Quantification of the Effect of Pressure Wire Drift on the Diagnostic Performance of Fractional Flow Reserve, Instantaneous Wave-Free Ratio, and Whole-Cycle Pd/Pa

Effect of prolonged pressure equalization on final drifting during pressure wire studies

Pressure drifting is a troublesome error in invasive coronary function tests. This study aimed to evaluate the relationship between prolonged and short-time pressure equalizations in pressure drifting. Pressure drifting was defined as the pressure gradient between the mean pressure of the distal wire sensor (Pd) and aortic pressure (Pa) when the wire was withdrawn to the tip of the guiding catheter. Significant drifts 1 and 2 were defined as the absolute values of pressure gradients > 2 and > 3 mmHg, respectively. A logistic regression model was used to evaluate the associations between prolonged pressure equalization and each pressure drifting. The prolonged pressure equalization strategy was associated with a lower incidence of drift 1 than the short-time pressure equalization strategy (6.84% vs. 16.92%, p < 0.05). However, no statistical differences were found in the incidence of drift 2 between the prolonged and short-time pressure equalization strategies (4.27% vs. 7.69%, p = 0.34). In the multivariable regression model, only the prolonged pressure equalization strategy predicted a lower incidence of pressure drift 1. In conclusion, the prolonged pressure equalization strategy was associated with a lower incidence of significant pressure drifting with more stringent thresholds than the short-time pressure equalization strategy.

Assessment of the functional severity of coronary lesions from optical coherence tomography based on ensembled learning

BACKGROUND

Atherosclerosis is one of the most frequent cardiovascular diseases. The dilemma faced by physicians is whether to treat or postpone the revascularization of lesions that fall within the intermediate range given by an invasive fractional flow reserve (FFR) measurement. The paper presents a monocentric study for lesions significance assessment that can potentially cause ischemia on the large coronary arteries.

METHODS

A new dataset is acquired, comprising the optical coherence tomography (OCT) images, clinical parameters, echocardiography and FFR measurements collected from 80 patients with 102 lesions, with stable multivessel coronary artery disease. Having the ground truth given by the invasive FFR measurement, the dataset is challenging because almost 40% of the lesions are in the gray zone, having an FFR value between 0.75 and 0.85. Twenty-six features are extracted from OCT images, clinical characteristics, and echocardiography and the most relevant are identified by examining the models' accuracy. An ensembled learning is performed for solving the binary classification problem of lesion significance considering the leave-one-out cross-validation approach.

RESULTS

Ensemble models are designed from the multi-features voting from 5 features models by prediction aggregation with a maximum accuracy of 81.37% and a maximum area under the curve score (AUC) of 0.856.

CONCLUSIONS

The proposed explainable supervised learning-based lesion classification is a new method that can be improved by training with a larger multicenter dataset for further designing a tool for guiding the decision making of the clinician for the cases outside the gray zone and for the other situation extra clinical information about the lesion is needed.

Coronary Physiology: Modern Concepts for the Guidance of Percutaneous Coronary Interventions and Medical Therapy

Recent evidence on ischemia, rather than coronary artery disease (CAD), representing a major determinant of outcomes, has led to a progressive shift in the management of patients with ischemic heart disease. According to most recent guidelines, myocardial revascularization strategies based on anatomical findings should be progressively abandoned in favor of functional criteria for the guidance of PCI. Thus, emerging importance has been assigned to the assessment of coronary physiology in order to determine the ischemic significance of coronary stenoses. However, despite several indexes and tools that have been developed so far, the existence of technical and clinical conditions potentially biasing the functional evaluation of the coronary tree still cause debates regarding the strategy of choice. The present review provides an overview of the available methods and the most recent acquirements for the invasive assessment of ischemia, focusing on the most widely available indexes, fractional flow reserve (FFR) and instant-wave free ratio (iFR), in addition to emerging examples, as new approaches to coronary flow reserve (CFR) and microvascular resistance, aiming at promoting the knowledge and application of those "full physiology" principles, which are generally advocated to allow a tailored treatment and the achievement of the largest prognostic benefits.

Understanding the Basis for Hyperemic and Nonhyperemic Coronary Pressure Assessment

Despite the now routine integration of invasive physiologic systems into coronary catheter laboratories worldwide, it remains critical that all operators maintain a sound understanding of the fundamental physiologic basis for coronary pressure assessment. More specifically, performing operators should be well informed regarding the basis for hyperemic (ie, fractional flow reserve) and nonhyperemic (ie, instantaneous wave-free ratio and other nonhyperemic pressure ratio) coronary pressure assessment. In this article, we provide readers a comprehensive history charting the inception, development, and validation of hyperemic and nonhyperemic coronary pressure assessment.

