая прямая связь высокой тесноты по шкале Чеддока (r=0,854; p<0,001). Независимыми предикторами "плохой согласованности" оказались частота сердечных сокращений и уровень систолического артериального давления до операции. Расхождение в принимаемых решениях касательно выбора стентируемых поражений и необходимого числа стентов на основании коронароангиографии (КАГ) и МРК имело место у 21 пациента (62%) и 16 пациентов (47%), соответственно. Так, после измерения МРК отмечалось статистически значимое снижение средней протяженности пораженного сегмента (с 61,82±19,68 мм на основании КАГ и 49,15±19,19 мм по результатам МРК), что позволило статистически значимо снизить число фактически имплантированных стентов с 1,91±0,57 (визуальная оценка КАГ) до 1,50±0,56 (р=0,001).

Заключение

Заключение. Картирование показателя МРК и технология виртуального стентирования позволяет пересматривать классификацию поражений коронарного русла по протяженности, что приводит к статистически значимому снижению числа имплантируемых стентов и протяженности стентированного сегмента. Достигнутая в нашем исследовании высокая степень корреляции между МРКпр и МРКф свидетельствует о высокой точности технологии виртуального стентирования в отношении прогнозирования физиологического эффекта стентирования.

Aim

Aim. To evaluate the accuracy of virtual stenting in predicting the physiological effect of percutaneous coronary intervention (PCI) for multilevel coronary artery disease (CAD).

Material and methods

Material and methods. In order to define PCI strategy, 34 patients with multilevel CAD underwent assessment of instantaneous wave-free ratio (iFR) with mapping. Using the virtual stenting, predicted iFR (priFR) was assessed. After stent implantation, the factual iFR (fiFR) was re-assessed. A discrepancy between the priFR and fiFR by 0,03 was considered the threshold level of a significant difference and "poor agreement" criterion between measurements.

Results

Results. Mean iFR before PCI was 0,77±0,11; after PCI, this indicator increased significantly and amounted to 0,94±0,04 (p<0,001). Comparison of the predicted and factual iFR revealed that the difference did not significantly depend on the value (rxy=-0,183; p=0,300), and mean difference between measurements was 0,013 (standard deviation, ±0,019), which indicates no systematic discrepancy and good comparability of the studied methods. In addition, correlation analysis of priFR and fiFR revealed a significant strong (Chaddock scale) direct relationship (r=0,854; p<0,001). Independent predictors of "poor agreement" were heart rate and systolic blood pressure before surgery. Discrepancy in decisions on the choice of stented lesions and the required number of stents based on coronary angiography (CAG) and MRI occurred in 21 patients (62%) and 16 patients (47%), respectively. After iFR measurement, there was a significant decrease in the mean length of affected segment (from 61,82±19,68 mm (CAG) and 49,15±19,19 mm (iFR)), which made it possible to significantly reduce the number of implanted stents from 1,91±0,57 (CAG) to 1,50±0,56 (p=0,001).

Conclusion

Conclusion. Mapping the iFR and virtual stenting technology makes it possible to revise the classification of coronary lesions by length, which leads to a significant reduction in the number of implanted stents and the length of stented segment. High correlation between priFR and fiFR achieved in our study indicates the high accuracy of virtual stenting in predicting the physiological effect of stenting.

