Fezzi Simone, Huang Jiayue, Wijns William, Tu Shengxian, Ribichini Flavio
The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, University of Galway, University Road, H91 TK33 Galway, Ireland.
Division of Cardiology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126 Verona, Italy.
Eur Heart J Case Rep. 2023 Jul 19;7(8):ytad309. doi: 10.1093/ehjcr/ytad309. eCollection 2023 Aug.
Physiology-guided coronary revascularization was shown to improve clinical outcomes in multiple patient subsets, whilst in those presenting with acute coronary syndromes, it seems to be associated with an excess of cardiovascular events. One of the major drawbacks in this setting is the potential deferral of non-flow-limiting but 'vulnerable' coronary plaques.
A 40-year-old patient presented with a myocardial infarction without ST-segment elevation (NSTEMI). At the invasive coronary angiography (ICA) a sub-occlusive stenosis on his left circumflex artery was detected and treated with percutaneous coronary intervention (PCI). The treatment of a concomitant intermediate eccentric focal stenosis on the right coronary artery (RCA) was deferred after a negative pressure wire-based physiological assessment. The patient was re-admitted 9 months later due to a recurrent NSTEMI, and a severe progression of the deferred RCA lesion was found at the ICA. In retrospect, an angiography-based assessment of physiological severity and plaque vulnerability of the non-culprit RCA stenosis by means of Murray's law-based QFR (μQFR) and radial wall strain (RWS) was performed. At baseline, μQFR value (0.90) corroborated the non-ischaemic findings of wire-based assessment. However, RWS analysis showed a marked hotspot (maximum RWS value 27.7%), indicating the presence of a vulnerable plaque.
Radial wall strain is a novel biomechanical deformation index derived from coronary angiography. Segments with high RWS are associated with lipid-rich plaques that are prone to progression and plaque rupture. Therefore, the identification of RWS hotspots might potentially improve the risk stratification of non-culprit lesions and empower secondary prevention strategies.
生理学指导下的冠状动脉血运重建已被证明可改善多个患者亚组的临床结局，而在急性冠状动脉综合征患者中，它似乎与心血管事件增多有关。这种情况下的一个主要缺点是可能会延迟对无血流限制但“易损”的冠状动脉斑块的治疗。
一名40岁患者出现非ST段抬高型心肌梗死（NSTEMI）。在有创冠状动脉造影（ICA）检查中，发现其左旋支动脉有亚闭塞性狭窄，并接受了经皮冠状动脉介入治疗（PCI）。基于负压导丝的生理学评估结果为阴性后，对右冠状动脉（RCA）上同时存在的中度偏心局灶性狭窄的治疗被推迟。9个月后，患者因复发性NSTEMI再次入院，在ICA检查中发现延迟治疗的RCA病变有严重进展。回顾性分析时，通过基于Murray定律的定量血流分数（μQFR）和径向壁应变（RWS）对非罪犯RCA狭窄的生理学严重程度和斑块易损性进行了基于血管造影的评估。基线时，μQFR值（0.90）证实了基于导丝评估的非缺血性结果。然而，RWS分析显示有一个明显的热点（最大RWS值为27.7%），表明存在易损斑块。
径向壁应变是一种从冠状动脉造影中得出的新型生物力学变形指数。RWS高的节段与富含脂质的斑块相关，这些斑块易于进展和斑块破裂。因此，识别RWS热点可能会改善非罪犯病变的风险分层，并加强二级预防策略。