Novel Method to Detect Pitfalls of Intracoronary Pressure Measurements by Pressure Waveform Analysis

Potential pitfalls of fractional flow reserve (FFR) measurements are well-known drawbacks of invasive physiology measurement, e.g., significant drift of the distal pressure trace may lead to the misclassification of stenoses. Thus, a simultaneous waveform analysis of the pressure traces may be of help in the quality control of these measurements by online detection of such artefacts as the drift or the wedging of the catheter. In the current study, we analysed the intracoronary pressure waveform with a dedicated program. In 130 patients, 232 FFR measurements were performed and derivative pressure curves were calculated. Local amplitude around the dicrotic notch was calculated from the distal intracoronary pressure traces (δdP_n/dt). A unidimensional arterial network model of blood flow was employed to simulate the intracoronary pressure traces at different flow rates. There was a strong correlation between δdP_n/dt values measured during hyperaemia and FFR (r = 0.88). Diagnostic performance of distal δdP_n/dt ≤ 3.52 for the prediction of FFR ≤ 0.80 was 91%. The correlation between the pressure gradient and the corresponding δdP_n/dt values obtained from all measurements independently of the physiological phase was also significant (r = 0.80). During simulation, the effect of flow rate on δdP_n/dt further supported the close correlation between the pressure ratios and δdP_n/dt. Discordance between the FFR and the δdP_n/dt can be used as an indicator of possible technical problems of FFR measurements. Hence, an online calculation of the δdP_n/dt may be helpful in avoiding some pitfalls of FFR evaluation.

Comparative analysis of instantaneous wave-free ratio and quantitative real-time myocardial contrast echocardiography for the assessment of myocardial perfusion

Background and hypothesis

The field of coronary artery physiology is developing rapidly and changing the practice of interventional cardiology. A new functional evaluation technique using the instantaneous wave-free ratio (iFR) has become an alternative to fractional flow reserve. Future research studies need to determine whether physiological indicators play a role in evaluating myocardial perfusion in the catheter room.

Materials and methods

Thirty-eight patients scheduled for coronary angiography and iFR evaluation underwent a real-time myocardial contrast echocardiography (RT-MCE) examination at rest. The myocardial perfusion parameters (A, β, and A × β) on the myocardial perfusion curve were quantitatively analyzed using Q-Lab software. Coronary angiography and iFR assessment were completed within 1 week after the RT-MCE examination in all patients. Correlation analysis was used to identify iFR- and MCE-related indicators. The sensitivity and specificity of iFR in the quantitative detection of coronary microcirculation were obtained.

Results

The correlation coefficients between iFR and A, β, and A × β were 0.81, 0.66, and 0.82, respectively. The cut-off value for iFR was 0.85 for microvascular ischemia detection, while the sensitivity and specificity for the diagnosis of myocardial perfusion were 90.7 and 89.9%, respectively. The receiver operating characteristic (ROC) curve area for iFR was 0.946 in the segments related to myocardial blood flow.

Conclusion

The iFR is an effective tool for detecting myocardial microcirculation perfusion, with satisfactory diagnostic performance and a demonstrated role in physiological indices used for the perfusion assessment.

Calculation of Intracoronary Pressure-Based Indexes with JLabChart

The Fractional Flow Reserve (FFR) and instantaneous wave-Free Ratio (iFR) have been proposed and clinically validated to measure the pressure gradient across coronary stenoses. They provide quantitative information on stenosis severity. Both are used in coronary revascularization procedures to measure intracoronary pressure giving quantitative information to evaluate coronary diseases during angiographic procedures. We designed and implemented a tool able to acquire and measure iFR and FFR supporting the physicians studying and treating patients in interventional cardiology laboratories. We designed an extensive case study to assess the performance of the tool in (i) acquiring pressure signals from blood pressure measurement systems; (ii) calculating FFR and iFR; and (iii) filtering out extra-beats signals during realtime signal analysis phases. The tool, named JLabChart, is available online. We tested it on two sets of data for a total of 600 cycles from 201 pressure measurements performed on 65 patients, from the Interventional Cardiology Unit of Magna Graecia University. The recognition of cardiac cycles and keypoint of the pressure curve was effective in 100% of cases for proximal (aortic) pressure and in 99.2% for distal pressure. The FFR calculated by JLabChart had an excellent correlation (Rp=0.960; p<0.001) with the FFR values obtained through the commercial systems. Similar results were obtained with iFR (Rp=0.998; p<0.001). Finally, the tool measurement results were compared with a commercial tool proving JLabChart’s efficiency with real cases. It was also compared with measurements performed on synthetic vessels and stenosis designed using the Comsol commercial tool. JLabChart is able to provide reliable measurements of FFR and iFR indexes used to support decisions on interventional procedures. It represents a valuable open source support system that can be used in an interventional cardiology laboratory.

FFR pressure wire comparative study for drift: piezo resistive versus optical sensor

BACKGROUND

This study aimed to assess the stability of pressure derived fractional flow reserve (FFR) measurement and the handling performance of the OptoWire Deux with an optical pressure sensor relative to the PressureWire X with piezo resistive pressure sensors.

METHODS

This multicenter centre observational study included 50 patients between June 2017 and November 2018 undergoing a diagnostic coronary angiography with FFR measurement of moderate to severe lesions. The reliability of FFR measurement measured with the OptoWire Deux relative to the PressureWire X in each lesion was assessed by the presence of drift. Handling characteristics for both pressure wires were assessed by a 5-point scale and by comparing the time between equalization and crossing the distal target lesion.

