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Ullrich-Daub H, Olschewski M, Schnorbus B, Belhadj KA, Köhler T, Vosseler M, Münzel T, Gori T. Quantitative flow ratio or angiography for the assessment of non-culprit lesions in acute coronary syndromes, a randomized trial. Clin Res Cardiol 2024:10.1007/s00392-024-02484-5. [PMID: 38980329 DOI: 10.1007/s00392-024-02484-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 06/20/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Patients undergoing percutaneous coronary intervention for acute coronary syndromes often have multivessel disease (MVD). Quantitative flow ratio (QFR) is an angiography-based technology that may help quantify the functional significance of non-culprit lesions, with the advantage that measurements are possible also once the patient is discharged from the catheterization laboratory. AIM Our two-center, randomized superiority trial aimed to test whether QFR, as compared to angiography, modifies the rate of non-culprit lesion interventions (primary functional endpoint) and improves the outcomes of patients with acute coronary syndromes and MVD (primary clinical endpoint). METHODS In total, 202 consecutive patients (64 [56-71] years of age, 160 men) with STEMI (n = 69 (34%)), NSTEMI (n = 94 (47%)), or unstable angina (n = 39 (19%)) and MVD who had undergone successful treatment of all culprit lesions were randomized 1:1 to angiography- vs. QFR-guided delayed revascularization of 246 non-culprit stenoses (1.2/patient). RESULTS The proportion of patients assigned to percutaneous intervention was not different between groups (angiography group: 45 (45%) vs. QFR: 56 (55%), P = 0.125; relative risk = 0.80 (0.60-1.06)). At 12 months, a primary clinical endpoint event (composite of death, nonfatal myocardial infarction, revascularization, and significant angina) occurred in 24 patients (angiography-guided) and 23 patients (QFR-guided; P = 0.637, HR = 1.16 [0.63-2.15]). None of its components was different between groups. DISCUSSION QFR guidance based on analysis of images from the primary intervention was not associated with a difference in the rate of non-culprit lesion staged revascularization nor in the 12-month incidence of clinical events in patients with acute coronary syndromes and multivessel disease. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04808310).
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Affiliation(s)
- Helen Ullrich-Daub
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Frankfurt, Germany
| | - Maximilian Olschewski
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Frankfurt, Germany
| | | | - Khelifa-Anis Belhadj
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Frankfurt, Germany
| | - Till Köhler
- Cardiopraxis Mainz and Ingelheim, Mainz, Germany
| | - Markus Vosseler
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Frankfurt, Germany
| | - Tommaso Gori
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Frankfurt, Germany.
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Erriquez A, Campo G, Guiducci V, Casella G, Menozzi M, Cerrato E, Sacchetta G, Moreno R, Arena M, Amat Santos I, Diez Gil JL, Scarsini R, Ruozzi M, Arioti M, Picchi A, Barbierato M, Moscarella E, Musto D'Amore S, Lanzilotti V, Cavazza C, Rezzaghi M, Cocco M, Marrone A, Verardi FM, Escaned J, Barbato E, Colaiori I, Pesenti N, Carrara G, Biscaglia S. QFR for the Revascularization of Nonculprit Vessels in MI Patients: Insights From the FIRE Trial. JACC Cardiovasc Interv 2024; 17:1425-1436. [PMID: 38752972 DOI: 10.1016/j.jcin.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The role of quantitative flow ratio (QFR) in the treatment of nonculprit vessels of patients with myocardial infarction (MI) is a topic of ongoing discussion. OBJECTIVES This study aimed to investigate the predictive capability of QFR for adverse events and its noninferiority compared to wire-based functional assessment in nonculprit vessels of MI patients. METHODS The FIRE (Functional Assessment in Elderly MI Patients With Multivessel Disease) trial randomized 1,445 older MI patients to culprit-only (n = 725) or physiology-guided complete revascularization (n = 720). In the culprit-only arm, angiographic projections of nonculprit vessels were prospectively collected, centrally reviewed for QFR computation, and associated with endpoints. In the complete revascularization arm, endpoints were compared between nonculprit vessels investigated with QFR or wire-based functional assessment. The primary endpoint was the vessel-oriented composite endpoint (VOCE) at 1 year. RESULTS QFR was measured on 903 nonculprit vessels from 685 patients in the culprit-only arm. Overall, 366 (40.5%) nonculprit vessels showed a QFR value ≤0.80, with a significantly higher incidence of VOCEs (22.1% vs 7.1%; P < 0.001). QFR ≤0.80 emerged as an independent predictor of VOCEs (HR: 2.79; 95% CI: 1.64-4.75). In the complete arm, QFR was used in 320 (35.2%) nonculprit vessels to guide revascularization. When compared with propensity-matched nonculprit vessels in which treatment was guided by wire-based functional assessment, no significant difference was observed (HR: 0.57; 95% CI: 0.28-1.15) in VOCEs. CONCLUSIONS This prespecified subanalysis of the FIRE trial provides evidence supporting the safety and efficacy of QFR-guided interventions for the treatment of nonculprit vessels in MI patients. (Functional Assessment in Elderly MI Patients With Multivessel Disease [FIRE]; NCT03772743).
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Affiliation(s)
- Andrea Erriquez
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy.
| | - Vincenzo Guiducci
- Cardiology Unit, Azienda Unità Sanitaria Locale (USL)-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Reggio Emilia, S. Maria Nuova Hospital, Reggio Emilia, Italy
| | | | - Mila Menozzi
- Cardiovascular Department, Infermi Hospital, Rimini, Italy
| | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy; Rivoli Infermi Hospital Azienda Sanitaria Locale Torino 3 (ASLTO3), Rivoli, Turin, Italy
| | | | - Raul Moreno
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Instituto de Investigación Hospital La Paz, University Hospital La Paz, Madrid, Spain
| | - Marco Arena
- S.C. Cardiologia, Ospedale Sant'Andrea, La Spezia, Italy
| | - Ignacio Amat Santos
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Jose Luis Diez Gil
- Centro de Investigation Biomedica end Red en Enfermedades Cardiovasculares, Cardiology Department, H. Universitario y Politécnico La Fe, Valencia, Spain
| | - Roberto Scarsini
- Azienda Ospedaliero Universitaria Integrata di Verona, Verona, Italy
| | - Marco Ruozzi
- Ospedale Civile di Baggiovara, Azienda Sanitaria Locale (ASL) di Modena, Modena, Italy
| | - Manfredi Arioti
- Ospedale Santa Maria delle Croci, ASL Romagna, Ravenna, Italy
| | - Andrea Picchi
- Cardiovascular Department, Azienda Unità Sanitaria Locale (USL) Toscana Sud-Est, Misericordia Hospital, Grosseto, Italy
| | - Marco Barbierato
- Interventional Cardiology, Department of Cardio-Thoracic and Vascular Sciences, Ospedale dell'Angelo, Mestre, Venice, Italy
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy
| | - Sergio Musto D'Amore
- Cardiology Unit, Azienda Unità Sanitaria Locale (USL)-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Reggio Emilia, S. Maria Nuova Hospital, Reggio Emilia, Italy
| | | | | | - Marco Rezzaghi
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Instituto de Investigación Hospital La Paz, University Hospital La Paz, Madrid, Spain
| | - Marta Cocco
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Andrea Marrone
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | | | - Javier Escaned
- Hospital Clínico San Carlos Instituto de Investigación Sanitaria of the Hospital Clínico San Carlos (IDISCC), Complutense University of Madrid, Madrid, Spain
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Roma, Italy
| | - Iginio Colaiori
- Cardiology Unit, Ospedale Santa Maria Goretti, Latina, Italy
| | | | | | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
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Castaldi G, Benedetti A, Poletti E, Moroni A, Scott B, Vermeersch P, Zivelonghi C, Bennett J, Agostoni P. Angiography-derived physiological assessment after percutaneous coronary intervention of chronic total occlusions. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:1001-1009. [PMID: 38509396 DOI: 10.1007/s10554-024-03065-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/05/2024] [Indexed: 03/22/2024]
Abstract
Scant data exploring potential suboptimal physiological results after angiographic successful percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) are available. Sixty cases of successful CTO-PCI were selected for this retrospective analysis. Post-CTO-PCI angiography-based fractional flow reserve was computed using the Murray-based fractional flow reserve (μFR) software. Vessel-specific μFR, residual trans-stent gradient (TSG) and corrected TSGstent were calculated. In physiological suboptimal results (μFR < 0.90), the virtual pullback pressure gradient (PPG) curves were analyzed to localize the main pressure drop-down and characterize the patterns of residual disease. The virtual pullback pressure gradient index (vPPGi) was then calculated to objectively characterize the predominant pattern of residual disease (diffuse vs focal). The physiological result was suboptimal in 28 cases (46.7%). The main pressure drop was localised proximal to the stent in 2 (7.1%), distal in 17 (60.7%) and intra-stent in 9 cases (32.2%). Intra-stent residual disease was diffuse in 7 cases and mixed in 2. Distal residual disease was characterised by a pure focal pattern in 12 cases, diffuse in 2 and mixed in 3. In the predominant diffuse phenotype (vPPGi < 0.65), we found a higher rate of TSG ≥ 0.04 (61.5% vs 20.0%, p = 0.025) and TSGstent ≥ 0.009 (46.2% vs 20.0%, p = 0.017) while in the dominant focal phenotype poor-quality distal vessel was constantly present. In our cohort, post-CTO-PCI suboptimal physiological result was frequent (46.7%). Predominant focal phenotype was constantly associated with poor-quality distal vessel, while in the predominant diffuse phenotype, the rate of TSG ≥ 0.04 and TSGstent ≥ 0.009 were significantly higher.
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Affiliation(s)
- Gianluca Castaldi
- Department of Cardiovascular Medicine, University Hospital Leuven, Leuven, Belgium.
