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Aktuelle Kardiologie 2025; 14(02): 141-147
DOI: 10.1055/a-2515-8220
Kurzübersicht

Individualisierte Diagnostik und Therapie im Herzkatheterlabor: wann Funktionsdiagnostik oder Bildgebung?

Personalized Work up in the Cath Lab: When to Use Physiological Assessment or Intravascular Imaging?
Alexandru Patrascu
1   Medizinische Klinik I, HELIOS Klinikum Pforzheim GmbH, Pforzheim, Deutschland (Ringgold ID: RIN15006)
,
Feraas AlFarwan
1   Medizinische Klinik I, HELIOS Klinikum Pforzheim GmbH, Pforzheim, Deutschland (Ringgold ID: RIN15006)
,
Ilka Ott
1   Medizinische Klinik I, HELIOS Klinikum Pforzheim GmbH, Pforzheim, Deutschland (Ringgold ID: RIN15006)
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Zusammenfassung

Die Koronarangiografie stellt nach wie vor den Goldstandard bei der Diagnostik der koronaren Herzerkrankung dar. Ihre Limitationen in Bezug auf die Evaluation prognostischer Bedeutung intermediärer Stenosen oder die morphologische Beurteilung komplexer Läsionen haben zur Entwicklung invasiver physiologischer Messungen sowie der intravaskulären Bildgebung geführt. Sowohl die Funktionsdiagnostik als auch die intrakoronare Bildgebung sind aus der modernen interventionellen Kardiologie nicht mehr wegzudenken und helfen bei der Auswahl von Patienten für eine Revaskularisierung und bei der Optimierung der perkutanen Koronarintervention. Das pathophysiologische Zusammenspiel zwischen der hämodynamischen Relevanz und der Plaquemorphologie bietet einen Mehrwert für die Festlegung der diagnostischen Strategie, was individuell vom behandelnden Kardiologen beurteilt werden muss.

Abstract

Coronary angiography remains the gold standard in the diagnosis of coronary artery disease (CAD). Its limitations with regard to the evaluation of the prognostic significance of intermediate stenoses or morphological assessment of complex lesions have led to the development of invasive physiological measurements and intravascular imaging. Both methods have become indispensable in modern interventional cardiology and help in the selection of patients for revascularization, and with PCI optimization. The pathophysiological interplay between hemodynamic status and plaque morphology can offer added value for one or the other diagnostic strategy, but this must be assessed individually by the treating cardiologist.

Was ist wichtig?

  • Die Koronarangiografie stellt der Goldstandard in der invasiven Diagnostik der koronaren Herzkrankheit dar, entspricht jedoch einem Luminogramm und erlaubt weder die physiologische Beurteilung der hämodynamischen Relevanz von Koronarstenosen noch die Charakterisierung der Plaquemorphologie.

  • Methoden der invasiven Funktionsdiagnostik, FFR (fraktionierte Flussreserve) und iFR (Instantaneous Wave-free Ratio) geben wichtige Rückschlüsse auf die Relevanz intermediärer Stenosen und helfen bei der Entscheidungsfindung für oder gegen Revaskularisierung.

  • Die intravaskuläre Bildgebung erlaubt die genaue morphologische Beurteilung höhergradiger Koronarstenosen, steuert Interventionen und ermöglicht die Ergebnisoptimierung.

  • Die Frage, „wann Funktionsdiagnostik oder Bildgebung“ verwendet werden sollen, kann nur individuell beantwortet werden und hängt von einer Vielzahl an Faktoren ab.

Schlüsselwörter

intravaskulärer Ultraschall - fraktionierte Flussreserve - optische Kohärenztomografie

Keywords

intravascular ultrasound - optical coherence tomography - fractional flow reserve


Publication History

Article published online:
02 April 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • Literatur