ишемическая болезнь сердцачрескожное коронарное вмешательствомгновенный резерв кровотокамногоуровневое поражение коронарных артерийвиртуальное стентированиеcoronary artery diseasepercutaneous coronary interventioninstantaneous wave-free ratiomultilevel coronary artery diseasevirtual stentingнетReferencesLawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 2022;145(3):E4-E17. doi:10.1161/CIR.0000000000001039.Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 2022;145(3):E4-E17. doi:10.1161/CIR.0000000000001039.Sousa-Uva M, Neumann FJ, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur. J. Cardio-thoracic Surg. 2019;55(1):4-90. doi:10.1093/ejcts/ezy289.Sousa-Uva M, Neumann FJ, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur. J. Cardio-thoracic Surg. 2019;55(1):4-90. doi:10.1093/ejcts/ezy289.Park SH, Jeon KH, Lee JM, et al. Long-Term Clinical Outcomes of Fractional Flow ReserveGuided Versus Routine Drug-Eluting Stent Implantation in Patients with Intermediate Coronary Stenosis: Five-Year Clinical Outcomes of DEFER-DES Trial. Circ. Cardiovasc. Interv. 2015;8(12):e002442. doi:10.1161/CIRCINTERVENTIONS.115.002442.Park SH, Jeon KH, Lee JM, et al. Long-Term Clinical Outcomes of Fractional Flow ReserveGuided Versus Routine Drug-Eluting Stent Implantation in Patients with Intermediate Coronary Stenosis: Five-Year Clinical Outcomes of DEFER-DES Trial. Circ. Cardiovasc. Interv. 2015;8(12):e002442. doi:10.1161/CIRCINTERVENTIONS.115.002442.Escaned J, Ryan N, Mejía-Rentería H, et al. Safety of the Deferral of Coronary Revascularization on the Basis of Instantaneous Wave-Free Ratio and Fractional Flow Reserve Measurements in Stable Coronary Artery Disease and Acute Coronary Syndromes. JACC Cardiovasc. Interv. 2018;11(15):1437-49. doi:10.1016/j.jcin.2018.05.029.Escaned J, Ryan N, Mejía-Rentería H, et al. Safety of the Deferral of Coronary Revascularization on the Basis of Instantaneous Wave-Free Ratio and Fractional Flow Reserve Measurements in Stable Coronary Artery Disease and Acute Coronary Syndromes. JACC Cardiovasc. Interv. 2018;11(15):1437-49. doi:10.1016/j.jcin.2018.05.029.Zimmermann FM, Ferrara A, Johnson NP, et al. Deferral vs. performance of percutaneous coronary intervention of functionally non-significant coronary stenosis: 15-year follow-up of the DEFER trial. Eur. Heart J. 2015;36(45):3182-8. doi:10.1093/eurheartj/ehv452.Zimmermann FM, Ferrara A, Johnson NP, et al. Deferral vs. performance of percutaneous coronary intervention of functionally non-significant coronary stenosis: 15-year follow-up of the DEFER trial. Eur. Heart J. 2015;36(45):3182-8. doi:10.1093/eurheartj/ehv452.Xaplanteris P, Fournier S, Pijls NHJ, et al. Five-Year Outcomes with PCI Guided by Fractional Flow Reserve. N Engl J Med. 2018;379(3):250-9. doi:10.1056/nejmoa1803538.Xaplanteris P, Fournier S, Pijls NHJ, et al. Five-Year Outcomes with PCI Guided by Fractional Flow Reserve. N Engl J Med. 2018;379(3):250-9. doi:10.1056/nejmoa1803538.Kern MJ, Seto AH. Instantaneous Wave-Free Ratio Pressure Pullback With Virtual Percutaneous Coronary Intervention Planning: Seeingthe Futureof Coronary Interventions? JACC Cardiovasc. Interv. 2018;11(8):768-70. doi:10.1016/j.jcin.2018.03.013.Kern MJ, Seto AH. Instantaneous Wave-Free Ratio Pressure Pullback With Virtual Percutaneous Coronary Intervention Planning: Seeingthe Futureof Coronary Interventions? JACC Cardiovasc. Interv. 2018;11(8):768-70. doi:10.1016/j.jcin.2018.03.013.Van Nunen LX, Zimmermann FM, Tonino PAL, et al. Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomized controlled trial. Lancet. 2015;386(10006):185360. doi:10.1016/S0140-6736(15)00057-4.Van Nunen LX, Zimmermann FM, Tonino PAL, et al. Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomized controlled trial. Lancet. 