- Hartcentrum Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium.
| | - Alice Benedetti
- Hartcentrum Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Enrico Poletti
- Hartcentrum Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Alice Moroni
- Hartcentrum Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Benjamin Scott
- Hartcentrum Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Paul Vermeersch
- Hartcentrum Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Carlo Zivelonghi
- Hartcentrum Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Johan Bennett
- Department of Cardiovascular Medicine, University Hospital Leuven, Leuven, Belgium
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Asano T, Tanigaki T, Ikeda K, Ono M, Yokoi H, Kobayashi Y, Kozuma K, Tanaka N, Kawase Y, Matsuo H. Consensus document on the clinical application of invasive functional coronary angiography from the Japanese Association of Cardiovascular Intervention and Therapeutics. Cardiovasc Interv Ther 2024; 39:109-125. [PMID: 38367157 PMCID: PMC10940478 DOI: 10.1007/s12928-024-00988-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/09/2024] [Indexed: 02/19/2024]
Abstract
Invasive functional coronary angiography (FCA), an angiography-derived physiological index of the functional significance of coronary obstruction, is a novel physiological assessment tool for coronary obstruction that does not require the utilization of a pressure wire. This technology enables operators to rapidly evaluate the functional relevance of coronary stenoses during and even after angiography while reducing the burden of cost and complication risks related to the pressure wire. FCA can be used for treatment decision-making for revascularization, strategy planning for percutaneous coronary intervention, and procedure optimization. Currently, various software-computing FCAs are available worldwide, with unique features in their computation algorithms and functions. With the emerging application of this novel technology in various clinical scenarios, the Japanese Association of Cardiovascular Intervention and Therapeutics task force was created to outline expert consensus on the clinical use of FCA. This consensus document advocates optimal clinical applications of FCA according to currently available evidence while summarizing the concept, history, limitations, and future perspectives of FCA along with globally available software.
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Affiliation(s)
- Taku Asano
- Department of Cardiovascular Medicine, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, P.O. Box 104-8560, Tokyo, Japan.
| | - Toru Tanigaki
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Kazumasa Ikeda
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Masafumi Ono
- Department of Cardiovascular Medicine, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, P.O. Box 104-8560, Tokyo, Japan
| | - Hiroyoshi Yokoi
- Department of Cardiovascular Medicine, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University, Chiba, Japan
| | - Ken Kozuma
- Department of Cardiology, Teikyo University, Tokyo, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Yoshiaki Kawase
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
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Bär S, Kavaliauskaite R, Otsuka T, Ueki Y, Häner J, Lanz J, Fürholz M, Praz F, Hunziker L, Siontis GCM, Pilgrim T, Stortecky S, Losdat S, Windecker S, Räber L. Quantitative Flow Ratio to Predict Non-Target-Vessel Events Before Planned Staged Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome. J Am Heart Assoc 2024; 13:e031847. [PMID: 38156592 PMCID: PMC10863833 DOI: 10.1161/jaha.123.031847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/01/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND The optimal time point of staged percutaneous coronary intervention (PCI) among patients with acute coronary syndrome (ACS) remains a matter of debate. Quantitative flow ratio (QFR) is a novel noninvasive method to assess the hemodynamic significance of coronary stenoses. We aimed to investigate whether QFR could refine the timing of staged PCI of non-target vessels (non-TVs) on top of clinical judgment for patients with ACS. METHODS AND RESULTS For this cohort study, patients with ACS from Bern University Hospital, Switzerland, scheduled to undergo out-of-hospital non-TV staged PCI were eligible. The primary end point was the composite of non-TV myocardial infarction and urgent unplanned non-TV PCI before planned staged PCI. The association between lowest QFR per patient measured in the non-TV (from index angiogram) and the primary end point was assessed using multivariable adjusted Cox proportional hazards regressions with QFR included as linear or penalized spline (nonlinear) term. QFR was measured in 1093 of 1432 patients with ACS scheduled to undergo non-TV staged PCI. Median time to staged PCI was 28 days. The primary end point occurred in 5% of the patients. In multivariable analysis (1018 patients), there was no independent association between non-TV QFR and the primary end point (hazard ratio, 0.87 [95% CI, 0.69-1.05] per 0.1 increase; P=0.125; nonlinear P=0.648). CONCLUSIONS In selected patients with ACS scheduled to undergo staged PCI at a median of 4 weeks after index PCI, QFR did not emerge as an independent predictor of non-TV events before planned staged PCI. Thus, this study does not provide conceptual evidence that QFR is helpful to refine the timing of staged PCI on top of clinical judgment. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02241291.
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Affiliation(s)
- Sarah Bär
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
| | - Raminta Kavaliauskaite
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
| | - Tatsuhiko Otsuka
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
- Department of CardiologyItabashi Chuo Medical CenterTokyoJapan
| | - Yasushi Ueki
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
- Department of Cardiovascular MedicineShinshu University School of MedicineNaganoJapan
| | - Jonas Häner
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
| | - Jonas Lanz
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
| | - Monika Fürholz
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
| | - Fabien Praz
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
| | - Lukas Hunziker
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
| | - George CM Siontis
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
| | - Thomas Pilgrim
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
| | - Stefan Stortecky
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
| | | | - Stephan Windecker
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
| | - Lorenz Räber
- Department of CardiologyBern University Hospital, Inselspital, University of BernSwitzerland
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Liontou C, Kalogera V, Oikonomou D, Stalikas D, Pappas L, Triantafyllou K. Diagnostic performance of quantitative flow ratio in non-ST elevation acute coronary syndromes in comparison to non-hyperemic pressure ratios: a prospective study. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:2567-2574. [PMID: 37882959 DOI: 10.1007/s10554-023-02967-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/21/2023] [Indexed: 10/27/2023]
Abstract
Quantitative flow ratio (QFR) is a new angiography-based coronary physiology tool aimed to evaluate functional relevance of intermediate coronary lesions. Aim of the study is to assess diagnostic performance of QFR in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) in comparison to currently used non-hyperaemic pressure ratios (NHPRs). In this prospective, single-centre study, coronary physiology of intermediate coronary stenoses of non-culprit vessels in patients presenting with NSTE-ACS was evaluated using NHPRs (iFR, DFR or RFR). Subsequently, QFR was computed offline by a QFR analyst blinded to the NHPR results. Diagnostic performance of QFR was assessed in comparison to NHPRs as reference standard. A total of 60 vessels with intermediate coronary stenoses was investigated. The NHPRs were used as follows: RFR 38%, DFR 47% and iFR 15% of the cases. The NHPR result was positive, showing significant lesion, in 19 cases. A significant correlation was found between NHPR and QFR (r = 0.84, p < 0.001). Classification agreement of the two methods (95%) and diagnostic performance of QFR in comparison to NHPR (AUC: 0.962 [0.914-1.00]) were both high. Sensitivity, specificity, positive and negative predictive value of QFR in comparison to NHPR were 84.2%, 100%, 100% and 93.2% respectively. QFR has high diagnostic performance in detecting functionally significant lesions of non-culprit arteries in patients with NSTE-ACS and multivessel disease. Due to its high negative predictive value, it can be used to safely avoid unnecessary invasive physiological assessment of these lesions.
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Affiliation(s)
- Catherine Liontou
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece.
| | - Vasiliki Kalogera
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Dimitrios Oikonomou
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Dimitrios Stalikas
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Loukas Pappas
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
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Demola P, Colaiori I, Bosi D, Musto D’Amore S, Vitolo M, Benatti G, Vignali L, Tadonio I, Gabbieri D, Losi L, Magnavacchi P, Sgura FA, Boriani G, Guiducci V. Quantitative flow ratio-based outcomes in patients undergoing transcatheter aortic valve implantation quaestio study. Front Cardiovasc Med 2023; 10:1188644. [PMID: 37711555 PMCID: PMC10499393 DOI: 10.3389/fcvm.2023.1188644] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
Background Coronary artery disease (CAD) is common in patients with aortic valve stenosis (AS) ranging from 60% to 80%. The clinical and prognostic role of coronary artery lesions in patients undergoing Transcatheter Aortic Valve Implantation (TAVI) remains unclear. The aim of the present observational study was to estimate long-term clinical outcomes by Quantitative Flow Ratio (QFR) characterization of CAD in a well-represented cohort of patients affected by severe AS treated by TAVI. Methods A total of 439 invasive coronary angiographies of patients deemed eligible for TAVI by local Heart Teams with symptomatic severe AS were retrospectively screened for QFR analysis. The primary endpoint of the study was all-cause mortality. The secondary endpoint was a composite of cardiovascular mortality, stroke/transient ischemic attack (TIA), acute myocardial infarction (AMI), and any hospitalization after TAVI. Results After exclusion of patients with no follow-up data, coronary angiography not feasible for QFR analysis and previous surgical myocardial revascularization (CABG) 48/239 (20.1%) patients had a QFR value lower or equal to 0.80 (QFR + value), while the remaining 191/239 (79.9%) did not present any vessel with a QFR positive value. In the adjusted Cox regression analysis, patients with positive QFR were independently associated with an increased risk of all-casual mortality (Model 1, HR 3.47, 95% CI, 2.35-5.12; Model 2, HR 5.01, 95% CI, 3.17-7.90). In the adjusted covariate analysis, QFR+ involving LAD (37/48, 77,1%) was associated with the higher risk of the composite outcome compared to patients without any positive value of QFR or non-LAD QFR positive value (11/48, 22.9%). Conclusions Pre-TAVI QFR analysis can be used for a safe, simple, wireless functional assessment of CAD. QFR permits to identify patients at high risk of cardiovascular mortality or MACE, and it could be considered by local Heart Teams.
