Vol 27, No 6 (2020)
Original Article
Published online: 2019-12-09

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Quantitative flow ratio-guided surgical intervention in symptomatic myocardial bridging

Quan Qi1, Gang Liu2, Zhize Yuan3, Lili Liu4, Shengxian Tu4, Qiang Zhao3
Pubmed: 31909471
Cardiol J 2020;27(6):685-692.

Abstract

Background: Patients with myocardial bridging (MB) are associated with adverse cardiovascular events, but a decision to perform surgical intervention, especially for patients with systolic intermediate stenosis, is a difficult clinical issue. Fractional flow reserve (FFR) represents a novel method for the functional evaluation of coronary stenosis, but the relationship between FFR and MB remains controversial because of the cyclic dynamic stenosis of MB. Quantitative flow ratio (QFR) is a novel index allowing fast assessment of FFR from a diagnostic coronary angiography. This study aimed to investigate the relationship between QFR and MB patients and to further develop a prediction model of QFR-guided surgical intervention for these patients.

Methods:
Forty-five symptomatic lone MB patients who had undergone coronary angiography were consecutively enrolled in this study. MB was located in the middle of left anterior descending artery with intermediate stenosis during systole. The patients were retrospectively divided into a medical therapy group or a surgical therapy group. Systolic geometry based QFR (SG-QFR) and diastolic geometry based QFR (DG-QFR) were calculated based on three-dimensional quantitative coronary angiography and patient-specific flow velocity. Subsequently, time-averaged QFR (TA-QFR) is defined as the average of SG-QFR and DG-QFR.

Results:
Receiver operating characteristic curve analysis revealed that TA-QFR (AUC = 0.91; 95% CI: 0.79–0.98) was found to be the best pre-operative index for surgical intervention to MB, when compared with DG-QFR (AUC = 0.69; 95% CI: 0.53–0.82; difference: 0.22; 95% CI: 0.04–0.41; p = 0.02) and SG-QFR (AUC = 0.87; 95% CI: 0.74–0.95; difference: 0.04; 95% CI: 0.00–0.08; p = 0.03).

Conclusions: TA-QFR improved the performance of functional evaluation in MB patients with intermediate stenosis during systole and is useful for guiding surgical intervention.

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References

  1. Corban MT, Hung OY, Eshtehardi P, et al. Myocardial bridging: contemporary understanding of pathophysiology with implications for diagnostic and therapeutic strategies. J Am Coll Cardiol. 2014; 63(22): 2346–2355.
  2. Tarantini G, Migliore F, Cademartiri F, et al. Left Anterior Descending Artery Myocardial Bridging: A Clinical Approach. J Am Coll Cardiol. 2016; 68(25): 2887–2899.
  3. Ryan N, Escaned J. Myocardial bridge as a cause of persistent post percutaneous coronary intervention angina identified with exercise intracoronary physiology. Eur Heart J. 2017; 38(13): 1001.
  4. Pijls NHJ, Klauss V, Siebert U, et al. Coronary pressure measurement after stenting predicts adverse events at follow-up: a multicenter registry. Circulation. 2002; 105(25): 2950–2954.
  5. Luu JM, Friedrich MG, Harker J, et al. Relationship of vasodilator-induced changes in myocardial oxygenation with the severity of coronary artery stenosis: a study using oxygenation-sensitive cardiovascular magnetic resonance. Eur Heart J Cardiovasc Imaging. 2014; 15(12): 1358–1367.
  6. Neglia D, Rovai D, Caselli C, et al. Detection of significant coronary artery disease by noninvasive anatomical and functional imaging. Circ Cardiovasc Imaging. 2015; 8(3).
  7. Xu Bo, Tu S, Qiao S, et al. Diagnostic accuracy of angiography-based quantitative flow ratio measurements for online assessment of coronary stenosis. J Am Coll Cardiol. 2017; 70(25): 3077–3087.
  8. Tu S, Westra J, Yang J, et al. Diagnostic accuracy of fast computational approaches to derive fractional flow reserve from diagnostic coronary angiography. JACC: Cardiovascular Interventions. 2016; 9(19): 2024–2035.
  9. Westra J, Tu S, Campo G, et al. Diagnostic performance of quantitative flow ratio in prospectively enrolled patients: An individual patient-data meta-analysis. Catheter Cardiovasc Interv. 2019; 94(5): 693–701.
  10. Escaned J, Cortés J, Flores A, et al. Importance of diastolic fractional flow reserve and dobutamine challenge in physiologic assessment of myocardial bridging. J Am Coll Cardiol. 2003; 42(2): 226–233.
  11. Tu S, Barbato E, Köszegi Z, et al. Fractional flow reserve calculation from 3-dimensional quantitative coronary angiography and TIMI frame count: a fast computer model to quantify the functional significance of moderately obstructed coronary arteries. JACC Cardiovasc Interv. 2014; 7(7): 768–777.
  12. Gupta MD, Girish MP, Trehan V, et al. Myocardial bridging in all major epicardial vessels. JACC Cardiovasc Interv. 2014; 7(10): e129–e131.
  13. Xu Z, Wu Q, Li H, et al. Myotomy after previous coronary artery bypass grafting for treatment of myocardial bridging. Circulation. 2011; 123(10): 1136–1137.
  14. Ding H, Yang Q, Shang K, et al. Estimation of shear stress by using a myocardial bridge-mural coronary artery simulating device. Cardiol J. 2017; 24(5): 530–538.
  15. Azzalini L, Ancona MB, Mitomo S, et al. Self-apposing stent fracture in the context of myocardial bridging leading to in-stent chronic total occlusion: When the muscle trumps the metal. Cardiol J. 2018; 25(1): 144–145.
  16. Tremmel J, Schnittger I. Myocardial bridging. J Am Coll Cardiol. 2014; 64(20): 2178–2179.
  17. Okutucu S, Aparci M, Sabanoglu C, et al. Assessment of cardiac autonomic functions by heart rate recovery indices in patients with myocardial bridge. Cardiol J. 2016; 23(5): 524–531.
  18. Honda K, Okamura Y, Nishimura Y, et al. Graft flow assessment using a transit time flow meter in fractional flow reserve-guided coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2015; 149(6): 1622–1628.
  19. Montalescot G, Sechtem U, et al. 2013 ESC guidelines on the management of stable coronary artery disease. Eur Heart J. 2013; 34(38): 2949–3003.
  20. Westra J, Andersen B, Campo G, et al. Diagnostic performance of in‐procedure angiography‐derived quantitative flow reserve compared to pressure‐derived fractional flow reserve: the FAVOR II europe‐japan study. J Am Heart Assoc. 2018; 7(14).
  21. Yoshino S, Cassar A, Matsuo Y, et al. Fractional Flow Reserve With Dobutamine Challenge and Coronary Microvascular Endothelial Dysfunction in Symptomatic Myocardial Bridging. Circulation. 2014; 78(3): 685–692.
  22. Kunamneni PB, Rajdev S, Krishnan P, et al. Outcome of intracoronary stenting after failed maximal medical therapy in patients with symptomatic myocardial bridge. Catheter Cardiovasc Interv. 2008; 71(2): 185–190.
  23. Farag A, Al-najjar Y, Eichhöfer J. Adenosine-Induced vasospasticity in a Myocardial bridge…endothelial dysfunction? JACC: Cardiovascular Interventions. 2015; 8(2): e21–e22.