RESULTS

Hundred and sixteen measurements in 50 patients were performed. Very stable and reliable FFR measurements with the optical sensors were registered, relative to the piezo resistive pressure sensors. There is statistically significant difference in favor of the OptoWire Deux over the PressureWire X (P=0.001). However, the differences are small, when drift values were compared as continuous variables, no statistically significant difference was found for both directional (P=0.435) as for absolute drift (P=0.058).

CONCLUSIONS

In patients undergoing FFR measurement, both optical sensor pressure wires (Optowire Deux) as piezo resistive sensor pressure wires (PressureWire X) generate stable and reliable pressure and thus FFR measurement. The optical pressure sensor is less susceptible for drift relative to the piezo resistive pressure sensor, but the difference is within an acceptable range.

Comparison of Resting Full-Cycle Ratio and Fractional Flow Reserve in a German Real-World Cohort

Objective: The aim of this study was to evaluate non-hyperemic resting pressure ratios (NHPRs), especially the novel “resting full-cycle ratio” (RFR; lowest pressure distal to the stenosis/aortic pressure during the entire cardiac cycle), compared to the gold standard fractional flow reserve (FFR) in a “real-world” setting.

Methods: The study included patients undergoing coronary pressure wire studies at one German University Hospital. No patients were excluded based on any baseline or procedural characteristics, except for insufficient quality of traces. The diagnostic performance of four NHPRs vs. FFR ≤ 0.80 was tested. Morphological characteristics of stenoses were analyzed by quantitative coronary angiography.

Results: 617 patients with 712 coronary lesions were included. RFR showed a significant correlation with FFR (r = 0.766, p < 0.01). Diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of RFR were 78% (95% confidence interval = 75; 81), 72% (65; 78), 81% (77; 84), 63% (57; 69), and 86% (83; 89). Relevant predictors for discordance of RFR ≤ 0.89/FFR > 0.8 were LAD lesions, peripheral artery disease, age, female sex and non-focal stenoses. Predictors for discordance of RFR > 0.89/FFR ≤ 0.8 included non-LCX lesions, percent diameter stenosis and previous percutaneous coronary intervention in the target vessel. RFR and all other NHPRs were highly correlated with each other.

Conclusion: All NHPRs have a similar correlation with the gold standard FFR and may facilitate the acceptance and implementation of physiological assessments of lesion severity. However, we found ~20% discordant results between NHPRs and FFR in our “all-comers” German cohort.

A novel algorithm for the computation of the diastolic pressure ratio in the invasive assessment of the functional significance of coronary artery disease

BACKGROUND

Invasive functional assessment is a mainstay in the management of patients with coronary artery disease (CAD), but there is uncertainty on the comparative accuracy of diagnostic indices of functional significance. We aimed to validate the diagnostic performance of a novel non-hyperemic diastolic pressure ratio (dPR).

METHODS

We performed a retrospective analysis including two separate registries (VERIFY 2, Latina, Italy) of patients in whom functional indices were measured for lesions with angiographically moderate severity. On top of fractional flow reserve, distal coronary pressure (Pd)/aortic pressure (Pa) ratio, instantaneous wave-free ratio (iFR) and diastolic pressure ratio (dPR) were computed using a novel dedicated algorithm over 4 consecutive beats. Agreement/discrepancy between indexes was appraised Bland-Altman analysis, area under the receiver operating characteristic curve (AUC), and unsupervised machine learning.

RESULTS

A total of 525 lesions from 479 patients were included. The novel dPR was highly correlated with iFR (R²=0.99, P<0.001), with a mean difference of -0.004±0.014. The diagnostic performance of dPR (best cutoff value: ≤0.89) against iFR was as follows: accuracy =96%; sensitivity =94%; specificity =97%; positive-predictive value =94%; and negative-predictive value =96%. Additionally, AUC to predict iFR≤0.89 was 0.99, which was significantly higher than that of Pd/Pa (0.97, P<0.001). In the iFR range of 0.85-0.93 ("grey zone"), the diagnostic performance was well maintained (accuracy =91%; sensitivity =87%; specificity =93%; and AUC=0.96). Results were supported also by unsupervised learning analysis.

CONCLUSIONS

This multicenter registry suggests this novel dPR algorithm provides results that are numerically equivalent to iFR. Pending further studies, physicians may consider using this novel dPR algorithm to gauge the functional significance of a coronary lesion.

Optimising physiological endpoints of percutaneous coronary intervention

Invasive coronary physiology to select patients for coronary revascularisation has become established in contemporary guidelines for the management of stable coronary artery disease. Compared to revascularisation based on angiography alone, the use of coronary physiology has been shown to improve clinical outcomes and cost efficiency. However, recent data from randomised controlled trials have cast doubt upon the value of ischaemia testing to select patients for revascularisation. Importantly, 20-40% of patients have persistence or recurrence of angina after angiographically successful percutaneous coronary intervention (PCI). This state-of-the-art review is focused on the transitioning role of invasive coronary physiology from its use as a dichotomous test for ischaemia with fixed cut-points, towards its utility for real-time guidance of PCI to optimise physiological results. We summarise the contemporary evidence base for ischaemia testing in stable coronary artery disease, examine emerging indices which allow advanced physiological guidance of PCI, and discuss the rationale and evidence base for post-PCI physiological assessments to assess the success of revascularisation.