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Affiliation(s)
- Pierluigi Demola
- Cardiology Unit, Azienda USL—IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Iginio Colaiori
- Cardiology Unit, Azienda USL—IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Davide Bosi
- Cardiology Unit, Azienda USL—IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Giorgio Benatti
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Luigi Vignali
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Iacopo Tadonio
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | | | - Luciano Losi
- U.O. Cardiologia, Ospedale “Guglielmo da Saliceto”, Piacenza, Italy
| | | | - Fabio Alfredo Sgura
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Vincenzo Guiducci
- Cardiology Unit, Azienda USL—IRCCS di Reggio Emilia, Reggio Emilia, Italy
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8
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Lopez-Palop R, Carrillo P, Leithold G, Lozano I, Nieto A, Frutos A, Garcia J, Freites A, Lacunza J, Duran JM, Hurtado J, Gimeno JR, Valdesuso R, Pinar E, Pascual D. Accuracy of the angiography-based quantitative flow ratio in intermediate left main coronary artery lesions and comparison with visual estimation. Int J Cardiol 2023:S0167-5273(23)00590-9. [PMID: 37085119 DOI: 10.1016/j.ijcard.2023.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/05/2023] [Accepted: 04/18/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Revascularization of left main coronary artery (LMCA) stenosis is mostly based on angiography. Indices based on angiography might increase accuracy of the decision, although they have been scarcely used in LMCA. The objective of this study is to study the diagnostic agreement of QFR (quantitative flow ratio) with wire-based fractional flow reserve (FFR) in LMCA lesions and to compare with visual severity assessment. METHODS In a series of patients with invasive FFR assessment of intermediate LMCA stenoses we retrospectively compared the measured value of QFR with that of FFR and the estimate of significance from angiography. RESULTS 107 QFR studies were included. The QFR intra-observer and inter-observer agreement was 87% and 82% respectively. The mean QFR-FFR difference was 0.047 ± 0.05 with a concordance of 90.7%, sensitivity 88.1%, specificity 92.3%, positive predictive value 88.1% and negative predictive value 92.3%. All these values were superior to those observed with the visual estimation which showed an intra- and inter-observer agreement of 73% and 72% respectively, besides 78% with the FFR value. The low diagnostic performance of the visual estimation and the acceptable performance of the QFR index measurement were observed in all subgroups analysed. CONCLUSIONS QFR allows an acceptable estimate of the FFR obtained with intracoronary pressure guidewire in intermediate LMCA lesions, and clearly superior to the assessment based on angiography alone. The decision to revascularize patients with moderate LMCA lesions should not be based solely on the degree of angiographic stenosis.
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Affiliation(s)
- Ramon Lopez-Palop
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.
| | - Pilar Carrillo
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Gunnar Leithold
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Iñigo Lozano
- Sección de Cardiología, Hospital Universitario San Juan de Alicante, Spain
| | - Alberto Nieto
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Araceli Frutos
- Servicio de Cardiología, Hospital Universitario de Cabueñes, Gijón, Spain
| | - Juan Garcia
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Alfonso Freites
- Servicio de Cardiología, Hospital Universitario de Cabueñes, Gijón, Spain
| | - Javier Lacunza
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Juan M Duran
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Jose Hurtado
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Juan R Gimeno
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Raul Valdesuso
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Eduardo Pinar
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Domingo Pascual
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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9
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Quantitative flow ratio vs. angiography-only guided PCI in STEMI patients: one-year cardiovascular outcomes. BMC Cardiovasc Disord 2023; 23:136. [PMID: 36918808 PMCID: PMC10015917 DOI: 10.1186/s12872-023-03153-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Coronary physiology-guided PCIs are recommended worldwide. However, invasive coronary physiology methods prolong the procedure, create additional risks for the patients, and prolong the fluoroscopy time for an interventional cardiologist. Otherwise, there is a noninvasive coronary physiology evaluation method, QFR, that can be safely used even in STEMI patients. METHODS A total of 198 patients admitted with STEMI and at least one intermediate (35-75%) diameter stenosis other than the culprit artery between July 2020 and June 2021 were prospectively included in this single-center study. All patients were randomized into one of two groups (1 - QFR-guided PCI; 2 - visual-estimation-only guided PCI). A 12-month follow-up with echocardiography, exercise stress test, and quality of life evaluation was performed in all included patients. For the QOF evaluation, the Seattle Angina Score Questionnaire was chosen. Statistical analysis was performed using the Kolmogorov-Smirnov test, Student's t-test, Mann-Whitney U test, Pearson's chi-squared test and Kaplan-Meier estimator. RESULTS Ninety-eight (49.5%) patients were randomized to the first group, and 100 (50.5%) patients were included in the second group. Statistically, significantly more patients had a medical history of dyslipidemia (98 vs. 91, p = 0.002) and slightly better left ventricular ejection fraction (42.21 ± 7.88 vs. 39.45 ± 9.62, p = 0.045) in the QFR group. Six fewer patients required non-culprit artery revascularization within the 12-month FU in the QFR group (1.02% vs. 6%, p = 0.047). Survival analysis proved that patients in the Angio group had a more than 6-fold greater risk for death within a 12-month period after MI (OR 6.23, 95% CI 2.20-17.87, p = 0.006), with the highest mortality risk within the first two months after initial treatment. CONCLUSION Using QFR in non-culprit lesions in patients with ST-elevation myocardial infarction reduces mortality and revascularization at the 12-month follow-up and improves the quality of life of the patient. TRIAL REGISTRATION The study was approved by the Regional Bioethical Committee and conducted under the principles of the Helsinki Declaration and local laws and regulations.
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10
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Groenland FTW, Huang J, Scoccia A, Neleman T, Ziedses Des Plantes AC, Nuis RJ, den Dekker WK, Wilschut JM, Diletti R, Kardys I, Van Mieghem NM, Daemen J. Vessel fractional flow reserve-based non-culprit lesion reclassification in patients with ST-segment elevation myocardial infarction: Impact on treatment strategy and clinical outcome (FAST STEMI I study). Int J Cardiol 2023; 373:33-38. [PMID: 36436683 DOI: 10.1016/j.ijcard.2022.11.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Complete revascularization in patients with ST-segment elevation myocardial (STEMI) improves clinical outcome. Vessel fractional flow reserve (vFFR) has been validated as a non-invasive physiological technology to evaluate hemodynamic lesion significance without need for a dedicated pressure wire or hyperemic agent. This study aimed to assess discordance between vFFR reclassification and treatment strategy in intermediate non-culprit lesions of STEMI patients and to assess the clinical impact of this discordance. METHODS This was a single-center, retrospective cohort study. From January 2018 to December 2019, consecutive eligible STEMI patients were screened based on the presence of a non-culprit vessel with an intermediate lesion (30-80% angiographic stenosis) feasible for offline vFFR analysis. The primary outcome was the percentage of non-culprit vessels with discordance between vFFR and actual treatment strategy. The secondary outcome was two-year vessel-oriented composite endpoint (VOCE), a composite of vessel-related cardiovascular death, vessel-related myocardial infarction, and target vessel revascularization. RESULTS A total of 441 patients (598 non-culprit vessels) met the inclusion criteria. Median vFFR was 0.85 (0.73-0.91). Revascularization was performed in 34.4% of vessels. Discordance between vFFR and actual treatment strategy occurred in 126 (21.1%) vessels. Freedom from VOCE was higher for concordant vessels (97.5%) as compared to discordant vessels (90.6%)(p = 0.003), particularly due to higher adverse event rates in discordant vessels with a vFFR ≤0.80 but deferred revascularization. CONCLUSIONS In STEMI patients with multivessel disease, discordance between vFFR reclassification and treatment strategy was observed in 21.1% of non-culprit vessels with an intermediate lesion and was associated with increased vessel-related adverse events.
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Affiliation(s)
- Frederik T W Groenland
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jager Huang
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Alessandra Scoccia
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tara Neleman
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Rutger-Jan Nuis
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wijnand K den Dekker
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen M Wilschut
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Isabella Kardys
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.
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11
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Milzi A, Dettori R, Lubberich RK, Burgmaier K, Marx N, Reith S, Burgmaier M. Quantitative Flow Ratio Is Related to Anatomic Left Main Stem Lesion Parameters as Assessed by Intravascular Imaging. J Clin Med 2022; 11:jcm11206024. [PMID: 36294345 PMCID: PMC9604622 DOI: 10.3390/jcm11206024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/29/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Previously, an association between anatomic left main stem (LMS) lesion parameters, as described by intravascular ultrasound (IVUS) and fractional flow reserve (FFR), was shown. Quantitative flow ratio (QFR) is a novel, promising technique which can assess functional stenosis relevance based only on angiography. However, as little is known about the relationship between anatomic LMS parameters and QFR, it was thus investigated in this study. Methods: In 53 patients with LMS disease, we tested the association between anatomic assessment using OCT (n = 28) or IVUS (n = 25) on the one hand and functional assessment as determined by QFR on the other hand. LMS-QFR was measured using a dedicated approach, averaging QFR over left anterior descending (LAD) and circumflex (LCX) and manually limiting segment of interest to LMS. Results: The minimal luminal area of the LMS (LMS-MLA) as measured by intravascular imaging showed a consistent correlation with QFR (R = 0.61, p < 0.001). QFR could predict a LMS-MLA < 6 mm2 with very good diagnostic accuracy (AUC 0.919) and a LMS-MLA < 4.5 mm2 with good accuracy (AUC 0.798). Similar results were obtained for other stenosis parameters. Conclusions: QFR might be a valuable tool to assess LMS disease. Further studies focusing on patient outcomes are needed to further validate the effectiveness of this approach.
