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[Angiographic assessment of functionally insignificant left main coronary artery stenoses: reliability compared to
M Lindstaedt1, M Spiecker, T Lawo
1Medizinische Klinik II, Universitätsklinik Bergmannsheil, Bochum. michael.lindstaedt@rub.de
Insights
Visual assessment of intermediate left main coronary artery (LMCA) disease is unreliable for surgical decisions. Fractional flow reserve (FFR) is crucial for determining the significance of LMCA lesions, ensuring appropriate treatment and patient outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Diagnostic Imaging
Background:
- Left main coronary artery (LMCA) disease often requires bypass surgery.
- Intermediate LMCA disease assessment by angiography alone is unreliable.
- Fractional flow reserve (FFR) > 0.75 safely allows deferral of surgery.
Purpose of the Study:
- Compare visual angiographic assessment accuracy with FFR for intermediate LMCA stenoses.
- Evaluate interventional cardiologists' ability to classify LMCA lesions visually.
- Assess long-term outcomes after deferring surgery based on FFR.
Main Methods:
- Retrospective review of angiograms by 3 blinded interventional cardiologists.
- Patients with intermediate LMCA disease deferred from surgery if FFR > 0.75.
- Classification of lesions as significant, not significant, or unsure.
Main Results:
- Mean follow-up of 29 months with no death or myocardial infarction.
- Individual reviewers correctly classified lesions in 58-82% of cases.
- Interobserver agreement was low (46%), with a mean Kappa coefficient of 0.04.
- Over 50% might have had unnecessary surgery if decisions were solely based on angiography.
Conclusions:
- Visual assessment alone is insufficient for determining the functional significance of intermediate LMCA lesions.
- FFR measurements are essential for guiding revascularization decisions in LMCA disease.
- Relying solely on angiography can lead to inappropriate surgical interventions.
Background And Objective:
Left main coronary artery disease (LMCA) is still a widely accepted indication for coronary artery bypass surgery. Intermediate LMCA disease, however, often cannot be evaluated reliably on the basis of clinical and angiographic information alone. The deferral of surgical revascularization based on fractional flow reserve (FFR) measurements has been shown to be safe and feasible when taking an FFR value of (3) 0.75 as cutoff. This study was performed to compare the accuracy of visual angiographic assessment of intermediate LMCA stenoses by experienced interventional cardiologists with functional assessment by FFR in a patient population with excellent long-term outcome after deferral of surgery on the basis of FFR measurements.
Patients And Methods:
24 of 51 consecutive patients with intermediate LMCA disease were deferred from surgery based on an FFR value of > or = 0.75. Each angiogram was retrospectively reviewed independently by three experienced interventional cardiologists. Reviewers were blinded to initial FFR results, clinical data, and clinical outcome and asked to classify each lesion as SIGNIFICANT (FFR < 0.75), NOT SIGNIFICANT (FFR > or = 0.75), or UNSURE if the observer was unable to make a decision based on the angiogram.
Results:
Mean follow-up was 29 +/- 13.6 months. No death or myocardial infarction was observed, event-free survival was 69 %. When taking the "unsure" classifications into consideration the individual reviewers achieved correct lesion classification with respect to FFR results on average in 58 % to 82 % of cases. Interobserver variability resulted in only 46 % of cases in concordant lesion classification (3 agreements or 2 agreements and 1 "unsure" evaluation). The number of concordant agreements between the individual pairs of reviewers did not exceed the rate of coincidental agreements that could be expected to result from simple guessing (mean KAPPA coefficient 0.04). More than 50 % of patients with excellent long-term outcome after deferral of surgery would potentially have undergone operative revascularization if consensual decision making had been solely based on angiographic lesion assessment.
Conclusion:
The functional significance of intermediate or equivocal LMCA lesions should not be based on visual assessment alone, even when performed by experienced interventional cardiologists.