Assessing the Accuracy of a second-generation optical sensor pressor wire in a wire to wire comparison (The ACCURACY study)

BACKGROUND

The phenomenon of "pressure drift" increases uncertainty about the correct FFR value. Redesigned and incorporating an optical pressure sensor, the "OptoWire Deux™" is purported to be less prone to the pressure drift seen with piezoelectric coronary pressure wires. The aim of this first in vivo real-world clinical study is to evaluate the performance of OptoWire Deux™ in terms of measurements agreement and propensity to pressure drift in a wire to wire comparison.

METHODS

This is a single center, prospective, non-blinded clinical investigation enrolling 45 consecutive patients with a clinical indication for coronary lesion FFR assessment. Lesions were either simultaneously assessed with two optical sensor pressure wires (OSPW) (Group O-O; 30 patients, 34 lesions) or one OSPW and one piezoelectric pressure wire (PEPW) simultaneously (Group O-P; 15 patients, 15 lesions). Significant drift was defined as a pressure ratio deviation of >0.03.

RESULTS

Mean FFR measurements in Group OO were not statistically different between the two sets of OSPW (overall 0.84±0.10; P = 0.52). In Group OP, however, mean FFR measurement with PEPW (0.85±0.09) was numerically lower than that observed with the OSPW (0.88±0.08; P = 0.09). Level of agreement using the Bland-Altman method was higher when 2 OSPW were used for FFR assessment (-0.002 95% CI [-0.033,0.029] vs. 0.026 95% CI [-0.078, 0.130], respectively). The rate of drift was significantly lower with an OSPW compared to a PEPW (4.8% vs. 26.7% respectively, P = 0.02).

CONCLUSION

The optical sensor guidewire showed a high level of readings' agreement after simultaneous usage of 2 optical sensor guidewires. There was also significantly less drift when compared to a piezoelectric guidewire.

Coronary angiography-derived contrast fractional flow reserve

BACKGROUND

Based on coronary angiography and mean aortic pressure, a specially designed computational flow dynamics (CFD) method is proposed to determine contrast fractional flow reserve (cFFR) without using invasive pressure wire. This substudy assessed diagnostic performance of coronary angiography-derived cFFR in catheterization laboratory, based on a previous multicenter trial for online assessment of coronary angiography-derived FFR (caFFR).

METHODS

Patients with diagnosis of stable angina pectoris or unstable angina pectoris were enrolled in six centers. Wire-based FFR was measured in coronary arteries with 30-90% diameter stenosis. Offline angiography-derived cFFR was computed in blinded fashion against the wire-based FFR and caFFR at an independent core laboratory.

RESULTS

A total of 330 patients were enrolled to fulfill inclusion/exclusion criteria from June 26 to December 18, 2018. Offline angiography-derived cFFR and wire-based FFR results were compared in 328 interrogated vessels. The statistical analysis showed the highest diagnostic accuracy of 89.0 and 86.6% for angiography-derived cFFR with a cutoff value of 0.94 and 0.93 against the wire-based FFR with a cutoff value of 0.80 and 0.75, respectively. The corresponding sensitivity and specificity were 92.2 and 87.3% for the cutoff value of 0.94 and 80.0 and 88.4% for the cutoff value of 0.93, which are similar to those against the caFFR. The receiver-operating curve has area under the curve of 0.951 and 0.972 for the wire-based FFR with the cutoff value of 0.80 and 0.75, respectively.

CONCLUSIONS

Coronary angiography-derived cFFR showed higher accuracy, sensitivity, and specificity against wired-based FFR and caFFR. Hence, angiography-derived cFFR could enhance the hemodynamic assessment of coronary lesions.

Physiology-Based Revascularization of Left Main Coronary Artery Disease

It is of critical importance to correctly assess the significance of a left main lesion. Underestimation of significance beholds the risk of inappropriate deferral of revascularization, whereas overestimation may trigger major but unnecessary interventions. This article addresses the invasive physiological assessment of left main disease and its role in deciding upon revascularization. It mainly focuses on the available evidence for fractional flow reserve and instantaneous wave-free ratio, their interpretation, and limitations. We also discuss alternative invasive physiological indices and imaging, as well as the link between physiology, ischemia, and prognosis.

Coronary Angiography-Derived Diastolic Pressure Ratio

Aims

Based on the aortic pressure waveform, a specially designed computational fluid dynamic (CFD) method was proposed to determine coronary angiography-derived diastolic pressure ratio (caDPR) without using invasive pressure wire. The aim of the study is to retrospectively assess diagnostic performance of the caDPR in the catheterization laboratory, based on a previous multicenter trial for online assessment of coronary angiography-derived FFR (caFFR).

Methods and Results

Patients with diagnosis of stable or unstable angina pectoris were enrolled in six centers. Wire-derived FFR was measured in coronary arteries with 30–90% diameter stenosis. Offline caDPR was assessed in blinded fashion against wire-derived FFR at an independent core laboratory. A total of 330 patients who met the inclusion/exclusion criteria were enrolled from June 26 to December 18, 2018. Offline computed caDPR and wire-derived FFR were compared in 328 interrogated vessels. The caDPR with a cutoff value of 0.89 shows diagnostic accuracy of 87.7%, sensitivity of 89.5%, specificity of 86.8%, and AUC of 0.940 against the wire-derived FFR with a cutoff value of 0.80.

