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Computertomographie bei Patienten mit stabiler Angina Pectoris

Messung der fraktionellen Flussreserve

Computed tomography in patients with chronic stable angina

Fractional flow reserve measurement

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Zusammenfassung

Die koronare CT-Angiographie (cCTA) hat sich als nichtinvasive Methode zur direkten Darstellung von Erkrankungen der Herzkranzgefäße (KHK) etabliert. Mithilfe dieses Verfahrens konnte in früheren Studien eine KHK mit hoher Wahrscheinlichkeit ausgeschlossen werden. Limitierend beim Einsatz der cCTA erscheint jedoch, dass sich viele visuell signifikant eingeschätzte Stenosen, gemessen an der invasiv ermittelbaren fraktionellen Flussreserve (FFR), als nicht hämodynamisch relevant erweisen. Als eine im Vergleich zur myokardialen CT-Perfusion vielversprechende Methode zur besseren Erfassung der funktionellen Bedeutung von Koronarstenosen stellt sich die auf Erkenntnissen der numerischen Strömungsmechanik und bildbasierter Simulation beruhende, CT-basierte FFR (CT-FFR) dar. Die CT-FFR kann aus regulären CT-Datensätzen, ohne zusätzliche Bildakquisition, Kontrastmittel- oder Medikamentengabe, bestimmt werden. Es werden zwei unterschiedliche Techniken zur Ermittlung der CT-FFR unterschieden. Das initiale Verfahren erfordert eine externe CT-FFR-Berechnung durch Hochleistungsrechner, wobei die behördliche Zulassung hierfür in den USA bereits erfolgt ist. Andererseits wurde ein Software-Prototyp beschrieben, der aufgrund der Integration vereinfachter Berechnungsmodelle geringere Rechnerkapazität erfordert und somit eine intrahospitale Anwendungsmöglichkeit bietet. Im folgenden Beitrag werden diese Verfahren im Kontext mit den jeweiligen Studienergebnissen und den Daten der Metaanalysen dargestellt. Des Weiteren werden sowohl methodische Einschränkungen und Zukunftsperspektiven der CT-FFR aufgezeigt.

Abstract

Coronary computed tomography angiography (cCTA) has been established for the non-invasive diagnosis of coronary artery disease (CAD). Previous studies demonstrated the high diagnostic accuracy of cCTA, particularly for ruling out CAD. As a known limitation of cCTA a large number of visually significant coronary stenoses are found to be hemodynamically not relevant by invasive fractional flow reserve (FFR). CT-based FFR (CT-FFR) builds on recent advances in computational fluid dynamics and image simulation techniques. Along with CT myocardial perfusion imaging, CT-FFR is a promising approach towards a more accurate estimation of the hemodynamic relevance of coronary artery stenoses. CT-FFR is derived from regular CT datasets without additional image acquisitions, contrast material, or medication. Two CT-FFR techniques can be differentiated. The initial method requires external use of supercomputers and has gained approval for clinical use in the USA. Furthermore, a prototype-software has been introduced which is less computationally demanding via integration of reduced-order models for on-site calculation of CT-FFR. The present article reviews these methods in the context of available study results and meta-analyses. Furthermore, limitations and future concepts of CT-FFR are discussed.

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Authors and Affiliations

  1. Abteilung für Kardiologie, Kerckhoff-Klinik, Bad Nauheim, Deutschland

    M. Renker, W. Kim, A. Rolf & C. W. Hamm

  2. Heart & Vascular Center, Medical University of South Carolina, Charleston, SC, USA

    U. J. Schoepf

  3. I.Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und DZHK (Deutsches Zentrum für Herz-Kreislaufforschung), Theodor-Kutzer-Ufer 1–3, 68167, Mannheim, Deutschland

    T. Becher, N. Krampulz, M. Borggrefe, I. Akin & S. Baumann

  4. Klinik für Innere Medizin I, St.-Johannes-Hospital, Dortmund, Deutschland

    H. Möllmann

  5. Institut für Klinische Radiologie und Nuklearmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Heidelberg, Deutschland

    T. Henzler

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  1. M. Renker
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Correspondence to M. Renker.

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Interessenkonflikt

U. J. Schoepf erhält Forschungsmittel und/oder Honorare von Astellas (Tokyo, Japan), Bayer (Wayne, NJ, USA), Bracco (Princeton, NJ, USA), GE Healthcare (Little Chalfont, Buckinghamshire, UK), Guerbet (Villepinte, Frankreich), Medrad (Warrendale, PA, USA) und Siemens Healthcare (Malvern, PA, USA). H. Möllmann erhält Beratungs- und Vortragshonorare von St. Jude Medical (St. Paul, MN, USA). M. Renker, T. Becher, N. Krampulz, W. Kim, A. Rolf, C. W. Hamm, T. Henzler, M. Borggrefe, I. Akin und S. Baumann geben an, dass kein Interessenkonflikt besteht. Messungen der CT-basierten fraktionellen Flussreserve in den Bildbeispielen wurden nicht in den USA erhoben.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Renker, M., Schoepf, U.J., Becher, T. et al. Computertomographie bei Patienten mit stabiler Angina Pectoris. Herz 42, 51–57 (2017). https://doi.org/10.1007/s00059-016-4433-5

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