2015;386(10006):185360. doi:10.1016/S0140-6736(15)00057-4.Fearon WF, Zimmermann FM, De Bruyne B, et al. Fractional Flow Reserve-Guided PCI as Compared with Coronary Bypass Surgery. N. Engl. J. Med. 2022;386(2):128-37. doi:10.1056/nejmoa2112299.Fearon WF, Zimmermann FM, De Bruyne B, et al. Fractional Flow Reserve-Guided PCI as Compared with Coronary Bypass Surgery. N. Engl. J. Med. 2022;386(2):128-37. doi:10.1056/nejmoa2112299.Yang X, Yu Q, Yang J, et al. Intracoronary nicorandil induced hyperemia for physiological assessments in the coronary artery lesions. Front. Cardiovasc. Med. 2022;9(2):1023641. doi:10.3389/fcvm.2022.1023641.Yang X, Yu Q, Yang J, et al. Intracoronary nicorandil induced hyperemia for physiological assessments in the coronary artery lesions. Front. Cardiovasc. Med. 2022;9(2):1023641. doi:10.3389/fcvm.2022.1023641.Matsuo H, Kawase Y. FFR and iFR guided percutaneous coronary intervention. Cardiovasc. Interv. Ther. 2016;31(3):183-95. doi:10.1007/s12928-016-0404-2.Matsuo H, Kawase Y. FFR and iFR guided percutaneous coronary intervention. Cardiovasc. Interv. Ther. 2016;31(3):183-95. doi:10.1007/s12928-016-0404-2.Chhabria R, Mehta NP, Jain N, et al. Diagnostic utility and safety of intracoronary nicorandil as a hyperemic agent for the measurement of fractional flow reserve. Indian Heart J. 2020;72(6):603-5. doi:10.1016/j.ihj.2020.10.004.Chhabria R, Mehta NP, Jain N, et al. Diagnostic utility and safety of intracoronary nicorandil as a hyperemic agent for the measurement of fractional flow reserve. Indian Heart J. 2020;72(6):603-5. doi:10.1016/j.ihj.2020.10.004.Golukhova EZ, Petrosian KV, Abrosimov AV, Losev VV. Current state of practical application of invasive methods for assessing intracoronary physiology. Creative Cardiology. 2020;14(3):272-9. doi:10.24022/1997-3187-2020-14-3-272-279.Golukhova EZ, Petrosian KV, Abrosimov AV, Losev VV. Current state of practical application of invasive methods for assessing intracoronary physiology. Creative Cardiology. 2020;14(3):272-9. doi:10.24022/1997-3187-2020-14-3-272-279.De Waard GA, Cook CM, Van Royen N, et al. Coronary autoregulation and assessment of stenosis severity without pharmacological vasodilation. Eur. Heart J. 2018;39(46):4062-71. doi:10.1093/eurheartj/ehx669.De Waard GA, Cook CM, Van Royen N, et al. Coronary autoregulation and assessment of stenosis severity without pharmacological vasodilation. Eur. Heart J. 2018;39(46):4062-71. doi:10.1093/eurheartj/ehx669.Fezzi S, Huang J, Lunardi M, et al. Coronary physiology in the catheterisation laboratory: an A to Z practical guide. AsiaIntervention. 2022;8(2):86-109. doi:10.4244/AIJ-D-2200022.Fezzi S, Huang J, Lunardi M, et al. Coronary physiology in the catheterisation laboratory: an A to Z practical guide. AsiaIntervention. 2022;8(2):86-109. doi:10.4244/AIJ-D-2200022.Kawase Y, Matsuo H, Akasaka T, et al. Clinical use of physiological lesion assessment using pressure guidewires: an expert consensus document of the Japanese Association of Cardiovascular Intervention and Therapeutics. Cardiovasc. Interv. Ther. 2019;34(1):85-96. doi:10.1007/s12928-018-0559-0.Kawase Y, Matsuo H, Akasaka T, et al. Clinical use of physiological lesion assessment using pressure guidewires: an expert consensus document of the Japanese Association of Cardiovascular Intervention and Therapeutics. Cardiovasc. Interv. Ther. 2019;34(1):85-96. doi:10.1007/s12928-018-0559-0.Götberg M, Berntorp K, Rylance R, et al. 5-Year Outcomes of PCI Guided by Measurement of Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve. J. Am. Coll. Cardiol. 2022;79(10):965-74. doi:10.1016/j.jacc.2021.12.030.Götberg M, Berntorp K, Rylance R, et al. 5-Year Outcomes of PCI Guided by Measurement of Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve. J. Am. Coll. Cardiol. 2022;79(10):965-74. doi:10.1016/j.jacc.2021.12.030.Lee JM, Choi KH, Koo BK, et al. Comparison of Major Adverse Cardiac Events between Instantaneous Wave-Free Ratio and Fractional Flow Reserve-Guided Strategy in Patients with or Without Type 2 Diabetes: A Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol. 2019;4(9):857-64. doi:10.1001/jamacardio.2019.2298.Lee JM, Choi KH, Koo BK, et al. Comparison of Major Adverse Cardiac Events between Instantaneous Wave-Free Ratio and Fractional Flow Reserve-Guided Strategy in Patients with or Without Type 2 Diabetes: A Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol. 