Conclusions

Using wired-based FFR as the standard reference, there is good diagnostic performance of the novel-CFD-design caDPR. Hence, caDPR could enhance the hemodynamic assessment of coronary lesions.

Algorithmic Versus Expert Human Interpretation of Instantaneous Wave-Free Ratio Coronary Pressure-Wire Pull Back Data

Objectives

The aim of this study was to investigate whether algorithmic interpretation (AI) of instantaneous wave-free ratio (iFR) pressure-wire pull back data would be noninferior to expert human interpretation.

Background

Interpretation of iFR pressure-wire pull back data can be complex and is subjective.

Methods

Fifteen human experts interpreted 1,008 iFR pull back traces (691 unique, 317 duplicate). For each trace, experts determined the hemodynamic appropriateness for percutaneous coronary intervention (PCI) and, in such cases, the optimal physiological strategy for PCI. The heart team (HT) interpretation was determined by consensus of the individual expert opinions. The same 1,008 pull back traces were also interpreted algorithmically. The coprimary hypotheses of this study were that AI would be noninferior to the interpretation of the median expert human in determining: 1) the hemodynamic appropriateness for PCI; and 2) the physiological strategy for PCI.

Results

Regarding the hemodynamic appropriateness for PCI, the median expert human demonstrated 89.3% agreement with the HT in comparison with 89.4% for AI (p < 0.01 for noninferiority). Across the 372 cases judged as hemodynamically appropriate for PCI according to the HT, the median expert human demonstrated 88.8% agreement with the HT in comparison with 89.7% for AI (p < 0.0001 for noninferiority). On reproducibility testing, the HT opinion itself changed 1 in 10 times for both the appropriateness for PCI and the physiological PCI strategy. In contrast, AI showed no change.

Conclusions

AI of iFR pressure-wire pull back data was noninferior to expert human interpretation in determining both the hemodynamic appropriateness for PCI and the optimal physiological strategy for PCI.

All Resting Physiological Indices May Not Be Equivalent - Comparison Between the Diastolic Pressure Ratio and Resting Full-Cycle Ratio

BACKGROUND

Differences between resting full-cycle ratio (RFR) and diastolic pressure ratio (dPR) have not been sufficiently discussed. This study aimed to investigate if there is a difference in diagnostic performance between RFR and dPR for the functional lesion assessment and to assess if there are specific characteristics for discordant revascularization decision-makings between RFR and dPR.Methods and Results:A total of 936 intermediate lesions in 776 patients who underwent measurements of fractional flow reserve (FFR), coronary flow reserve (CFR), and the index of microcirculatory resistance (IMR) were retrospectively studied. Physiological indices were measured from anonymized pressure recordings at an independent core laboratory. Both RFR and dPR measures were highly correlated (r=0.997, P<0.001), with equivalent diagnostic performance relative to FFR-based decision-makings measured by using a dichotomous threshold of 0.80 (accuracy, 79.7% vs. 80.1%, respectively, P=0.960). The rate of diagnostic discordance was 4.7% (44/936), with no RFR-/dPR+ lesions observed. An overall significant difference in FFR and CFR values were detected among RFR/dPR-based classifications. The prevalence of positive studies was significantly higher for RFR than dPR (54.3% vs. 49.6%, respectively, P=0.047) when using the cut-off value of 0.89.

CONCLUSIONS

Both RFR and dPR were highly correlated, but the prevalence of positive studies was significantly different. The revascularization rate may differ significantly according to the resting index used.

Physiological Pattern of Disease Assessed by Pressure-Wire Pullback Has an Influence on Fractional Flow Reserve/Instantaneous Wave-Free Ratio Discordance

BACKGROUND

Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) disagree on the hemodynamic significance of a coronary lesion in ≈20% of cases. It is unknown whether the physiological pattern of disease is an influencing factor for this. This study assessed whether the physiological pattern of coronary artery disease influences discordance between FFR and iFR measurement.

METHODS AND RESULTS

Three-hundred and sixty intermediate coronary lesions (345 patients; mean age, 64.4±10.3 years; 76% men) with combined FFR, iFR, and iFR pressure-wire pullback were included for analysis from an international multicenter registry. Cut points for hemodynamic significance were FFR ≤0.80 and iFR ≤0.89, respectively. Lesions were classified into FFR+/iFR+ (n=154; 42.7%), FFR-/iFR+ (n=38; 10.6%), FFR+/iFR- (n=41; 11.4%), and FFR-/iFR- (n=127; 35.3%) groups. The physiological pattern of disease was classified according to the iFR pullback recordings as predominantly physiologically focal (n=171; 47.5%) or predominantly physiologically diffuse (n=189; 52.5%). Median FFR and iFR were 0.80 (interquartile range, 0.75-0.85) and 0.89 (interquartile range, 0.86-0.92), respectively. FFR disagreed with iFR in 22% (79 of 360). The physiological pattern of disease was the only influencing factor relating to FFR/iFR discordance: predominantly physiologically focal was significantly associated with FFR+/iFR- (58.5% [24 of 41]), and predominantly physiologically diffuse was significantly associated with FFR-/iFR+ (81.6% [31 of 38]; P<0.001 for pattern of disease between FFR+/iFR- and FFR-/iFR+ groups).