  • 1 Ryan TJ. The coronary angiogram and its seminal contribution to cardiovascular medicine over five decades. Circulation 2002; 106: 752-756
    CrossrefPubMedSearch in Google Scholar
  • 2 Nogic J, Prosser H, O’Brien J. et al. The assessment of intermediate coronary lesions using intracoronary imaging. Cardiovasc Diag Ther 2020; 10: 1445-1460
    CrossrefPubMedSearch in Google Scholar
  • 3 Lee CH, Hur SH. Optimization of Percutaneous Coronary Intervention Using Optical Coherence Tomography. Korean Circ J 2019; 49: 771-793
    CrossrefPubMedSearch in Google Scholar
  • 4 Vrints C, Andreotti F, Koskinas KC. ESC Scientific Document Group. et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 2024; 45: 3415-3537
    CrossrefPubMedSearch in Google Scholar
  • 5 Anderson HV, Roubin GS, Leimgruber PP. et al. Measurement of transstenotic pressure gradient during percutaneous transluminal coronary angioplasty. Circulation 1986; 73: 1223-1230
    CrossrefPubMedSearch in Google Scholar
  • 6 De Bruyne B, Pijls NH, Paulus WJ. et al. Transstenotic coronary pressure gradient measurement in humans: In vitro and in vivo evaluation of a new pressure monitoring angioplasty guide wire. J Am Coll Cardiol 1993; 22: 119-126
    CrossrefPubMedSearch in Google Scholar
  • 7 Tonino PA, De Bruyne B, Pijls NH. FAME Study Investigators. et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009; 360: 213-224
    CrossrefPubMedSearch in Google Scholar
  • 8 De Bruyne B, Pijls NH, Kalesan B. FAME 2 Trial Investigators. et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012; 367: 991-1001
    CrossrefPubMedSearch in Google Scholar
  • 9 Fearon WF, Zimmermann FM, De Bruyne B. FAME 3 Investigators. et al. Fractional Flow Reserve-Guided PCI as Compared with Coronary Bypass Surgery. N Engl J Med 2022; 386: 128-137
    CrossrefPubMedSearch in Google Scholar
  • 10 Puymirat E, Cayla G, Simon T. FLOWER-MI Study Investigators. et al. Multivessel PCI Guided by FFR or Angiography for Myocardial Infarction. N Engl J Med 2021; 385: 297-308
    CrossrefPubMedSearch in Google Scholar
  • 11 Götberg M, Christiansen EH, Gudmundsdottir IJ. iFR-SWEDEHEART Investigators. et al. Instantaneous Wave-free Ratio versus Fractional Flow Reserve to Guide PCI. N Engl J Med 2017; 376: 1813-1823
    CrossrefPubMedSearch in Google Scholar
  • 12 Malmberg S, Lauermann J, Karlström P. et al. Resting Full-Cycle Ratio versus Fractional Flow Reserve: A SWEDEHEART-Registry-Based Comparison of Two Physiological Indexes for Assessing Coronary Stenosis Severity. J Interv Cardiol 2023; 2023
    CrossrefPubMedSearch in Google Scholar
  • 13 Toth GG, Toth B, Johnson NP. et al. Revascularization Decisions in Patients With Stable Angina and Intermediate Lesions. Circ Cardiovas. Interv 2014; 7: 751-759
    CrossrefPubMedSearch in Google Scholar
  • 14 Xu B, Tu S, Qiao S. et al. Diagnostic Accuracy of Angiography-Based Quantitative Flow Ratio Measurements for Online Assessment of Coronary Stenosis. J Am Coll Cardiol 2017; 70: 3077-3087
    CrossrefPubMedSearch in Google Scholar
  • 15 Westra J, Tu S, Winther S. et al. Evaluation of Coronary Artery Stenosis by Quantitative Flow Ratio During Invasive Coronary Angiography: The WIFI II Study (Wire-Free Functional Imaging II). Circ Cardiovasc Imaging 2018; 11
    CrossrefPubMedSearch in Google Scholar
  • 16 Kanaji Y, Murai T, Yonetsu T. et al. Effect of elective percutaneous coronary intervention on hyperhemic absolute coronary blood flow volume and microvascular resistance. Circ Cardiovasc Interv 2017; 10
    CrossrefPubMedSearch in Google Scholar
  • 17 Lee JM, Choi KH, Song YB. RENOVATE-COMPLEX-PCI Investigators. et al. Intravascular Imaging-Guided or Angiography-Guided Complex PCI. N Engl J Med 2023; 388: 1668-1679
    CrossrefPubMedSearch in Google Scholar
  • 18 Neumann FJ, Sousa-Uva M, Ahlsson A. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40: 87-165
    CrossrefPubMedSearch in Google Scholar
  • 19 Byrne RA, Rossello X, Coughlan JJ. ESC Scientific Document Group. et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44: 3720-3826
    CrossrefPubMedSearch in Google Scholar
  • 20 Abizaid A, Mintz GS, Pichard AD. et al. Clinical, intravascular ultrasound, and quantitative angiographic determinants of the coronary flow reserve before and after percutaneous transluminal coronary angioplasty. Am J Cardiol 1998; 82: 423-428
