Department of Medicine, Jeju University Hospital, Jeju National University School of Medicine, Jeju, Korea.
Department of Medicine, Inje University Ilsan-Paik Hospital, College of Medicine, Goyang, Korea.
JACC Cardiovasc Interv. 2017 Mar 27;10(6):571-581. doi: 10.1016/j.jcin.2016.11.033. Epub 2017 Mar 1.
The authors sought to identify whether a coronary side branch (SB) is supplying a myocardial mass that may benefit from revascularization.
The amount of subtending myocardium and physiological stenosis is frequently different between the main vessel (MV) and SB.
In this multicenter registry, 482 patients who underwent coronary computed tomography angiography and fractional flow reserve (FFR) measurement were enrolled. The % fractional myocardial mass (FMM), the ratio of vessel-specific myocardial mass to whole myocardium, was assessed in 5,860 MV or SB consisting of 2,930 bifurcations. Physiological stenosis was defined by fractional flow reserve (FFR) <0.80. Myocardial mass that may benefit from revascularization was defined by %FMM ≥10%.
In per-bifurcation analysis, MV supplied a 1.5- to 9-fold larger myocardial mass compared with SB. Unlike left main bifurcation (n = 482), only 1 of every 5 non-left main SB (n = 2,448) supplied %FMM ≥10% (97% vs. 21%; p < 0.001). SB length ≥73 mm could estimate %FMM ≥10% (c-statistic = 0.85; p < 0.001). In 604 vessels interrogated by FFR, diameter stenosis was similar (p = NS), but %FMM ≥10%, FMM/minimal luminal diameter, and frequency of FFR <0.80 was higher in MV compared with SB (p < 0.001, all). Generalized estimating equations modeling demonstrate that vessel diameter, left myocardial mass, and FFR were not (p = NS), but SB length ≥73 mm and left main bifurcation were significant predictors for %FMM ≥10% (p < 0.001).
Compared with MV, SB supplies a smaller myocardial mass and showed less physiological severity despite similar stenosis severity. SB supplying a myocardial mass of %FMM≥10%, which may benefit revascularization could be identified by vessel length ≥73 mm. Pre-procedural recognition of these findings may guide optimal revascularization strategy for bifurcation.
作者旨在确定冠状动脉的分支血管（SB）是否为可能从血运重建中获益的心肌供血。
在主血管（MV）和 SB 之间，心肌的覆盖范围和生理性狭窄的程度通常是不同的。
在这个多中心注册研究中，纳入了 482 名接受冠状动脉计算机断层血管造影和血流储备分数（FFR）测量的患者。在由 2930 个分叉组成的 5860 个 MV 或 SB 中，评估了血管特异性心肌质量与整个心肌的比值，即分心肌质量比（%FMM）。通过 FFR<0.80 定义生理性狭窄。通过 %FMM≥10%来定义可能从血运重建中获益的心肌质量。
在每个分叉的分析中，MV 供应的心肌质量比 SB 大 1.5 到 9 倍。与左主干分叉（n=482）不同，只有 1/5 的非左主干 SB（n=2448）供应的 %FMM≥10%（97% vs. 21%；p<0.001）。SB 长度≥73mm 可以估计 %FMM≥10%（c 统计量=0.85；p<0.001）。在接受 FFR 检测的 604 个血管中，直径狭窄程度相似（p=NS），但 MV 中的 %FMM≥10%、FMM/最小管腔直径和 FFR<0.80 的频率均高于 SB（p<0.001，均）。广义估计方程模型表明，血管直径、左心肌质量和 FFR 不是（p=NS），但 SB 长度≥73mm 和左主干分叉是 %FMM≥10%的显著预测因素（p<0.001）。
与 MV 相比，SB 供应的心肌质量较小，尽管狭窄程度相似，但显示出的生理性狭窄程度较小。通过 SB 长度≥73mm 可以识别出 SB 供应的 %FMM≥10%、可能从血运重建中获益的心肌质量。术前识别这些发现可能有助于指导分叉病变的最佳血运重建策略。