CONCLUSIONS

The physiological pattern of coronary artery disease was an important influencing factor for FFR/iFR discordance.

Novel Indices of Coronary Physiology

Fractional flow reserve is the current invasive gold standard for assessing the ischemic potential of an angiographically intermediate coronary stenosis. Procedural cost and time, the need for coronary vessel instrumentation, and the need to administer adenosine to achieve maximal hyperemia remain integral components of invasive fractional flow reserve. The number of new alternatives to fractional flow reserve has proliferated over the last ten years using techniques ranging from alternative pressure wire metrics to anatomic simulation via angiography or intravascular imaging. This review article provides a critical description of the currently available or under-development alternatives to fractional flow reserve with a special focus on the available evidence, pros, and cons for each with a view towards their clinical application in the near future for the functional assessment of coronary artery disease.

Optimizing the Technique for Invasive Fractional Flow Reserve to Assess Lesion-Specific Ischemia

Background:

Invasive fractional flow reserve (FFR INV ) is the standard technique for assessing myocardial ischemia. Pressure distortions and measurement location may influence FFR INV interpretation. We report a technique for performing invasive fractional flow reserve (FFR INV ) by minimizing pressure distortions and identifying the proper location to measure FFR INV .

Methods:

FFR INV recordings were obtained prospectively during manual hyperemic pullback in 100 normal and diseased coronary arteries with single stenosis, using 4 measurements from the terminal vessel, distal-to-the-lesion, proximal vessel, and guiding catheter. FFR INV profiles were developed by plotting FFR INV values ( y -axis) and site of measurement ( x -axis), stratified by stenosis severity. FFR INV ≤0.8 was considered positive for lesion-specific ischemia.

Results:

Erroneous FFR INV values were observed in 10% of vessels because of aortic pressure distortion and in 21% because of distal pressure drift; these were corrected by disengagement of the guiding catheter and re-equalization of distal pressure/aortic pressure, respectively. There were significant declines in FFR INV from the proximal to the terminal vessel in normal and stenotic coronary arteries ( P <0.001). The rate of positive FFR INV was 41% when measured from the terminal vessel and 20% when measured distal-to-the-lesion ( P <0.001); 41.5% of positive terminal measurements were reclassified to negative when measured distal-to-the-lesion. Measuring FFR INV 20 to 30 mm distal-to-the-lesion (rather than from the terminal vessel) can reduce errors in measurement and optimize the assessment of lesion-specific ischemia.

Conclusions:

Meticulous technique (disengagement of the guiding catheter, FFR INV pullback) is required to avoid erroneous FFR INV , which occur in 31% of vessels. Even with optimal technique, FFR INV values are influenced by stenosis severity and the site of pressure measurement. FFR INV values from the terminal vessel may overestimate lesion-specific ischemia, leading to unnecessary revascularization.

Diagnostic Performance of the Instantaneous Wave-Free Ratio: Comparison With Fractional Flow Reserve

BACKGROUND

Aim of the present study was to perform a meta-analysis of all available studies comparing the instantaneous wave-free ratio (iFR) with fractional flow reserve (FFR).

METHODS AND RESULTS

Published trials comparing the iFR with FFR were searched for in PubMed, Google Scholar, and Scopus electronic databases. A total of 23 studies were available for the analysis, including 6381 stenoses. First, a meta-analysis of all studies was performed exploring the correlation between FFR and iFR. Interestingly, we found good correlation (0.798 [0.78-0.82]) between the 2 indices (P<0.001). In addition, to evaluate the diagnostic performance of iFR to identify FFR-positive coronary stenoses, we performed an additional meta-analysis, summarizing the results of receiver operating characteristics analyses from individual studies reporting the area under the curve. Summing the results of these studies, we found that iFR has a good diagnostic performance for the identification of FFR-positive stenoses (area under the curve=0.88 [0.86-0.90]; P<0.001). Furthermore, our search results included 5 studies that compared iFR and FFR to a third independent reference standard. Interestingly, no significant differences between iFR and FFR were reported in those studies.

CONCLUSIONS

The present meta-analysis shows that iFR significantly correlates with standard FFR and shows a good diagnostic performance in identifying FFR-positive coronary stenoses. Finally, iFR and FFR have similar diagnostic efficiency for detection of ischemia-inducing stenoses when tested against a third comparator.

New pressure sensing elements for FFR coronary catheter

The next generation FFR Coronary Catheter includes a new stable pressure sensor, AD conversion at the tip of the catheter and mount of these components on the sidewall of the catheter instead of the guide wire enabling thus to use standard guide wires. The new ultrathin capacitive MEMS pressure sensor die with corresponding readout ASIC circuit offers better accuracy, robustness and automated assembly. The measured performance values of the fabricated chips correlate well with the simulated ones indicating comprehensive understanding of the sensor operation and control of the fabrication process. The test measurements outperformed the specifications for the FFR pressure sensing.

