Cardiovascular Division, St Thomas' Hospital Campus, King's College London, England.
Royal North Shore Hospital and University of Sydney, Sydney, Australia.
JAMA Cardiol. 2018 May 1;3(5):432-438. doi: 10.1001/jamacardio.2018.0236.
Ischemia-guided revascularization is the cornerstone of contemporary management of coronary artery disease and has evolved from noninvasive functional evaluation to real-time assessment with invasive physiological indices during diagnostic catheterization. However, serial/diffuse disease is common, and revascularization decisions often need to be made about individual lesions within the same vessel. It is unclear whether current physiological techniques, such as fractional flow reserve, can be reliably used to discern the individual contribution of lesions within a serially diseased vessel with erroneous measurements, potentially leading to suboptimal revascularization decisions. This review addresses the application of physiological techniques to serial coronary disease, highlighting challenges and potential solutions.
Physiological indices, such as fractional flow reserve, are well validated and correlated with clinical outcomes; however, the challenging physiology of serial stenoses makes it difficult to apply conventional techniques to identify the physiological significance of individual lesions. The 2 methods are most accurate in assessing serial disease are the manual pullback, with treatment of the greatest pressure gradient, or adopting the use of a large disease-free side branch to isolate the significance of the proximal lesion in the context of serial disease involving the left main coronary artery. In addition, resting indices, such as instantaneous wave-free ratio, have theoretical benefits that may make them more reliable in serial disease, with further data awaited.
Serial coronary artery disease is common, and physiological assessment is prone to errors. The future, whether it be in improving the interpretation of fractional flow reserve, using resting indices such as instantaneous wave-free ratio, or examining novel flow-based resistance indices, will hopefully improve our management of this common yet unresolved clinical conundrum. In the meantime, revascularisation decisions in this challenging scenario should focus on clinical presentation and physiologic evaluation using a pressure-wire pullback maneuver and left main disease-free side branch where appropriate.
缺血指导的血运重建是当代冠心病管理的基石，已经从非侵入性的功能评估发展到在诊断性导管检查期间使用侵入性生理指数进行实时评估。然而，串联/弥漫性疾病很常见，并且经常需要对同一血管内的单个病变做出血运重建决策。目前尚不清楚是否可以可靠地使用生理技术（如血流储备分数）来辨别串联病变血管内的单个病变的贡献，潜在地导致血运重建决策不佳。本综述探讨了生理技术在串联冠状动脉疾病中的应用，强调了挑战和潜在的解决方案。
生理指数，如血流储备分数，已得到充分验证，并与临床结果相关；然而，串联狭窄的挑战性生理学使得难以应用传统技术来确定单个病变的生理意义。评估串联疾病最准确的两种方法是手动回撤，以治疗最大压力梯度，或采用使用大的无病变侧支来隔离左主干冠状动脉串联病变中近端病变的意义。此外，瞬时无波比等静息指数具有理论优势，在串联病变中可能更可靠，有待进一步的数据验证。
串联冠状动脉疾病很常见，生理评估容易出错。未来，无论是改进血流储备分数的解释，还是使用瞬时无波比等静息指数，或者检查新的基于流量的阻力指数，都有望改善我们对这一常见但尚未解决的临床难题的管理。同时，在这种具有挑战性的情况下，血运重建决策应侧重于临床表现和使用压力导丝回撤操作和左主干无病变侧支进行的生理评估，如果合适的话。
