The Influence of Lesion Location on the Diagnostic Accuracy of Adenosine-Free Coronary Pressure Wire Measurements

Kobayashi, Yuhei; Johnson, Nils P.; Berry, Colin; Bruyne, Bernard De; Gould, K. Lance; Jeremias, Allen; Oldroyd, Keith G.; Pijls, Nico H.J.; Fearon, William F.

doi:10.1016/j.jcin.2016.08.041

Cited by 88 publications

(64 citation statements)

References 29 publications

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“…Finally, Kobayashi et al have already reported on the relationship between left main and proximal LAD stenoses and greater discordance between iFR and FFR; in this setting, the larger myocardial mass subtended by these vessels may result in greater coronary flow variation between resting and hyperemic conditions compared with vessels subtending smaller amounts of myocardium and therefore a greater chance for discordance (FFR+/iFR‐). On the other hand, in older patients, FFR across a similar angiographic stenosis is higher than in younger patients, perhaps due to a greater degree of microvascular dysfunction in older patients .…”

Section: Discussionmentioning

confidence: 99%

Predictive factors of discordance between the instantaneous wave‐free ratio and fractional flow reserve

Dérimay

Johnson

Zimmermann

et al. 2019

Cathet Cardio Intervent

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Objectives To identify clinical, angiographic and hemodynamic predictors of discordance between instantaneous wave‐free ratio (iFR) and fractional flow reserve (FFR). Background The iFR was found to be non‐inferior to the gold‐standard FFR for guiding coronary revascularization, although it is discordant with FFR in 20% of cases. A better understanding of the causes of discordance may enhance application of these indices. Methods Both FFR and iFR were measured in the prospective multicenter CONTRAST study. Clinical, angiographic and hemodynamic variables were compared between patients with concordant values of FFR and iFR (cutoff ≤0.80 and ≤0.89, respectively). Results Out of the 587 patients included, in 466 patients (79.4%) FFR and iFR agreed: both negative, n = 244 (41.6%), or positive, n = 222 (37.8%). Compared with FFR, iFR was negative discordant (FFR+/iFR‐) in 69 (11.8%) patients and positive discordant (FFR‐/iFR+) in 52 (8.9%) patients. On multivariate regression, stenosis location (left main or proximal left anterior descending) (OR: 3.30[1.68;6.47]), more severe stenosis (OR: 1.77[1.35;2.30]), younger age (OR: 0.93[0.90;0.97]), and slower heart rate (OR: 0.59[0.42;0.75]) were predictors of a negative discordant iFR. Absence of a beta‐blocker (OR: 0.41[0.22;0.78]), older age (OR: 1.04[1.00;1.07]), and less severe stenosis (OR: 0.69[0.53;0.89]) were predictors of a positive discordant iFR. Conclusions During iFR acquisition, stenosis location, stenosis degree, heart rate, age and use of beta blockers influence concordance with FFR and should be taken into account when interpreting iFR.

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Section: Discussionmentioning

confidence: 99%

Predictive factors of discordance between the instantaneous wave‐free ratio and fractional flow reserve

Dérimay

Johnson

Zimmermann

et al. 2019

Cathet Cardio Intervent

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“…This is likely due to the large amount of myocardium supplied by LAD and emphasizes the need for physiological assessment to identify LAD lesions that may benefit from revascularization. Kobayashi et al documented that all alternative pressure indices (contrastFFR, iFR, and resting Pd/Pa) showed impaired accuracy for combined left main coronary artery/proximal LAD disease with FFR as Reference . Hence, there may be a theoretical concern that nonhyperemic flow‐based and angiography‐derived assessment underestimates the severity of proximal LAD lesions by not appreciating the potential large increase in flow during hyperemia where a high peak flow leads to a large pressure gradient and thus a low FFR .…”

Section: Discussionmentioning

confidence: 99%

Diagnostic performance of quantitative flow ratio in prospectively enrolled patients: An individual patient‐data meta‐analysis