Meta-Analysis of Diagnostic Performance of Instantaneous Wave-Free Ratio versus Quantitative Flow Ratio for Detecting the Functional Significance of Coronary Stenosis

Background

Fractional flow reserve (FFR), as a functional measurement of coronary stenosis, is recommended for guiding revascularization in intermediate coronary lesions. However, it still remains underutilized for potential reasons including time consumption, costs, or contraindications associated with adenosine administration. Here we performed this meta-analysis to assess the diagnostic performance of two adenosine-free indices, instantaneous wave free-ratio (iFR), and quantitative flow ratio (QFR) in evaluating coronary stenosis severity with FFR as the reference standard.

Methods

PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to include relevant studies with the diagnostic accuracy of iFR or QFR referenced to FFR. A bivariate model was applied to pool diagnostic parameters. We used Cochran's Q test and I² index to assess heterogeneity and identify the potential source of heterogeneity by meta-regression.

Results

A total of 8213 lesions from 28 studies (19 for iFR and 9 for QFR) were included in this meta-analysis. The pooled sensitivity and specificity were 0.79 (95% CI, 0.75 to 0.83) and 0.85 (95% CI, 0.82 to 0.87) for iFR and 0.90 (95% CI, 0.84 to 0.93) and 0.88 (95% CI, 0.86 to 0.90) for QFR, respectively. Significantly higher sensitivity and specificity were observed in the bivariate analysis for QFR than for iFR (P < 0.001 for both). The area under summary receiver-operating curve of iFR and QFR was 0.89 (95% CI, 0.86 to 0.92) and 0.92 (95% CI, 0.89 to 0.94).

Conclusion

Evidence suggests that both of the two indices have good performance in detecting functional ischemia of coronary arteries and QFR might be a promising method without requiring the pressure wire. Further application of QFR may potentially provide important information to clinicians in the assessment of coronary lesions.

Fractional Flow Reserve/Instantaneous Wave-Free Ratio Discordance in Angiographically Intermediate Coronary Stenoses: An Analysis Using Doppler-Derived Coronary Flow Measurements

Objectives

The study sought to determine the coronary flow characteristics of angiographically intermediate stenoses classified as discordant by fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR).

Background

Discordance between FFR and iFR occurs in up to 20% of cases. No comparisons have been reported between the coronary flow characteristics of FFR/iFR discordant and angiographically unobstructed vessels.

Methods

Baseline and hyperemic coronary flow velocity and coronary flow reserve (CFR) were compared across 5 vessel groups: FFR+/iFR+ (108 vessels, n = 91), FFR–/iFR+ (28 vessels, n = 24), FFR+/iFR– (22 vessels, n = 22), FFR–/iFR– (208 vessels, n = 154), and an unobstructed vessel group (201 vessels, n = 153), in a post hoc analysis of the largest combined pressure and Doppler flow velocity registry (IDEAL [Iberian-Dutch-English] collaborators study).

Results

FFR disagreed with iFR in 14% (50 of 366). Baseline flow velocity was similar across all 5 vessel groups, including the unobstructed vessel group (p = 0.34 for variance). In FFR+/iFR– discordants, hyperemic flow velocity and CFR were similar to both FFR–/iFR– and unobstructed groups; 37.6 (interquartile range [IQR]: 26.1 to 50.4) cm/s vs. 40.0 [IQR: 29.7 to 52.3] cm/s and 42.2 [IQR: 33.8 to 53.2] cm/s and CFR 2.36 [IQR: 1.93 to 2.81] vs. 2.41 [IQR: 1.84 to 2.94] and 2.50 [IQR: 2.11 to 3.17], respectively (p > 0.05 for all). In FFR–/iFR+ discordants, hyperemic flow velocity, and CFR were similar to the FFR+/iFR+ group; 28.2 (IQR: 20.5 to 39.7) cm/s versus 23.5 (IQR: 16.4 to 34.9) cm/s and CFR 1.44 (IQR: 1.29 to 1.85) versus 1.39 (IQR: 1.06 to 1.88), respectively (p > 0.05 for all).

Conclusions

FFR/iFR disagreement was explained by differences in hyperemic coronary flow velocity. Furthermore, coronary stenoses classified as FFR+/iFR– demonstrated similar coronary flow characteristics to angiographically unobstructed vessels.

Fractional flow reserve derived from microcatheters versus standard pressure wires: a stenosis-level meta-analysis

Aims

To determine the agreement between sensor-tipped microcatheter (MC) and pressure wire (PW)-derived fractional flow reserve (FFR).

Methods and results

Studies comparing FFR obtained from MC (FFRMC, Navvus Microcatheter System, ACIST Medical Systems, Eden Prairie, Minnesota, USA) versus standard PW (FFRPW) were identified, and a meta-analysis of numerical and categorical agreement was performed. The relative levels of drift and device failure of MC and PW systems from each study were assessed. Six studies with 440 lesions (413 patients) were included. The mean overall bias between FFRMC and FFRPW was -0.029 (FFRMC lower). Bias and variance were greater for lesions with lower FFRPW (p<0.001). Using a cut-off of 0.80, 18 % of lesions were reclassified by FFRMC versus FFRPW (with 15 % being false positives). The difference in reported drift between FFRPW and FFRMC was small. Device failure was more common with MC than PW (7.1% vs 2%).

