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Physiological Severity of Coronary Artery Stenosis Depends on the Amount of Myocardial Mass Subtended by the Coronary Artery

https://doi.org/10.1016/j.jcin.2016.04.008Get rights and content
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Abstract

Objectives

This study investigated the role of fractional myocardial mass (FMM), a vessel-specific myocardial mass, in the evaluation of physiological severity of stenosis. Using computed tomography angiography, the study investigated fractional myocardial mass, a concept of myocardial mass subtended by specific vessel, which could reduce anatomical-physiological mismatch.

Background

Discordance between anatomical stenosis and physiological severity is common but remains poorly understood.

Methods

This multicenter study enrolled 463 patients with 724 lesions, who underwent coronary computed tomography angiography (CCTA) and invasive coronary angiography with fractional flow reserve (FFR) measurement. FMM was assessed by allometric scaling analysis of arterial tree length and myocardial mass from CCTA.

Results

FFR <0.80, a criteria for vessel-specific physiological stenosis, was found in 281 vessels (39%). FMM decreased consistently according to the vessel downstream (p < 0.001, all). The frequency of FFR <0.80 increased in proportion to FMM and inverse proportion to angiographic minimal luminal diameter (MLD) (p < 0.001). In per-vessel analysis, FMM per MLD (FMM/MLD) showed good correlation with FFR (r = 0.61) and was superior to diameter stenosis (DS) for FFR <0.80 by receiver operating characteristic and reclassification analysis (C-statistics = 0.84 versus 0.74, net reclassification improvement [NRI] = 0.63, integrated discrimination improvement [IDI] = 0.18; p < 0.001, all). The optimal cutoff of FMM/MLD was 29 g/mm, with sensitivity = 75%, specificity = 77%, positive predictive value = 68%, negative predictive value = 83%, and accuracy = 77%. Addition of FMM/MLD to DS could further discriminate vessels with FFR <0.80 (C-statistic = 0.86 vs. 0.84, NRI = 0.34, IDI = 0.03; p < 0.005, all). In per-range classification analysis, agreement between FFR and FMM/MLD maintained >80% when the severity of disease was away from cutoff.

Conclusions

FMM/MLD could find physiological severity of coronary artery with higher accuracy than anatomical stenosis. FMM may explain the anatomical-physiological discordance.

Key Words

anatomical-physiological discordance
coronary artery physiology
fractional flow reserve
fractional myocardial mass

Abbreviations and Acronyms

CAG
coronary angiography
CCTA
computed tomography angiography
DS
diameter stenosis
FFR
fractional flow reserve
FMM
fractional myocardial mass
MLD
minimal luminal diameter
QCA
quantitative coronary angiography
RD
reference diameter

Cited by (0)

This study was supported by Korean Society of Interventional Cardiology grant 2014-1 and Samsung Biomedical Research Institute grant GL1B33211, and by the Heart Vascular and Stroke Institute of Samsung Medical Center. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.