    CrossrefPubMedSearch in Google Scholar
  • 21 Kim N, Lee JH, Jang SY. et al. Intravascular modality-guided versus angiography-guided percutaneous coronary intervention in acute myocardial infarction. Catheter Cardiovasc Interv 2020; 95: 696-703
    CrossrefPubMedSearch in Google Scholar
  • 22 Cameron A, Kemp jr HG, Fisher LD. et al. Left main coronary artery stenosis: Angiographic determination. Circulation 1983; 68: 484-489
    CrossrefPubMedSearch in Google Scholar
  • 23 Andell P, Karlsson S, Mohammad MA. et al. Intravascular Ultrasound Guidance Is Associated With Better Outcome in Patients Undergoing Unprotected Left Main Coronary Artery Stenting Compared With Angiography Guidance Alone. Circ Cardiovasc Interv 2017; 10
    CrossrefPubMedSearch in Google Scholar
  • 24 Cameron A, Kemp jr HG, Fisher LD. et al. Left main coronary artery stenosis: Angiographic determination. Circulation 1983; 68: 484-489
    CrossrefPubMedSearch in Google Scholar
  • 25 Kim BK, Shin DH, Hong MK. et al. Clinical Impact of Intravascular Ultrasound-Guided Chronic Total Occlusion Intervention With Zotarolimus-Eluting Versus Biolimus-Eluting Stent Implantation. Circ Cardiovasc Interv 2015; 8
    CrossrefPubMedSearch in Google Scholar
  • 26 Prati F, Regar E, Mintz GS. et al. Expert review document on methodology, terminology, and clinical applications of optical coherence tomography: Physical principles, methodology of image acquisition, and clinical application for assessment of coronary arteries and atherosclerosis. Eur Heart J 2010; 31: 401-415
    CrossrefPubMedSearch in Google Scholar
  • 27 Holm NR, Adriaenssens T, Motreff P. et al. OCT for bifurcation stenting: What have we learned?. EuroIntervention 2015; 11: V64-V70
    CrossrefPubMedSearch in Google Scholar
  • 28 Adriaenssens T, Joner M, Godschalk TC. et al. Optical Coherence Tomography Findings in Patients With Coronary Stent Thrombosis: A Report of the PRESTIGE Consortium (Prevention of Late Stent Thrombosis by an Interdisciplinary Global European Effort). Circulation 2017; 136: 1007-1021
    CrossrefPubMedSearch in Google Scholar
  • 29 Yu W, Huang J, Jia D. et al. Diagnostic accuracy of intracoronary optical coherence tomography-derived fractional flow reserve for assessment of coronary stenosis severity. EuroIntervention 2019; 15: 189-197
    CrossrefPubMedSearch in Google Scholar
  • 30 Kang DY, Ahn JM, Yun SC. et al. Optical Coherence Tomography-Guided or Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: The OCTIVUS Randomized Clinical Trial. Circulation 2023; 148: 1195-1206
    CrossrefPubMedSearch in Google Scholar
  • 31 Yang S, Koo BK, Narula J. Interactions between morphological plaque characteristics and coronary physiology: from pathophysiological basis to clinical implications. JACC Cardiovasc Imaging 2022; 15: 1139-1151
    CrossrefPubMedSearch in Google Scholar
  • 32 Holm NR, Andreasen LN, Neghabat O. OCTOBER Trial Group. et al. OCT or Angiography Guidance for PCI in Complex Bifurcation Lesions. N Engl J Med 2023; 389: 1477-1487
    CrossrefPubMedSearch in Google Scholar
  • 33 Hwang D, Koo BK, Zhang J. et al. Prognostic implications of fractional flow reserve after coronary stenting: a systematic review and meta-analysis. JAMA Netw Open 2022; 5
    CrossrefPubMedSearch in Google Scholar
  • 34 Scarsini R, Fezzi S, Leone AM. et al. Functional patterns of coronary disease: diffuse, focal, and serial lesions. JACC Cardiovasc Interv 2022; 15: 2174-2191
    CrossrefPubMedSearch in Google Scholar
  • 35 Iannaccone M, Abdirashid M, Annone U. et al. Comparison between functional and intravascular imaging approaches guiding percutaneous coronary intervention: a network meta-analysis of randomized and propensity matching studies. Catheter Cardiovasc Interv 2020; 95: 1259-1266
    CrossrefPubMedSearch in Google Scholar
  • 36 Burzotta F, Leone AM, Aurigemma C. et al. Fractional flow reserve or optical coherence tomography to guide management of angiographically intermediate coronary stenosis: a single-center trial. J Am Coll Cardiol Interv 2020; 13: 49-58
    CrossrefPubMedSearch in Google Scholar
  • 37 Koo BK, Hu X, Kang J. et al. Fractional flow reserve or intravascular ultrasonography to guide PCI. N Engl J Med 2022; 387: 779-789
    CrossrefPubMedSearch in Google Scholar