Conclusion

FFRMC systematically overestimates lesion severity, with increased bias in more severe lesions. Using FFRMC changes revascularisation guidance in approximately one out of every five cases. PW drift was similar between systems. Device failure was higher with MC.

Discordance between pressure drift after wire pullback and intracoronary distal pressure offset affects stenosis physiology appraisal

BACKGROUND

Drift is a well-known issue affecting intracoronary pressure measurements. A small pressure offset at the end of the procedure is generally considered acceptable, while repeat assessment is advised for drift exceeding ±2 mmHg. This practice implies that drift assessed after wire pullback equals that at the time of stenosis appraisal, but this assumption has not been systematically investigated. Our aim was to compare intra-and post-procedural pressure sensor drift and assess benefits of correction for intra-procedural drift and its effect on diagnostic classification.

METHODS

In 70 patients we compared intra- and post-procedural pressure drift for 120 hemodynamic tracings obtained at baseline and throughout the hyperemic response to intracoronary adenosine. Intra-procedural drift was derived from the intercept of the stenosis pressure gradient-velocity relationship. Diagnostic reclassification after correction for intra-procedural drift was assessed for the mean distal-to-aortic pressure ratio at baseline (Pd/Pa) and hyperemia (fractional flow reserve, FFR), and corresponding stenosis resistances.

RESULTS

Post- and intra-procedural drift exceeding the tolerated threshold was observed in 73% and 64% of the hemodynamic tracings, respectively. Discordance in terms of acceptable drift level was present for 42% of the tracings, with avoidable repeat physiological assessment in 25% and unacceptable intra-procedural drift unrecognized at final drift check in 17% of the tracings. Correction for intra-procedural drift caused higher reclassification rates for baseline than hyperemic functional indices.

CONCLUSIONS

Post-procedural pressure drift frequently does not match drift during physiological assessment. Tracing-specific correction for intra-procedural drift can potentially lower the risk of inadvertent diagnostic misclassification and prevent unnecessary repeats.

Invasive physiological indices to determine the functional significance of coronary stenosis

Physiological measurements are now commonly used to assess coronary lesions in the cardiac catheterisation laboratory, and this practice is evidence-based and supported by clinical guidelines. Fractional flow reserve is currently the gold standard method to determine whether coronary lesions are functionally significant, and is used to guide revascularization. There are however several other physiological measurements that have been proposed as alternatives to the fractional flow reserve. This review aims to comprehensively discuss physiological indices that can be used in the cardiac catheterisation laboratory to determine the functional significance of coronary lesions. We will focus on their advantages and disadvantages, and the current evidence supporting their use.

The Evolving Future of Instantaneous Wave-Free Ratio and Fractional Flow Reserve

In this review, the authors reflect upon the role of coronary physiology in the modern management of coronary artery disease. They critically appraise the scientific background of the instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR), from early experimental studies to validation studies against indexes of ischemia, to clinical trials assessing outcome. At this important juncture for the field, the authors make predictions for the future of physiological stenosis assessment, outlining developments for both iFR and FFR in new clinical domains beyond the confines of stable angina. With a focus on the evolving future of iFR and FFR, the authors describe how physiological assessment with iFR may advance its application from simply justifying to guiding revascularization.

Influence of increased heart rate and aortic pressure on resting indices of functional coronary stenosis severity

Baseline assessment of functional stenosis severity has been proposed as a practical alternative to hyperemic indices. However, intact autoregulation mechanisms may affect intracoronary hemodynamics. The aim of this study was to investigate the effect of changes in aortic pressure (Pa) and heart rate (HR) on baseline coronary hemodynamics and functional stenosis assessment. In 15 patients (55 ± 3% diameter stenosis) Pa, intracoronary pressure (Pd) and flow velocity were obtained at control, and during atrial pacing at 120 bpm, increased Pa (+30 mmHg) with intravenous phenylephrine (PE), and elevated Pa while pacing at sinus heart rate (PE + sHR). We derived rate pressure product (RPP = systolic Pa × HR), baseline microvascular resistance (BMR = Pd/velocity), and stenosis resistance [BSR = (Pa − Pd)/velocity] as well as whole-cycle Pd/Pa. Tachycardia (120 ± 1 bpm) raised RPP by 74% vs. control. Accordingly, BMR decreased by 27% (p < 0.01) and velocity increased by 36% (p < 0.05), while Pd/Pa decreased by 0.05 ± 0.02 (p < 0.05) and BSR remained similar to control. Raising Pa to 121 ± 3 mmHg (PE) with concomitant reflex bradycardia increased BMR by 26% (p < 0.001) at essentially unchanged RPP and velocity. Consequently, BSR and Pd/Pa were only marginally affected. During PE + sHR, velocity increased by 21% (p < 0.01) attributable to a 46% higher RPP (p < 0.001). However, BMR, BSR, and Pd/Pa remained statistically unaffected. Nonetheless, the interventions tended to increase functional stenosis severity, causing Pd/Pa and BSR of borderline lesions to cross the diagnostic threshold. In conclusion, coronary microvascular adaptation to physiological conditions affecting metabolic demand at rest influences intracoronary hemodynamics, which may lead to altered basal stenosis indices used for clinical decision-making.