Noninvasive Fractional Flow Reserve Derived From Computed Tomography Angiography for Coronary Lesions of Intermediate Stenosis Severity : Results From the DeFACTO Study ” Correspondence
Noninvasive Fractional Flow Reserve Derived From Computed Tomography Angiography for Coronary Lesions of Intermediate Stenosis Severity : Results From the DeFACTO Study ” Correspondence
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针对中度狭窄严重程度的冠状动脉病变的计算机断层扫描血管造影得出的无创血流储备分数：DeFACTO 研究的结果“对应”
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Y. Mao;X. Qi;Lin Zhou;References Nakazato;Park Hb;Berman Ds;Gransar H;Koo Bk;Erglis A;Lin Fy;Dunning Am;Budoff Mj;Malpeso J;Leipsic J;Min Jk Noninvasive;Min Jk;Pencina Mj;C. Van Mieghem;Apruzzese P;Cole Jh;Jaffe Fa;Leon Mb;Mancini Gb;Park Sj;Schwartz Rs;Shaw Lj;Mauri L;De Bruyne;Hamilos M Cuisset;Wyffels E;Bartunek J;Heyndrickx Gr;Wijns W;Morris Pd;Ryan D;Morton Ac;Lycett R;Lawford Pv;Hose Dr;Gunn
我们赞扬 Nakazato 等人 1 发表的优秀文章，题为“CT 血管造影 (FFRCT) 中度狭窄严重程度的冠状动脉病变的非侵入性分数血流储备：DeFACTO 研究的结果”。这项执行良好的多中心研究得出结论，对于中度狭窄严重程度的冠状动脉缺血病变，FFR CT 比 CT 狭窄具有更高的诊断性能。此外，高敏感性和阴性预测值表明FFR CT能够有效排除引起缺血的中间病变。然而，我们对这项研究有一些担忧。首先，在解释 FFR CT 时，对冠状动脉进行了 3 维 (3D) 血流模拟，并将血液建模为牛顿流体，以使用不可压缩的纳维-斯托克斯方程。 1 使用了一种将微循环的集总参数模型耦合到 3D 模型的流出边界的方法。然而，体内模拟与体外模拟可能存在一些差异。例如，动脉壁的弹性可能极大地影响体内的心脏灌注压，而这一点在FFR CT的计算中被错误地忽略了。 2,3 其次，对于中等狭窄严重程度的病变，FFR CT 与 CT 狭窄准确性、敏感性、特异性、阳性预测值和阴性预测值分别为 71% 与 63%、74% 与 34%、67% 与 72%、41% 与 27% 以及 90% 与 78%。 1 虽然 FFR CT 的敏感性提高了 2 倍，且阴性预测值较高，但我们必须注意到 FFR CT 在特异性和阳性预测值方面表现不佳。尽管 FFR CT 具有高敏感性和阴性预测值，在排除缺血方面显示出有希望的作用，但较低的特异性和阳性预测值浇灭了人们对昂贵且复杂的 FFR CT 方法的热情。 4 此外，FFR CT 也受到限制，因为 CT 血管造影在晚期和钙化性冠状动脉疾病以及心律不齐、心动过速或运动伪影的患者中的适应证有限。 5 最后，基于首过分析和计算流体动力学，研究了一种源自侵入性冠状动脉造影 (ICA) 的虚拟 FFR 的最新方法。 5 ICA 衍生的虚拟 FFR 没有 FFR CT 的有限适应症。此外，由于 FFR CT 的诊断性能在特异性和阳性预测值方面较差，接受 FFR CT 的患者可能需要 ICA 确认。 1 因此，当虚拟……时不需要额外的测试和成本
We commend Nakazato et al 1 for their excellent article entitled , " Non-Invasive Fractional Flow Reserve Derived From CT Angiography (FFRCT) for Coronary Lesions of Intermediate Stenosis Severity: Results From the DeFACTO Study. " The well-performed multicenter study concluded that FFR CT possessed higher diagnostic performance for ischemic for coronary lesions of intermediate stenosis severity than CT stenosis. Besides, the high sensitivity and negative predictive values suggested the ability of FFR CT to rule out intermediate lesions effectively that cause ischemia. However, we have some concerns about the study. First, when interpreting FFR CT , 3-dimensional (3D) flow simulations of the coronary arteries were performed, and blood was modeled as a Newtonian fluid to use incompressible Navier–Stokes equations. 1 A method to couple lumped parameter models of the microcircula-tion to the outflow boundaries of the 3D model was used. However, there may be some differences in vivo versus in vitro simulation. For instance, the elasticity of arterial wall may greatly affect the cardiac perfusion pressure in vivo, which was improperly neglected in the computation of FFR CT. 2,3 Second, for lesions of intermediate stenosis severity, FFR CT versus CT stenosis accuracy, sensitivity, specificity, positive predictive value, and negative predictive value was 71% versus 63%, 74% versus 34%, 67% versus 72%, 41% versus 27%, and 90% versus 78%, respectively. 1 Although there was a 2-fold increase in sensitivity and high negative predictive value of FFR CT , we must notice the poor performance of FFR CT in specificity and positive predictive value. The lower specificity and positive predictive value quenched the passion for the costly and complicated method of FFR CT , although it showed a promising role in excluding ischemia with high sensitivity and negative predictive values. 4 Besides, FFR CT is also confined because of the limited indications of CT angiography in the condition of advanced and calcific coronary artery disease and in patients with irregular heart rhythm, tachycardia, or motion artifact. 5 Finally, a recent approach of virtual FFR derived from invasive coronary angiography (ICA) was investigated based on the first-pass analysis and computational fluid dynamics. 5 ICA-derived virtual FFR did not have the limited indications of FFR CT. Moreover, patients who underwent FFR CT will likely require the ICA confirmation because of the poor diagnostic performance of FFR CT in specificity and positive predictive value. 1 Thus, no additional test and cost are needed when virtual …