Aims
Ischaemic heart disease is the reduction of myocardial blood flow, caused by epicardial and/or microvascular disease. Both are common and prognostically important conditions, with distinct guideline-indicated management. Fractional flow reserve (FFR) is the current gold-standard assessment of epicardial coronary disease, but is only a surrogate of flow and only predicts percentage flow changes. It cannot assess absolute (volumetric) flow or microvascular disease. The aim of this study was to develop and validate a novel method that predicts absolute coronary blood flow and microvascular resistance (MVR) in the catheter laboratory.
Methods and Results
A computational fluid dynamics (CFD) model was used to predict absolute coronary flow (QCFD) and coronary microvascular resistance (MVR) using data from routine invasive angiography and pressure-wire assessment. QCFD was validated in an in vitro flow circuit which incorporated patient-specific, 3-D printed coronary arteries; and then in vivo, in patients with coronary disease. In vitro, QCFD agreed closely with the experimental flow over all flow rates (bias +2.08 mL/min; 95% CI (error range) -4.7 to + 8.8 mL/min; R2=0.999, p < 0.001; variability coefficient <1%). In vivo, QCFD and MVR were successfully computed in all 40 patients under baseline and hyperaemic conditions, from which coronary flow reserve (CFR) was also calculated. QCFD-derived CFR correlated closely with pressure-derived CFR (R2=0.92, P < 0.001). This novel method was significantly more accurate than Doppler-wire-derived flow both in vitro (±6.7 vs ± 34 mL/min) and in vivo (±0.9 vs ± 24.4 mmHg).
Conclusions
Absolute coronary flow and MVR can be determined alongside FFR, in absolute units, during routine catheter laboratory assessment, without the need for additional catheters, wires or drug infusions. Using this novel method, epicardial and microvascular disease can be discriminated and quantified. This comprehensive coronary physiological assessment may enable a new level of patient stratification and management.
Translational Perspective
Current pressure wire-based methods of assessing coronary disease cannot assess absolute flow or microvascular disease. Our novel QCFD method, using only angiography-based CFD and a pressure wire, simultaneously measures FFR, absolute coronary blood flow rate, microvascular resistance and coronary flow reserve. QCFD is suitable for use in the catheter laboratory and requires no dedicated catheters, wires or infusions. QCFD measures blood flow and microvascular resistance in absolute units and allows microvascular and epicardial disease to be differentiated, quantified and separately assessed, with the potential to improve diagnostic accuracy and clinical management.
CORE (COnnecting REpositories)
CORE (COnnecting REpositories)