Westra

Campo

et al. 2019

Cathet Cardio Intervent

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Objectives We aimed to provide robust performance estimates for quantitative flow ratio (QFR) in assessment of intermediary coronary lesions. Background Angiography‐based functional lesion assessment by QFR may appear as a cost saving and safe approach to expand the use of physiology‐guided percutaneous coronary interventions. QFR was proven feasible and showed good diagnostic performance in mid‐sized off‐line and on‐line studies with fractional flow reserve (FFR) as reference standard. Methods We performed a collaborative individual patient‐data meta‐analysis of all available prospective studies with paired assessment of QFR and FFR using the CE‐marked QFR application. The main outcome was agreement of QFR and FFR using a two‐step analysis strategy with a multilevel mixed model accounting for study and center level variation. Results Of 16 studies identified, four studies had prospective enrollment and provided patient level data reaching a total of 819 patients and 969 vessels with paired FFR and QFR: FAVOR Pilot (n = 73); WIFI II (n = 170); FAVOR II China (n = 304) and FAVOR II Europe‐Japan (n = 272). We found an overall agreement (mean difference 0.009 ± 0.068, I2 = 39.6) of QFR with FFR. The diagnostic performance was sensitivity 84% (95%CI: 77–90, I2 = 70.1), specificity 88% (95%CI: 84–91, I2 = 60.1); positive predictive value 80% (95%CI: 76–85, I2 = 33.4), and negative predictive value 95% (95%CI: 93–96, I2 = 75.9). Conclusions Diagnostic performance of QFR was good with FFR as reference in this meta‐analysis of high quality studies. QFR could provide an easy, safe, and cost‐effective solution for functional evaluation of coronary artery stenosis.

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“…Furthermore, because the greatest increments in transstenotic flow occur in vessel locations with the largest amounts of downstream myocardium, these situations occur most frequently in proximal left anterior descending artery or left main stem stenoses. 10,11 Such positive FFR values are similar to a young patient with mild aortic stenosis on echocardiographic assessment developing severe aortic stenosis in the same setting with increased flow during exercise. We do not perform aortic valve replacement in such circumstances because we know this measurement is an anomaly caused by a huge increase in flow.…”

Section: Ffr: a Surrogate Measure Of Coronary Flowmentioning

confidence: 63%

“…With FFR, the paradox exists in which patients with the mildest stenoses, the healthiest microcirculations, and the greatest increments in coronary flow can still generate low FFR values. Furthermore, because the greatest increments in transstenotic flow occur in vessel locations with the largest amounts of downstream myocardium, these situations occur most frequently in proximal left anterior descending artery or left main stem stenoses . Such positive FFR values are similar to a young patient with mild aortic stenosis on echocardiographic assessment developing severe aortic stenosis in the same setting with increased flow during exercise.…”

Section: Ffr: a Surrogate Measure Of Coronary Flowmentioning

confidence: 94%

Fractional Flow Reserve in Angiographically Insignificant Stenoses: Unmasking the Lesion or Creating Disease?

Cook

Davies

2017

JAHA

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The Influence of Lesion Location on the Diagnostic Accuracy of Adenosine-Free Coronary Pressure Wire Measurements

Abstract: The cFFR, iFR, and Pd/Pa are less accurate in LM/pLAD compared with other lesion locations, likely related to the larger amount of myocardium supplied by LM/pLAD. Nevertheless, cFFR provides the best diagnostic accuracy among the adenosine-free indices, regardless of lesion location.

Cited by 88 publications

References 29 publications

Predictive factors of discordance between the instantaneous wave‐free ratio and fractional flow reserve

Predictive factors of discordance between the instantaneous wave‐free ratio and fractional flow reserve

Diagnostic performance of quantitative flow ratio in prospectively enrolled patients: An individual patient‐data meta‐analysis

Fractional Flow Reserve in Angiographically Insignificant Stenoses: Unmasking the Lesion or Creating Disease?

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