2019;4(9):857-64. doi:10.1001/jamacardio.2019.2298.Lee JM, Lee SH, Shin D, et al. Physiology-Based Revascularization: A New Approach to Plan and Optimize Percutaneous Coronary Intervention. JACC Asia. 2021;1(1):14-36. doi:10.1016/j.jacasi.2021.03.002.Lee JM, Lee SH, Shin D, et al. Physiology-Based Revascularization: A New Approach to Plan and Optimize Percutaneous Coronary Intervention. JACC Asia. 2021;1(1):14-36. doi:10.1016/j.jacasi.2021.03.002.Pijls NHJ, De Bruyne B, Bech GJW, et al. Coronary pressure measurement to assess the hemodynamic significance of serial stenoses within one coronary artery: Validation in humans. Circulation. 2000;102(19 suppl.):2371-7. doi:10.1161/01.CIR.102.19.2371.Pijls NHJ, De Bruyne B, Bech GJW, et al. Coronary pressure measurement to assess the hemodynamic significance of serial stenoses within one coronary artery: Validation in humans. Circulation. 2000;102(19 suppl.):2371-7. doi:10.1161/01.CIR.102.19.2371.Higashioka D, Shiono Y, Kubo T, et al. The inter-study reproducibility of instantaneous wave-free ratio and angiography coregistration. J. Cardiol. 2020;75(5):507-12. doi:10.1016/j.jjcc.2019.09.016.Higashioka D, Shiono Y, Kubo T, et al. The inter-study reproducibility of instantaneous wave-free ratio and angiography coregistration. J. Cardiol. 2020;75(5):507-12. doi:10.1016/j.jjcc.2019.09.016.Kikuta Y, Cook CM, Sharp ASP, et al. Pre-Angioplasty Instantaneous Wave-Free Ratio Pullback Predicts Hemodynamic Outcome In Humans With Coronary Artery Disease: Primary Results of the International Multicenter iFR GRADIENT Registry. JACC Cardiovasc. Interv. 2018;11(8):757-67. doi:10.1016/j.jcin.2018.03.005.Kikuta Y, Cook CM, Sharp ASP, et al. Pre-Angioplasty Instantaneous Wave-Free Ratio Pullback Predicts Hemodynamic Outcome In Humans With Coronary Artery Disease: Primary Results of the International Multicenter iFR GRADIENT Registry. JACC Cardiovasc. Interv. 2018;11(8):757-67. doi:10.1016/j.jcin.2018.03.005.Matsuo A, Kasahara T, Ariyoshi M, et al. Utility of angiography-physiology coregistration maps during percutaneous coronary intervention in clinical practice. Cardiovasc. Interv. Ther. 2021;36(2):208-18. doi:10.1007/s12928-020-00668-0.Matsuo A, Kasahara T, Ariyoshi M, et al. Utility of angiography-physiology coregistration maps during percutaneous coronary intervention in clinical practice. Cardiovasc. Interv. Ther. 2021;36(2):208-18. doi:10.1007/s12928-020-00668-0.Omori H, Kawase Y, Mizukami T, et al. Comparisons of Nonhyperemic Pressure Ratios: Predicting Functional Results of Coronary Revascularization Using Longitudinal Vessel Interrogation. JACC Cardiovasc. Interv. 2020;13(22):2688-98. doi:10.1016/j.jcin.2020.06.060.Omori H, Kawase Y, Mizukami T, et al. Comparisons of Nonhyperemic Pressure Ratios: Predicting Functional Results of Coronary Revascularization Using Longitudinal Vessel Interrogation. JACC Cardiovasc. Interv. 2020;13(22):2688-98. doi:10.1016/j.jcin.2020.06.060.Kim HL, Koo BK, Nam CW, et al. Clinical and physiological outcomes of fractional flow reserve-guided percutaneous coronary intervention in patients with serial stenoses within one coronary artery. JACC Cardiovasc. Interv. 2012;5(10):1013-8. doi:10.1016/j.jcin.2012.06.017.Kim HL, Koo BK, Nam CW, et al. Clinical and physiological outcomes of fractional flow reserve-guided percutaneous coronary intervention in patients with serial stenoses within one coronary artery. JACC Cardiovasc. Interv. 2012;5(10):1013-8. doi:10.1016/j.jcin.2012.06.017.Nijjer SS, Petraco R, Van De Hoef TP, et al. Change in coronary blood flow after percutaneous coronary intervention in relation to baseline lesion physiology: Results of the JUSTIFY-PCI study. Circ. Cardiovasc. Interv. 2015;8(6):e001715. doi:10.1161/CIRCINTERVENTIONS.114.001715.Nijjer SS, Petraco R, Van De Hoef TP, et al. Change in coronary blood flow after percutaneous coronary intervention in relation to baseline lesion physiology: Results of the JUSTIFY-PCI study. Circ. Cardiovasc. Interv. 2015;8(6):e001715. doi:10.1161/CIRCINTERVENTIONS.114.001715.

The authors declare that there are no conflicts of interest present.