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Affiliation(s)
- Andrea Milzi
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
- Correspondence: ; Tel.: +49-241-8036098
| | - Rosalia Dettori
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Richard Karl Lubberich
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Kathrin Burgmaier
- Department of Pediatrics, Faculty of Medicine, University of Cologne, University Hospital of Cologne, 50931 Cologne, Germany
- Faculty of Applied Healthcare Science, Deggendorf Institute of Technology, 94469 Deggendorf, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Sebastian Reith
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Mathias Burgmaier
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
- Faculty of Applied Healthcare Science, Deggendorf Institute of Technology, 94469 Deggendorf, Germany
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12
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Wienemann H, Ameskamp C, Mejía-Rentería H, Mauri V, Hohmann C, Baldus S, Adam M, Escaned J, Halbach M. Diagnostic performance of quantitative flow ratio versus fractional flow reserve and resting full-cycle ratio in intermediate coronary lesions. Int J Cardiol 2022; 362:59-67. [PMID: 35662563 DOI: 10.1016/j.ijcard.2022.05.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/23/2022] [Accepted: 05/29/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Quantitative flow ratio (QFR) is a novel angiography-derived index aimed to assess the functional relevance of coronary stenoses without pressure wires and adenosine. Good diagnostic yield with the hyperemic fractional flow reserve (FFR) have been reported, while data on the comparison of QFR to non-hyperemic pressure ratios (NHPR) are scarce. METHODS In this retrospective, observational and single-center study with a large population representative of the real practice, we assessed and compared the diagnostic performance of contrast flow (cQFR) and fixed flow (fQFR) QFR against the NHPR resting full-cyle ratio (RFR) using FFR as reference standard. RESULTS A total of 626 lesions from 544 patients were investigated. Mean diameter stenosis, FFR, cQFR, fQFR and RFR were 44.8%, 0.842, 0.847, 0.857 and 0.912, respectively. The correlation between cQFR and FFR was stronger (r = 0.830, P < 0.001) compared to that between FFR and RFR (r = 0.777, P < 0.001) and between cQFR and RFR (r = 0.687, P < 0.001). Using FFR ≤0.80 as reference, the sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy for cQFR were 82%, 95%, 87%, 92%, and 91%, respectively. cQFR displayed a higher area under the curve (AUC) than fQFR and RFR (0.938 vs. 0.891 vs. 0.869, P < 0.01). The good diagnostic yield of cQFR appeared to be maintained in different clinical subsets including female gender, aortic valve stenosis and atrial fibrillation, and in different anatomical subsets including focal and non-focal lesions. CONCLUSION cQFR has a high and better diagnostic performance than the NHPR RFR in predicting FFR-based functional significance of coronary stenoses.
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Affiliation(s)
- Hendrik Wienemann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Christopher Ameskamp
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Hernán Mejía-Rentería
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Victor Mauri
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Christopher Hohmann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Stephan Baldus
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Matti Adam
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Marcel Halbach
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany.
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13
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Greco A, Buccheri S, Tamburino C, Capodanno D. Risk Stratification Approach to Multivessel Coronary Artery Disease. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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14
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Scoccia A, Tomaniak M, Neleman T, Groenland FTW, Plantes ACZD, Daemen J. Angiography-Based Fractional Flow Reserve: State of the Art. Curr Cardiol Rep 2022; 24:667-678. [PMID: 35435570 PMCID: PMC9188492 DOI: 10.1007/s11886-022-01687-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 12/02/2022]
Abstract
Purpose of Review Three-dimensional quantitative coronary angiography-based methods of fractional flow reserve (FFR) derivation have emerged as an appealing alternative to conventional pressure-wire-based physiological lesion assessment and have the potential to further extend the use of physiology in general. Here, we summarize the current evidence related to angiography-based FFR and perspectives on future developments. Recent Findings Growing evidence suggests good diagnostic performance of angiography-based FFR measurements, both in chronic and acute coronary syndromes, as well as in specific lesion subsets, such as long and calcified lesions, left main coronary stenosis, and bifurcations. More recently, promising results on the superiority of angiography-based FFR as compared to angiography-guided PCI have been published. Summary Currently available angiography -FFR indices proved to be an excellent alternative to invasive pressure wire-based FFR. Dedicated prospective outcome data comparing these indices to routine guideline recommended PCI including the use of FFR are eagerly awaited.
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Affiliation(s)
- Alessandra Scoccia
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Mariusz Tomaniak
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.,First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Tara Neleman
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Frederik T W Groenland
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Annemieke C Ziedses des Plantes
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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15
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Ullrich H, Olschewski M, Belhadj KA, Münzel T, Gori T. Quantitative Flow Ratio or Angiography for the Assessment of Non-culprit Lesions in Acute Coronary Syndromes: Protocol of the Randomized Trial QUOMODO. Front Cardiovasc Med 2022; 9:815434. [PMID: 35445090 PMCID: PMC9013799 DOI: 10.3389/fcvm.2022.815434] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Approximately 50% of the patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) have additional stenotic lesions in non-infarct-related coronary arteries. The decision whether these stenoses require further treatment is routinely based on angiography alone. The quantitative flow ratio (QFR) is a simple non-invasive method that may help quantify the functional significance of these intermediate coronary artery lesions. The aim of our single-center, randomized superiority trial is to test the impact and efficacy of QFR, as compared to angiography, in the treatment of patients with ACS with multivessel coronary artery disease. Primary goal of the study is to investigate 1. The impact of QFR on the proportion of patients receiving PCI vs. conservative therapy and 2. whether QFR improves angina pectoris and overall cardiovascular outcomes. Methods and Analysis After treatment of the culprit lesion(s), a total of 200 consecutive ACS patients will be randomized 1:1 to angiography- vs. QFR-guided revascularization of non-culprit stenoses. Patients and clinicians responsible are blinded to the randomization group. The primary functional endpoint is defined as the proportion of patients assigned to medical treatment in the two groups. The primary clinical endpoint is a composite of death, non-fatal myocardial infarction, revascularization and significant angina at 12 months. Secondary endpoints include changes in the SAQ subgroups, and clinical events at 3- and 12-month follow-up. Discussion This study is designed to investigate whether QFR-based decision-making is associated with a decrease in angina and an improved prognosis in patients with multivessel disease. Trial Registration Number ClinicalTrials.gov Registry (NCT04808310).
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Affiliation(s)
- Helen Ullrich
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Mainz, Germany
- *Correspondence: Helen Ullrich
| | - Maximilian Olschewski
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Mainz, Germany
| | - Khelifa-Anis Belhadj
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Mainz, Germany
| | - Tommaso Gori
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Mainz, Germany
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16
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Akasaka T, Shiono Y. Nonculprit Lesion PCI in STEMI: How to Decide and When to Perform? JACC Cardiovasc Interv 2022; 15:667-669. [PMID: 35331459 DOI: 10.1016/j.jcin.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/04/2022] [Accepted: 02/11/2022] [Indexed: 11/20/2022]
Affiliation(s)
- Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan.
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
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17
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Li X, Sun S, Luo D, Yang X, Ye J, Guo X, Xu S, Sun B, Zhang Y, Luo J, Zhou Y, Tu S, Dong H. Microvascular and Prognostic Effect in Lesions With Different Stent Expansion During Primary PCI for STEMI: Insights From Coronary Physiology and Intravascular Ultrasound. Front Cardiovasc Med 2022; 9:816387. [PMID: 35355977 PMCID: PMC8959302 DOI: 10.3389/fcvm.2022.816387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/07/2022] [Indexed: 12/05/2022] Open
Abstract
Background While coronary stent implantation in ST-elevation myocardial infarction (STEMI) can mechanically revascularize culprit epicardial vessels, it might also cause distal embolization. The relationship between geometrical and functional results of stent expansion during the primary percutaneous coronary intervention (pPCI) is unclear. Objective We sought to determine the optimal stent expansion strategy in pPCI using novel angiography-based approaches including angiography-derived quantitative flow ratio (QFR)/microcirculatory resistance (MR) and intravascular ultrasound (IVUS). Methods Post-hoc analysis was performed in patients with acute STEMI and high thrombus burden from our prior multicenter, prospective cohort study (ChiCTR1800019923). Patients aged 18 years or older with STEMI were eligible. IVUS imaging, QFR, and MR were performed during pPCI, while stent expansion was quantified on IVUS images. The patients were divided into three subgroups depending on the degree of stent expansion as follows: overexpansion (>100%), optimal expansion (80%−100%), and underexpansion (<80%). The patients were followed up for 12 months after PCI. The primary endpoint included sudden cardiac death, myocardial infarction, stroke, unexpected hospitalization or unplanned revascularization, and all-cause death. Results A total of 87 patients were enrolled. The average stent expansion degree was 82% (in all patients), 117% (in overexpansion group), 88% (in optimal expansion), and 75% (in under-expansion). QFR, MR, and flow speed increased in all groups after stenting. The overall stent expansion did not affect the final QFR (p = 0.08) or MR (p = 0.09), but it reduced the final flow speed (−0.14 cm/s per 1%, p = 0.02). Under- and overexpansion did not affect final QFR (p = 0.17), MR (p = 0.16), and flow speed (p = 0.10). Multivariable Cox analysis showed that stent expansion was not the risk factor for MACE (hazard ratio, HR = 0.97, p = 0.13); however, stent expansion reduced the risk of MACE (HR = 0.95, p = 0.03) after excluding overexpansion patients. Overexpansion was an independent risk factor for no-reflow (HR = 1.27, p = 0.02) and MACE (HR = 1.45, p = 0.007). Subgroup analysis shows that mild underexpansion of 70%−80% was not a risk factor for MACE (HR = 1.11, p = 0.08) and no-reflow (HR = 1.4, p = 0.08); however, stent expansion <70% increased the risk of MACE (HR = 1.36, p = 0.04). Conclusions Stent expansion does not affect final QFR and MR, but it reduces flow speed in STEMI. Appropriate stent underexpansion of 70–80% does not seem to be associated with short-term prognosis, so it may be tolerable as noninferior compared with optimal expansion. Meanwhile, overexpansion and underexpansion of <70% should be avoided due to the independent risk of MACEs and no-reflow events.
