State-of-the-Art Review
Functional Patterns of Coronary Disease: Diffuse, Focal, and Serial Lesions

https://doi.org/10.1016/j.jcin.2022.07.015Get rights and content
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Highlights

  • The assessment of functional patterns of CAD provides crucial information on the revascularization decision strategy and procedural planning.

  • PCI in diffuse disease often yields suboptimal results. In this scenario, physiological longitudinal assessment may identify residual gradients amenable to further intervention.

  • Longitudinal functional assessment provides a third dimension to CAD characterization, in addition to the angiographic and functional evaluation of lesion significance.

Abstract

The physiological assessment of coronary lesions is influenced by the pattern and distribution of coronary artery disease (CAD), including focal lesions, serial lesions, diffuse disease, and mixed patterns. These various patterns of CAD impact the accuracy of pressure wire and angiography-derived physiology indexes, and diffuse disease in particular is an important determinant of the anticipated outcome of percutaneous coronary intervention. Therefore, identification of the physiological pattern of disease provides relevant information for the management of CAD and percutaneous coronary intervention procedural planning. At present, the classification of physiological patterns and its implications for the tailored management of a patient with CAD are poorly defined. This state-of-the-art review provides an overview of the available evidence on functional patterns of CAD with a special focus on their diagnostic and therapeutic implications. It also aims to provide clear definitions of physiological patterns of CAD based on the available evidence and expert opinion. A practical algorithm is provided to optimize the use of pressure wire and angiography-derived indexes of coronary physiology in the settings of focal, serial, and diffuse lesions, with the addition of intracoronary imaging in selected cases.

Key Words

fractional flow reserve
functional angiography
instantaneous wave-free ratio
intracoronary imaging
percutaneous coronary intervention
quantitative flow ratio

Abbreviations and Acronyms

CAD
coronary artery disease
CFR
coronary flow reserve
dFFR(t)/dt
instantaneous fractional flow reserve gradient per unit time
FFR
fractional flow reserve
iFR
instantaneous wave-free ratio
IVUS
intravascular ultrasound
NHPR
nonhyperemic pressure ratio
OCT
optical coherence tomography
OFR
optical flow ratio
Pa
aortic pressure
PCI
percutaneous coronary intervention
Pd
distal coronary pressure
PPG
pullback pressure gradient
PW
pressure wire
QCA
quantitative coronary analysis
QFR
quantitative flow ratio
QVP
quantitative flow ratio virtual pullback

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The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.

Drs Scarsini and Fezzi contributed equally to this work.