Sonck, Jeroen (2021) Coronary physiology-guided revascularization: Paving the future for ischemia-driven coronary treatment. [Tesi di dottorato]

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An FFR measurement comprises a pressure wire introduction in the distal coronary bed and the use of a hyperemic agent, mostly intravenous adenosine. FFR entails a single-point, distal coronary pressure value. The measured pressure losses in the coronary arteries ensue due to viscous friction and flow separation. The contribution of each mechanism is highly dependent on patient-specific coronary geometries. Mild reductions in luminal area modulated by lesion length have shown to reduce coronary pressures distal to an epicardial stenosis. Lesion features affecting laminar flow conditions also contribute to pressure losses. As such, 2 comparable FFR values could be the resultant of distinct pressure loss patterns along the coronary vessel, i.e., focal or diffuse pressure gradients. Although not routinely assessed, the identification of functional focal and diffuse CAD patterns is of utmost importance for decision making about revascularization. Patients with focal disease have a more severe reduction in myocardial perfusion, lower FFR, and higher trans-stenotic gradients. These features have also been associated with plaque vulnerability and a worse prognosis. Conversely, patient with diffuse disease have relatively higher FFR values and lower plaque stress. Furthermore, treatment options differ in their ability to reestablish epicardial conductance. PCI with stent implantation is a focal treatment and despite the clinical benefit observed with FFR-guided PCI, one-third of the patients remain with a suboptimal post-PCI FFR, which has been associated with major adverse cardiac events. Indeed, in focal CAD, PCI has the potential to restore epicardial conductance and relieves ischemia. In contrast, PCI in cases of diffuse CAD results in a minor improvement in epicardial conductance and low post-PCI FFR16. As such, the conundrum of a comprehensive and precise diagnosis of the hemodynamic significance of coronary artery disease (CAD) entails a more detailed assessment of the distribution and hemodynamic consequences of atherosclerosis. This thesis aims at enhancing current available technologies and introduces novel tools for ischemia-driven coronary revascularization.

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