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Affiliation(s)
- Xida Li
- Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Hospital), Zhuhai, China
- Department of Cardiology, Southern Medical University, Guangzhou, China
| | - Shuo Sun
- Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Demou Luo
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xing Yang
- Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Hospital), Zhuhai, China
| | - Jingguang Ye
- Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Hospital), Zhuhai, China
| | - Xiaosheng Guo
- Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Hospital), Zhuhai, China
| | - Shenghui Xu
- Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Hospital), Zhuhai, China
| | - Boyu Sun
- Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Hospital), Zhuhai, China
| | - Youti Zhang
- Department of Cardiology, Guangdong Provincial Jiexi People's Hospital, Jiexi, China
| | - Jianfang Luo
- Department of Cardiology, Southern Medical University, Guangzhou, China
- Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yingling Zhou
- Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shengxian Tu
- Med-X Research Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- Shengxian Tu
| | - Haojian Dong
- Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- *Correspondence: Haojian Dong
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Takahashi T, Shin D, Kuno T, Lee JM, Latib A, Fearon WF, Maehara A, Kobayashi Y. Diagnostic performance of fractional flow reserve derived from coronary angiography, intravascular ultrasound, and optical coherence tomography; a meta-analysis. J Cardiol 2022; 80:1-8. [DOI: 10.1016/j.jjcc.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/06/2022] [Accepted: 02/17/2022] [Indexed: 10/18/2022]
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19
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Erbay A, Penzel L, Abdelwahed YS, Klotsche J, Heuberger A, Schatz AS, Steiner J, Haghikia A, Sinning D, Fröhlich GM, Landmesser U, Stähli BE, Leistner DM. Prognostic Impact of Pancoronary Quantitative Flow Ratio Assessment in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes. Circ Cardiovasc Interv 2021; 14:e010698. [PMID: 34674555 DOI: 10.1161/circinterventions.121.010698] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Quantitative flow ratio (QFR) has been introduced as a novel angiography-based modality for fast hemodynamic assessment of coronary artery lesions and validated against fractional flow reserve. This study sought to define the prognostic role of pancoronary QFR assessment in patients with acute coronary syndrome (ACS) including postinterventional culprit and nonculprit vessels. METHODS In a total of 792 patients with ACS (48.6% ST-segment-elevation ACS and 51.4% non-ST-segment-elevation ACS), QFR analyses of postinterventional culprit (n=792 vessels) and nonculprit vessels (n=1231 vessels) were post hoc performed by investigators blinded to clinical outcomes. The follow-up comprised of major adverse cardiovascular events, including all-cause mortality, nonfatal myocardial infarction, and ischemia-driven coronary revascularization within 2 years after the index ACS event. RESULTS Major adverse cardiovascular events as composite end point occurred in 99 patients (12.5%). QFR with an optimal cutoff value of 0.89 for postinterventional culprit vessels and 0.85 for nonculprit vessels emerged as independent predictor of major adverse cardiovascular events after ACS (nonculprit arteries: adjusted odds ratio, 3.78 [95% CI, 2.21-6.45], P<0.001 and postpercutaneous coronary intervention culprit arteries: adjusted odds ratio, 3.60 [95% CI, 2.09-6.20], P<0.001). CONCLUSIONS The present study for the first time demonstrates the prognostic implications of a pancoronary angiography-based functional lesion assessment in patients with ACS. Hence, QFR offers a novel tool to advance risk stratification and guide therapeutic management after ACS.
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Affiliation(s)
- Aslihan Erbay
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Lisa Penzel
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Youssef S Abdelwahed
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Jens Klotsche
- Institute for Epidemiology and Health Care Economics, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (J.K.)
| | - Andrea Heuberger
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Anne-Sophie Schatz
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Julia Steiner
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.).,German Rheumatism Research Centre Berlin, Germany (J.K.)
| | - Arash Haghikia
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - David Sinning
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.)
| | - Georg M Fröhlich
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.)
| | - Ulf Landmesser
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.).,Berlin Institute of Health (BIH), Germany (U.L., D.M.L.)
| | - Barbara E Stähli
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.).,Department of Cardiology, University Heart Centre, University Hospital Zurich, Switzerland (B.E.S.)
| | - David M Leistner
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Germany. (A.E., L.P., Y.S.A., A. Heuberger, A.-S.S., J.S., A. Haghikia, D.S., G.M.F., U.L., B.E.S., D.M.L.).,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (A.E., L.P., Y.S.A., A.H., A.-S.S., J.S., A. Haghikia, G.M.F., U.L., B.E.S., D.M.L.).,Berlin Institute of Health (BIH), Germany (U.L., D.M.L.)
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20
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Milzi A, Dettori R, Marx N, Reith S, Burgmaier M. Quantitative flow ratio (QFR) identifies functional relevance of non-culprit lesions in coronary angiographies of patients with acute myocardial infarction. Clin Res Cardiol 2021; 110:1659-1667. [PMID: 34251507 PMCID: PMC8484103 DOI: 10.1007/s00392-021-01897-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 06/14/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In patients with acute myocardial infarction (AMI) and multivessel coronary disease, revascularization of non-culprit lesions guided by proof of ischemia usually requires staged ischemia testing. Quantitative flow ratio (QFR) has been shown to be effective in assessing the hemodynamic relevance of lesions in stable coronary disease. However, its suitability in AMI patients is unknown. In this study, we tested the diagnostic value of QFR based on acute angiograms (aQFR) during AMI to assess the hemodynamic relevance of non-culprit lesions. METHODS We retrospectively assessed the diagnostic efficiency of aQFR in 280 vessels from 220 patients, comparing it with staged ischemia testing using elective coronary angiography with FFR (n = 47), stress cardiac MRI (n = 200) or SPECT (n = 33). RESULTS aQFR showed a very good diagnostic efficiency (AUC = 0.887, 95% CI 0.832-0.943, p < 0.001) in predicting ischemia of non-culprit lesions, significantly superior to coronary lesion's geometry as assessed by quantitative coronary angiography. The optimal cut-off for aQFR to predict ischemia was 0.80 (sensitivity = 83.7%, specificity = 86.1%). Maintaining a predefined level of 95% sensitivity and specificity, we created a decision model based on aQFR: lesions with aQFR ≤ 0.75 should be treated, lesions with aQFR ≥ 0.92 do not yield any hemodynamic relevance, and lesions in the "grey zone" (aQFR 0.75-0.92) benefit from further ischemia testings. This model would allow to reduce staged ischemia tests by 46.8% without a relevant loss in diagnostic efficiency. CONCLUSION Our data demonstrate that aQFR allows an effective assessment of hemodynamic relevance of non-culprit lesions in AMI and may guide interventions of non-culprit coronary lesions.
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Affiliation(s)
- Andrea Milzi
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany.
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Rosalia Dettori
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Sebastian Reith
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Mathias Burgmaier
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
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21
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Dettori R, Frick M, Burgmaier K, Lubberich RK, Hellmich M, Marx N, Reith S, Burgmaier M, Milzi A. Quantitative Flow Ratio Is Associated with Extent and Severity of Ischemia in Non-Culprit Lesions of Patients with Myocardial Infarction. J Clin Med 2021; 10:jcm10194535. [PMID: 34640551 PMCID: PMC8509261 DOI: 10.3390/jcm10194535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022] Open
Abstract
Quantitative flow ratio (QFR) is a novel method to assess the relevance of coronary stenoses based only on angiographic projections. We could previously show that QFR is able to predict the hemodynamic relevance of non-culprit lesions in patients with myocardial infarction. However, it is still unclear whether QFR is also associated with the extent and severity of ischemia, which can effectively be assessed with imaging modalities such as cardiac magnetic resonance (CMR). Thus, our aim was to evaluate the associations of QFR with both extent and severity of ischemia. We retrospectively determined QFR in 182 non-culprit coronary lesions from 145 patients with previous myocardial infarction, and compared it with parameters assessing extent and severity of myocardial ischemia in staged CMR. Whereas ischemic burden in lesions with QFR > 0.80 was low (1.3 ± 5.5% in lesions with QFR ≥ 0.90; 1.8 ± 7.3% in lesions with QFR 0.81–0.89), there was a significant increase in ischemic burden in lesions with QFR ≤ 0.80 (16.6 ± 15.6%; p < 0.001 for QFR ≥ 0.90 vs. QFR ≤ 0.80). These data could be confirmed by other parameters assessing extent of ischemia. In addition, QFR was also associated with severity of ischemia, assessed by the relative signal intensity of ischemic areas. Finally, QFR predicts a clinically relevant ischemic burden ≥ 10% with good diagnostic accuracy (AUC 0.779, 95%-CI: 0.666–0.892, p < 0.001). QFR may be a feasible tool to identify not only the presence, but also extent and severity of myocardial ischemia in non-culprit lesions of patients with myocardial infarction.
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Affiliation(s)
- Rosalia Dettori
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Michael Frick
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Kathrin Burgmaier
- Department of Pediatrics, University Hospital Cologne, D-50937 Cologne, Germany;
| | - Richard Karl Lubberich
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology (IMSB), Faculty of Medicine and University Hospital Cologne, University of Cologne, D-50937 Cologne, Germany;
| | - Nikolaus Marx
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Sebastian Reith
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Mathias Burgmaier
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Andrea Milzi
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
- Correspondence:
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22
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Terentes-Printzios D, Oikonomou D, Gkini KP, Gardikioti V, Aznaouridis K, Dima I, Tsioufis K, Vlachopoulos C. Angiography-based estimation of coronary physiology: A frame is worth a thousand words. Trends Cardiovasc Med 2021; 32:366-374. [PMID: 34329733 DOI: 10.1016/j.tcm.2021.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/04/2021] [Accepted: 07/21/2021] [Indexed: 02/04/2023]
Abstract
Cumulative evidence has shown that coronary revascularization should be guided by functional significance of coronary lesions. Fractional flow reserve (FFR) is the gold standard for assessment of hemodynamic significance of coronary stenosis and FFR-guided percutaneous coronary intervention has improved clinical outcomes in patients with coronary artery disease. However, limitations of FFR such as increased operational time and cost, requirement of pressure wire and adenosine and technical difficulties have led to significant underutilization of the method in clinical practice. In the last few years, several methods of FFR estimation based on coronary angiography images have emerged to overcome invasive FFR limitations. The common elements of the novel indices include a 3D anatomical reconstruction of coronary vessels by angiographic projections and various approaches to fluid dynamics computation. Angiography-derived FFR methods have shown high diagnostic accuracy compared to invasive FFR. Although there are promising results regarding their prognostic role, large randomized trials evaluating clinical outcomes are lacking. The aim of this review is to present currently available angiography-derived FFR indices and highlight their differences, advantages, disadvantages and potential clinical implications.
