Impact of Fractional Flow Reserve Derived From Coronary Computed Tomography Angiography on Heart Team Treatment Decision-Making in Patients With Multivessel Coronary Artery Disease

Abstract

Background: Fractional flow reserve (FFR) is a reliable tool for the functional assessment of coronary stenoses. FFR computed tomography (CT) derived (FFR CT ) has shown to be accurate, but its clinical usefulness in patients with complex coronary artery disease remains to be investigated. The present study sought to determine the impact of FFR CT on heart team’s treatment decision-making and selection of vessels for revascularization in patients with 3-vessel coronary artery disease. Methods: The trial was an international, multicenter study randomizing 2 heart teams to make a treatment decision between percutaneous coronary interventions and coronary artery bypass grafting using either coronary computed tomography angiography or conventional angiography. The heart teams received the FFR CT and had to make a treatment decision and planning integrating the functional component of the stenoses. Each heart team calculated the anatomic SYNTAX score, the noninvasive functional SYNTAX score and subsequently integrated the clinical information to compute the SYNTAX score III providing a treatment recommendation, that is, coronary artery bypass grafting, percutaneous coronary intervention, or equipoise coronary artery bypass grafting-percutaneous coronary intervention. The primary objective was to determine the proportion of patients in whom FFR CT changed the treatment decision and planning. Results: Overall, 223 patients were included. Coronary computed tomography angiography assessment was feasible in 99% of the patients and FFR CT analysis in 88%. FFR CT was available for 1030 lesions (mean FFR CT value 0.64±13). A treatment recommendation of coronary artery bypass grafting was made in 24% of the patients with coronary computed tomography angiography with FFR CT . The addition of FFR CT changed the treatment decision in 7% of the patients and modified selection of vessels for revascularization in 12%. With conventional angiography as reference, FFR CT assessment resulted in reclassification of 14% of patients from intermediate and high to low SYNTAX score tertile. Conclusions: In patients with 3-vessel coronary artery disease, a noninvasive physiology assessment using FFR CT changed heart team’s treatment decision-making and procedural planning in one-fifth of the patients. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02813473.

Computed tomographic evaluation of myocardial ischemia

“…A decision-making based on CTA and CT-FFR showed high agreement with the decision derived from ICA [126]. This study also showed that the addition of CT-FFR to CTA alone changed the treatment decision (between PCI and CABG) in 7% of the patients and modified selection of vessels for revascularization in 12% [127]. Using CT-FFR resulted in 12% fewer MACE at 1 year and 30% lower costs with improved quality of life in comparison with ICA and visual guidance [128].…”

Diagnosis and management of silent coronary ischemia in patients undergoing carotid endarterectomy

“…A randomized trial of heart team decision making and treatment planning for PCI or CABG in patients with multivessel coronary disease found high agreement between noninvasive CTA-based decisions and invasive angiography-based decisions 28 and showed that the physiologic assessment provided by FFR CT changed the heart team's treatment decision and procedural plan in one-fifth of patients. 30 The strategy of systematic preoperative coronary angiography followed by selective coronary revascularization to improve survival has also been tested in a population of 208 consecutive patients with medium to high risk undergoing major vascular surgery. Patients were randomized to selective preoperative coronary angiography based on the results of noninvasive cardiac stress tests or to a systematic strategy of preoperative coronary angiography in all patients.…”

Hengshun Aromatic Vinegar Ameliorates Vascular Endothelial Injury via Regulating PKCζ-Mediated Oxidative Stress and Apoptosis

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