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Affiliation(s)
- Dimitrios Terentes-Printzios
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece.
| | - Dimitrios Oikonomou
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Konstantia-Paraskevi Gkini
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Vasiliki Gardikioti
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Konstantinos Aznaouridis
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Ioanna Dima
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
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23
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Erbay A, Penzel L, Abdelwahed YS, Klotsche J, Schatz AS, Steiner J, Haghikia A, Landmesser U, Stähli BE, Leistner DM. Feasibility and diagnostic reliability of quantitative flow ratio in the assessment of non-culprit lesions in acute coronary syndrome. Int J Cardiovasc Imaging 2021; 37:1815-1823. [PMID: 33651231 PMCID: PMC8255265 DOI: 10.1007/s10554-021-02195-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/15/2021] [Indexed: 11/24/2022]
Abstract
Several studies have demonstrated the feasibility and safety of hemodynamic assessment of non-culprit coronary arteries in setting of acute coronary syndromes (ACS) using fractional flow reserve (FFR) measurements. Quantitative flow ratio (QFR), recently introduced as angiography-based fast FFR computation, has been validated with good agreement and diagnostic performance with FFR in chronic coronary syndromes. The aim of this study was to assess the feasibility and diagnostic reliability of QFR assessment during primary PCI. A total of 321 patients with ACS and multivessel disease, who underwent primary PCI and were planned for staged PCI of at least one non-culprit lesion were enrolled in the analysis. Within this patient cohort, serial post-hoc QFR analyses of 513 non-culprit vessels were performed. The median time interval between primary and staged PCI was 49 [42-58] days. QFR in non-culprit coronary arteries did not change between acute and staged measurements (0.86 vs 0.87, p = 0.114), with strong correlation (r = 0.94, p ≤ 0.001) and good agreement (mean difference -0.008, 95%CI -0.013-0.003) between measurements. Importantly, QFR as assessed at index procedure had sensitivity of 95.02%, specificity of 93.59% and diagnostic accuracy of 94.15% in prediction of QFR ≤ 0.80 at the time of staged PCI. The present study for the first time confirmed the feasibility and diagnostic accuracy of non-culprit coronary artery QFR during index procedure for ACS. These results support QFR as valuable tool in patients with ACS to detect further hemodynamic relevant lesions with excellent diagnostic performance and therefore to guide further revascularisation therapy.
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Affiliation(s)
- Aslihan Erbay
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Lisa Penzel
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Youssef S Abdelwahed
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Jens Klotsche
- German Rheumatism Research Centre Berlin, Berlin, Germany
- Institute for Epidemiology and Health Care Economics, Charité - University Medicine Berlin, Berlin, Germany
| | - Anne-Sophie Schatz
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Julia Steiner
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Arash Haghikia
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Barbara E Stähli
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Cardiology, University Heart Centre, University Hospital Zurich, Zurich, Switzerland
| | - David M Leistner
- Department of Cardiology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.
- Berlin Institute of Health (BIH), Berlin, Germany.
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24
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Bär S, Kavaliauskaite R, Ueki Y, Otsuka T, Kelbæk H, Engstrøm T, Baumbach A, Roffi M, von Birgelen C, Ostojic M, Pedrazzini G, Kornowski R, Tüller D, Vukcevic V, Magro M, Losdat S, Windecker S, Räber L. Quantitative Flow Ratio to Predict Nontarget Vessel-Related Events at 5 Years in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Angiography-Guided Revascularization. J Am Heart Assoc 2021; 10:e019052. [PMID: 33899509 PMCID: PMC8200733 DOI: 10.1161/jaha.120.019052] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 02/02/2021] [Indexed: 12/31/2022]
Abstract
Background In ST-segment-elevation myocardial infarction, angiography-based complete revascularization is superior to culprit-lesion-only percutaneous coronary intervention. Quantitative flow ratio (QFR) is a novel, noninvasive, vasodilator-free method used to assess the hemodynamic significance of coronary stenoses. We aimed to investigate the incremental value of QFR over angiography in nonculprit lesions in patients with ST-segment-elevation myocardial infarction undergoing angiography-guided complete revascularization. Methods and Results This was a retrospective post hoc QFR analysis of untreated nontarget vessels (any degree of diameter stenosis [DS]) from the randomized multicenter COMFORTABLE AMI (Comparison of Biolimus Eluted From an Erodible Stent Coating With Bare Metal Stents in Acute ST-Elevation Myocardial Infarction) trial by assessors blinded for clinical outcomes. The primary end point was cardiac death, spontaneous nontarget vessel myocardial infarction, and clinically indicated nontarget vessel revascularization (ie, ≥70% DS by 2-dimensional quantitative coronary angiography or ≥50% DS and ischemia) at 5 years. Of 1161 patients with ST-segment-elevation myocardial infarction, 946 vessels in 617 patients were analyzable by QFR. At 5 years, the rate of the primary end point was significantly higher in patients with QFR ≤0.80 (n=35 patients, n=36 vessels) versus QFR >0.80 (n=582 patients, n=910 vessels) (62.9% versus 12.5%, respectively; hazard ratio [HR], 7.33 [95% CI, 4.54-11.83], P<0.001), driven by higher rates of nontarget vessel myocardial infarction (12.8% versus 3.1%, respectively; HR, 4.38 [95% CI, 1.47-13.02], P=0.008) and nontarget vessel revascularization (58.6% versus 7.7%, respectively; HR, 10.99 [95% CI, 6.39-18.91], P<0.001) with no significant differences for cardiac death. Multivariable analysis identified QFR ≤0.80 but not ≥50% DS by 3-dimensional quantitative coronary angiography as an independent predictor of the primary end point. Results were consistent, including only >30% DS by 3-dimensional quantitative coronary angiography. Conclusions Our study suggests incremental value of QFR over angiography-guided percutaneous coronary intervention for nonculprit lesions among patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention.
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Affiliation(s)
- Sarah Bär
- Department of CardiologyBern University Hospital InselspitalBernSwitzerland
| | | | - Yasushi Ueki
- Department of CardiologyBern University Hospital InselspitalBernSwitzerland
| | - Tatsuhiko Otsuka
- Department of CardiologyBern University Hospital InselspitalBernSwitzerland
| | - Henning Kelbæk
- Department of CardiologyZealand University HospitalRoskildeDenmark
| | - Thomas Engstrøm
- Department of CardiologyCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and DevicesWilliam Harvey Research InstituteQueen Mary University of London and Barts Heart CentreLondonUnited Kingdom
| | - Marco Roffi
- Division of CardiologyUniversity Hospital GenevaGenevaSwitzerland
| | - Clemens von Birgelen
- Department of CardiologyThoraxcentrum Medisch Spectrum TwenteEnschedethe Netherlands
- Department of Health Technology and Services ResearchTechnical Medical CentreUniversity of TwenteEnschedethe Netherlands
| | | | | | - Ran Kornowski
- Cardiology DepartmentRabin Medical CenterTel Aviv UniversityPetah TikwaIsrael
| | - David Tüller
- Cardiology DepartmentTriemlispitalZurichSwitzerland
| | | | | | - Sylvain Losdat
- Clinical Trials Unit (CTU) BernUniversity of BernSwitzerland
| | - Stephan Windecker
- Department of CardiologyBern University Hospital InselspitalBernSwitzerland
| | - Lorenz Räber
- Department of CardiologyBern University Hospital InselspitalBernSwitzerland
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25
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Pagnoni M, Meier D, Candreva A, Maillard L, Adjedj J, Collet C, Mahendiran T, Cook S, Mujcinovic A, Dupré M, Rubimbura V, Roguelov C, Eeckhout E, De Bruyne B, Muller O, Fournier S. Future culprit detection based on angiography-derived FFR. Catheter Cardiovasc Interv 2021; 98:E388-E394. [PMID: 33913606 DOI: 10.1002/ccd.29736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/23/2021] [Accepted: 04/12/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES We sought to characterize the hemodynamic impact of mild coronary artery disease (CAD) using quantitative flow ratio (QFR, an angiography-derived fractional flow reserve [FFR]) in a population of patients with only non-significant CAD at baseline that subsequently experienced a myocardial infarction (MI). BACKGROUND The discriminatory value of FFR in patients with mild CAD remains imperfect. METHODS We retrospectively included patients who underwent invasive coronary angiography for an MI, in whom another angiogram had been performed within the previous 5 years. Three-dimensional quantitative coronary angiography, QFR, and lesion length analysis were conducted on lesions responsible for the MI (future culprit lesions, [FCL]) as well as on control lesions (non-culprit lesions, [NCL]). RESULTS Eighty-three FCL and 117 NCL were analyzed in 83 patients: FCL were more severe (median % diameter of stenosis [DS] 39.1% [29.8; 45.7] vs. 29.8% [25.0; 37.2], p < .001), had lower QFR values (0.94 [0.86; 0.98] vs. 0.98 [0.96; 1.00], p < .001) and tended to be longer (15.2 mm [10.0; 27.3] vs. 12.7 mm [9.3; 22.4], p = .070) than NCL. In lesions with an interval < 2 years between baseline angiography and MI, the difference in QFR was more pronounced compared to the lesions with a longer interval (FCL: 0.92 [0.85; 0.97] vs. NCL: 0.98 [0.94; 1.00], p < .001 and FCL: 0.96 [0.88; 1.00] vs. NCL: 0.98 [0.96;1.00], p = .006 respectively) CONCLUSION: Mild coronary stenoses that are subsequently responsible for an MI (FCL) exhibit a higher DS and lower QFR years before the event. Furthermore, FCL with a lower QFR at baseline appear to lead earlier to MI.
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Affiliation(s)
- Mattia Pagnoni
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - David Meier
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Luc Maillard
- Department of Cardiology, GCS ES Axium Rambot, Aix en Provence, France
| | - Julien Adjedj
- Department of Cardiology, Arnault Tzank Institute, Saint Laurent Du Var, France
| | - Carlos Collet
- Cardiovascular Center, OLV Ziekenhuis, Aalst, Belgium
| | - Thabo Mahendiran
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Stephane Cook
- Department of Cardiology, HFR Fribourg, Fribourg, Switzerland
| | - Alma Mujcinovic
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Marion Dupré
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Vladimir Rubimbura
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Christan Roguelov
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Eric Eeckhout
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Bernard De Bruyne
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.,Cardiovascular Center, OLV Ziekenhuis, Aalst, Belgium
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.,Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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26
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Cerrato E, Mejía-Rentería H, Franzè A, Quadri G, Belliggiano D, Biscaglia S, Lo Savio L, Spataro F, Erriquez A, Giacobbe F, Vergara-Uzcategui C, di Girolamo D, Tebaldi M, Varbella F, Campo G, Escaned J. Quantitative flow ratio as a new tool for angiography-based physiological evaluation of coronary artery disease: a review. Future Cardiol 2021; 17:1435-1452. [PMID: 33739146 DOI: 10.2217/fca-2020-0199] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The functional evaluation of coronary stenoses has obtained important clinical results in recent years, resulting in strong guideline recommendations. Nonetheless, the use of coronary wire-based functional evaluation has not yet become part of the routine in catheterization laboratories for several reasons, including the need to advance a wire into the coronary vessel to interrogate the stenosis. Angiography-derived indexes have been introduced to expand the current use of physiology to estimate the functional meaning of a stenosis on the basis of angiographic data only. The most studied and validated angiography-derived index is certainly the quantitative flow ratio. This article will summarize the basics of the quantitative flow ratio, the related validation studies and its current and future applications.
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Affiliation(s)
- Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano & Rivoli Infermi Hospital, Rivoli, Turin, Italy
| | - Hernan Mejía-Rentería
- Department of Cardiology, Hospital Clinico San Carlos, Instituto de Investigación Sanitaria San Carlos & Universidad Complutense de Madrid, Madrid, Spain
| | - Alfonso Franzè
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano & Rivoli Infermi Hospital, Rivoli, Turin, Italy
| | - Giorgio Quadri
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano & Rivoli Infermi Hospital, Rivoli, Turin, Italy
| | - Davide Belliggiano
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano & Rivoli Infermi Hospital, Rivoli, Turin, Italy
| | - Simone Biscaglia
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, RA, Italy
| | - Luca Lo Savio
- Interventional Cardiology Unit, Rivoli Infermi Hospital, Rivoli, Turin, Italy
| | - Fabio Spataro
- Interventional Cardiology Unit, Rivoli Infermi Hospital, Rivoli, Turin, Italy
| | - Andrea Erriquez
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, RA, Italy
| | - Federico Giacobbe
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano & Rivoli Infermi Hospital, Rivoli, Turin, Italy
| | - Carlos Vergara-Uzcategui
- Department of Cardiology, Hospital Clinico San Carlos, Instituto de Investigación Sanitaria San Carlos & Universidad Complutense de Madrid, Madrid, Spain
| | | | - Matteo Tebaldi
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, RA, Italy
| | - Ferdinando Varbella
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano & Rivoli Infermi Hospital, Rivoli, Turin, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, RA, Italy
| | - Javier Escaned
- Department of Cardiology, Hospital Clinico San Carlos, Instituto de Investigación Sanitaria San Carlos & Universidad Complutense de Madrid, Madrid, Spain
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27
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Influence of lesion and disease subsets on the diagnostic performance of the quantitative flow ratio in real-world patients. Sci Rep 2021; 11:2995. [PMID: 33542310 PMCID: PMC7862355 DOI: 10.1038/s41598-021-82235-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/08/2021] [Indexed: 11/26/2022] Open
Abstract
The quantitative flow ratio (QFR) is a novel angiography-based computational method assessing functional ischemia caused by coronary stenosis. This study aimed to evaluate the diagnostic performance of quantitative flow ratio (QFR) in patients with angina and acute myocardial infarction (AMI) and to identify the conditions with low diagnostic performance. We assessed the QFR for 1077 vessels under fractional flow ratio (FFR) evaluation in 915 patients with angina and AMI. The diagnostic accuracies of the QFR for identifying an FFR ≤ 0.8 were 95.98% (95% confidence interval [CI] 94.52 to 97.14%) for the angina group and 92.42% (95% CI 86.51 to 96.31%) for the AMI group. The diagnostic accuracy of the QFR in the borderline FFR zones (> 0.75, ≤ 0.85) (91.23% [95% CI 88.25 to 93.66%]) was significantly lower than that in others (difference: 4.32; p = 0.001). The condition accompanying both AMI and the borderline FFR zone showed the lowest QFR diagnostic accuracy in our data (83.93% [95% CI 71.67 to 92.38]). The diagnostic accuracy was reduced for tandem lesions (p = 0.04, not correcting for multiple testing). Our study found that the QFR method yielded a high overall diagnostic performance in real-world patients. However, low diagnostic accuracy has been observed in borderline FFR zones with AMI, and the hybrid FFR approach needs to be considered.
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28
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Sejr‐Hansen M, Christiansen EH, Ahmad Y, Vendrik J, Westra J, Holm NR, Thim T, Seligman H, Hall K, Sen S, Terkelsen CJ, Eftekhari A. Performance of quantitative flow ratio in patients with aortic stenosis undergoing transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2021; 99:68-73. [DOI: 10.1002/ccd.29518] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/25/2020] [Accepted: 12/13/2020] [Indexed: 01/09/2023]
Affiliation(s)
| | | | - Yousif Ahmad
- Department of Cardiology National Heart and Lung institute, Imperial College London London UK
| | - Jeroen Vendrik
- Department of Cardiology, AMC Medical Research BV Amsterdam The Netherlands
| | - Jelmer Westra
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Niels R. Holm
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Troels Thim
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Henry Seligman
- Department of Cardiology National Heart and Lung institute, Imperial College London London UK
| | - Kerry Hall
- Department of Cardiology National Heart and Lung institute, Imperial College London London UK
| | - Sayan Sen
- Department of Cardiology National Heart and Lung institute, Imperial College London London UK
| | | | - Ashkan Eftekhari
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
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29
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Thim T, van der Hoeven NW, Musto C, Nijveldt R, Götberg M, Engstrøm T, Smits PC, Oldroyd KG, Gershlick AH, Escaned J, Baptista SB, Raposo L, van Royen N, Maeng M. Evaluation and Management of Nonculprit Lesions in STEMI. JACC Cardiovasc Interv 2020; 13:1145-1154. [PMID: 32438985 DOI: 10.1016/j.jcin.2020.02.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/18/2020] [Accepted: 02/25/2020] [Indexed: 02/08/2023]
Abstract
Nonculprit lesions are frequently observed in patients with ST-segment elevation myocardial infarction. Results from recent randomized clinical trials suggest that complete revascularization after ST-segment elevation myocardial infarction improves outcomes. In this state-of-the-art paper, the authors review these trials and consider how best to determine which nonculprit lesions require revascularization and when this should be performed.
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Affiliation(s)
- Troels Thim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
| | | | - Carmine Musto
- Department of Interventional Cardiology, San Camillo Hospital, Rome, Italy
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Thomas Engstrøm
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pieter C Smits
- Department of Cardiology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Keith G Oldroyd
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Anthony H Gershlick
- University of Leicester, University Hospitals of Leicester, Leicester Biomedical Research Unit, Leicester, United Kingdom
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Sergio Bravo Baptista
- University Clinic of Cardiology, Faculty of Medicine at University of Lisbon, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Luis Raposo
- Cardiology Department, Santa Cruz Hospital-CHLO, Lisbon, Portugal
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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30
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Clinical implication of QFR in patients with ST-segment elevation myocardial infarction after drug-eluting stent implantation. Int J Cardiovasc Imaging 2020; 37:755-766. [PMID: 33044717 DOI: 10.1007/s10554-020-02068-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022]
Abstract
The feasibility and prognostic value of quantitative flow ratio (QFR) after percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients have not been assessed. The aim of this study was to investigate the prognostic utility of post-PCI QFR to predict outcomes in STEMI and determine the influence of functional results, in both culprit and nonculprit lesions, after PCI. Patients undergoing PCI of culprit lesions and receiving staged procedures of nonculprit lesions after 7 days were enrolled from 2 centers and underwent post-PCI QFR. The primary outcome was the vessel-oriented composite endpoints (VOCEs), defined as vessel-related cardiovascular death, vessel-related myocardial infarction, and target vessel revascularization. Four hundred fifteen vessels (186 culprit lesions and 219 nonculprit lesions) in 186 patients were analyzed. Measured at staged PCI, the post-PCI QFR of culprit lesions was significantly lower than that of nonculprit lesions (0.92 ± 0.10 versus 0.95 ± 0.08, p < 0.001). The multivariable model demonstrated that low post-PCI QFR was an independent predictor of 2-year VOCE (20.8% versus 5.7%; hazard ratio 2.718; 95% CI 1.347-5.486; p = 0.005). In STEMI patients with a low angiography-derived index of microcirculatory resistance (≤ 40U), a good correlation and agreement between post-PCI QFR value of culprit lesions at primary and staged procedures (r = 0.942; mean difference: - 0.0017 [- 0.074 to 0.070]) was identified. In conclusion, culprit lesions suffered from suboptimal functional results more frequently compared to nonculprit lesions after PCI in STEMI patients. Low post-PCI QFR was associated with subsequent adverse clinical outcomes. After stenting, culprit lesions may feasibly be assessed through QFR without significant microvascular dysfunction.
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31
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Westra J, Tu S. Overview of Quantitative Flow Ratio and Optical Flow Ratio in the Assessment of Intermediate Coronary Lesions. US CARDIOLOGY REVIEW 2020. [DOI: 10.15420/usc.2020.09] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) improves clinical outcome compared with angiography-guided PCI. Advances in computational technology have resulted in the development of solutions, enabling fast derivation of FFR from imaging data in the catheterization laboratory. The quantitative flow ratio is currently the most validated approach to derive FFR from invasive coronary angiography, while the optical flow ratio allows faster and more automation in FFR computation from intracoronary optical coherence tomography. The use of quantitative flow ratio and optical flow ratio has the potential for swift and safe identification of lesions that require revascularization, optimization of PCI, evaluation of plaque features, and virtual planning of PCI.
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Affiliation(s)
- Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Shengxian Tu
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
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32
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Mejía-Rentería H, Nombela-Franco L, Paradis JM, Lunardi M, Lee JM, Amat-Santos IJ, Veiga Fernandez G, Kalra A, Bansal EJ, de la Torre Hernandez JM, Rodés-Cabau J, Ribichini FL, Escaned J. Angiography-based quantitative flow ratio versus fractional flow reserve in patients with coronary artery disease and severe aortic stenosis. EUROINTERVENTION 2020; 16:e285-e292. [DOI: 10.4244/eij-d-19-01001] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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33
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Scarsini R, Terentes-Printzios D, De Maria GL, Ribichini F, Banning A. Why, When and How Should Clinicians Use Physiology in Patients with Acute Coronary Syndromes? ACTA ACUST UNITED AC 2020; 15:e05. [PMID: 32577130 PMCID: PMC7301203 DOI: 10.15420/icr.2019.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/13/2020] [Indexed: 12/14/2022]
Abstract
Current data support the use of coronary physiology in patients with acute coronary syndrome (ACS). In patients with ST-elevation MI, the extent of myocardial damage and microvascular dysfunction create a complex conundrum to assimilate when considering clinical management and risk stratification. In this setting, the index of microcirculatory resistance emerged as an accurate tool to identify patients at risk of suboptimal myocardial reperfusion after primary percutaneous coronary intervention who may benefit from novel adjunctive therapies. In the context of non-ST-elevation ACS, coronary physiology should be carefully interpreted and often integrated with intracoronary imaging, especially in cases of ambiguous culprit lesion. Conversely, the functional assessment of bystander coronary disease is favoured by the available evidence, aiming to achieve complete revascularisation. Based on everyday clinical scenarios, the authors illustrate the available evidence and provide recommendations for the functional assessment of infarct-related artery and non-culprit lesions in patients with ACS.
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Affiliation(s)
- Roberto Scarsini
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK.,Division of Cardiology, Department of Medicine, University of Verona Verona, Italy
| | | | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona Verona, Italy
| | - Adrian Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK.,Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford Oxford, UK
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34
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Safi H, Bourantas CV, Ramasamy A, Zanchin T, Bär S, Tufaro V, Jin C, Torii R, Karagiannis A, Reiber JHC, Mathur A, Onuma Y, Windecker S, Lansky A, Maehara A, Serruys PW, Stone P, Baumbach A, Stone GW, Räber L. Predictive value of the QFR in detecting vulnerable plaques in non-flow limiting lesions: a combined analysis of the PROSPECT and IBIS-4 study. Int J Cardiovasc Imaging 2020; 36:993-1002. [PMID: 32152810 DOI: 10.1007/s10554-020-01805-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/22/2020] [Indexed: 01/07/2023]
Abstract
Studies have shown that the quantitative flow ratio (QFR), recently introduced to assess lesion severity from coronary angiography, provides useful prognostic information; however the additive value of this technique over intravascular imaging in detecting lesions that are likely to cause events is yet unclear. We analysed data acquired in the PROSPECT and IBIS-4 studies, in particular the baseline virtual histology-intravascular ultrasound (VH-IVUS) and angiographic data from 17 non-culprit lesions with a presumable vulnerable phenotype (i.e., thin or thick cap fibroatheroma) that caused major adverse cardiac events or required revascularization (MACE) at 5-year follow-up and from a group of 78 vulnerable plaques that remained quiescent. The segments studied by VH-IVUS were identified in coronary angiography and the QFR was estimated. The additive value of 3-dimensional quantitative coronary angiography (3D-QCA) and of the QFR in predicting MACE at 5 year follow-up beyond plaque characteristics was examined. It was found that MACE lesions had a greater plaque burden (PB) and smaller minimum lumen area (MLA) on VH-IVUS, a longer length and a smaller minimum lumen diameter (MLD) on 3D-QCA and a lower QFR compared with lesions that remained quiescent. By univariate analysis MLA, PB, MLD, lesion length on 3D-QCA and QFR were predictors of MACE. In multivariate analysis a low but normal QFR (> 0.80 to < 0.97) was the only independent prediction of MACE (HR 3.53, 95% CI 1.16-10.75; P = 0.027). In non-flow limiting lesions with a vulnerable phenotype, QFR may provide additional prognostic information beyond plaque morphology for predicting MACE throughout 5 years.
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Affiliation(s)
- Hannah Safi
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Institute of Cardiovascular Sciences, University College London, London, UK
| | - Christos V Bourantas
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK. .,Institute of Cardiovascular Sciences, University College London, London, UK. .,William Harvey Research Institute, Queen Mary University London, London, UK.
| | - Anantharaman Ramasamy
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Queen Mary University London, London, UK
| | - Thomas Zanchin
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Sarah Bär
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Vincenzo Tufaro
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Chongying Jin
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ryo Torii
- Department of Mechanical Engineering, University College London, London, UK
| | - Alexios Karagiannis
- CTU Bern, Institute of Social and Preventive Medicine, Bern University, Bern, Switzerland
| | | | - Anthony Mathur
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Queen Mary University London, London, UK
| | - Yoshinubo Onuma
- Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Alexandra Lansky
- Institute of Cardiovascular Sciences, University College London, London, UK.,Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Akiko Maehara
- Department of Cardiology, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY, USA
| | - Patrick W Serruys
- Faculty of Medicine, National Heart & Lung Institute, Imperial College London, London, UK
| | - Peter Stone
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andreas Baumbach
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Queen Mary University London, London, UK
| | - Gregg W Stone
- Department of Cardiology, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY, USA
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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35
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van Diemen PA, Driessen RS, Kooistra RA, Stuijfzand WJ, Raijmakers PG, Boellaard R, Schumacher SP, Bom MJ, Everaars H, de Winter RW, van de Ven PM, Reiber JH, Min JK, Leipsic JA, Knuuti J, Underwood RS, van Rossum AC, Danad I, Knaapen P. Comparison Between the Performance of Quantitative Flow Ratio and Perfusion Imaging for Diagnosing Myocardial Ischemia. JACC Cardiovasc Imaging 2020; 13:1976-1985. [PMID: 32305469 DOI: 10.1016/j.jcmg.2020.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/12/2019] [Accepted: 02/05/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study compared the performance of the quantitative flow ratio (QFR) with single-photon emission computed tomography (SPECT) and positron emission tomography (PET) myocardial perfusion imaging (MPI) for the diagnosis of fractional flow reserve (FFR)-defined coronary artery disease (CAD). BACKGROUND QFR estimates FFR solely based on cine contrast images acquired during invasive coronary angiography (ICA). Head-to-head studies comparing QFR with noninvasive MPI are lacking. METHODS A total of 208 (624 vessels) patients underwent technetium-99m tetrofosmin SPECT and [15O]H2O PET imaging before ICA in conjunction with FFR measurements. ICA was obtained without using a dedicated QFR acquisition protocol, and QFR computation was attempted in all vessels interrogated by FFR (552 vessels). RESULTS QFR computation succeeded in 286 (52%) vessels. QFR correlated well with invasive FFR overall (R = 0.79; p < 0.001) and in the subset of vessels with an intermediate (30% to 90%) diameter stenosis (R = 0.76; p < 0.001). Overall, per-vessel analysis demonstrated QFR to exhibit a superior sensitivity (70%) in comparison with SPECT (29%; p < 0.001), whereas it was similar to PET (75%; p = 1.000). Specificity of QFR (93%) was higher than PET (79%; p < 0.001) and not different from SPECT (96%; p = 1.000). As such, the accuracy of QFR (88%) was superior to both SPECT (82%; p = 0.010) and PET (78%; p = 0.004). Lastly, the area under the receiver operating characteristics curve of QFR, in the overall sample (0.94) and among vessels with an intermediate lesion (0.90) was higher than SPECT (0.63 and 0.61; p < 0.001 for both) and PET (0.82; p < 0.001 and 0.77; p = 0.002), respectively. CONCLUSIONS In this head-to-head comparative study, QFR exhibited a higher diagnostic value for detecting FFR-defined significant CAD compared with perfusion imaging by SPECT or PET.
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Affiliation(s)
- Pepijn A van Diemen
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Roel S Driessen
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Wynand J Stuijfzand
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pieter G Raijmakers
- Department of Radiology, Nuclear Medicine, and PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ronald Boellaard
- Department of Radiology, Nuclear Medicine, and PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Stefan P Schumacher
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michiel J Bom
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Henk Everaars
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruben W de Winter
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - James K Min
- Institute for Cardiovascular Imaging, Weill-Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Jonathan A Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Richard S Underwood
- Department of Nuclear Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Albert C van Rossum
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ibrahim Danad
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
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36
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Oqab Z, Akl E, Mehta SR. Novel approaches to guide complete revascularisation in patients with STEMI and multivessel coronary artery disease. EUROINTERVENTION 2020; 15:e1558-e1559. [PMID: 32234687 DOI: 10.4244/eijv15i18a284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Zardasht Oqab
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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