Predicting the Physiological Effect of Revascularization in Serially Diseased Coronary Arteries
Bhavik N Modi1, Sethuraman Sankaran2, Hyun Jin Kim2
1NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King's College London (B.N.M., H.E., R.R., D.P.).
Insights
Fractional flow reserve (FFR) pullback and FFR by computed tomography (FFRCT) underestimate stenosis in serial coronary artery disease. A new FFRCT-based planning tool (FFRCT-P) significantly improves accuracy in assessing individual stenoses.
Area of Science:
- Cardiovascular Medicine
- Medical Imaging
- Interventional Cardiology
Background:
- Fractional flow reserve (FFR) is crucial for assessing coronary artery disease significance.
- Evaluating individual stenoses in serially diseased vessels poses theoretical limitations for FFR.
- Noninvasive FFR by computed tomography (FFRCT) offers an alternative but requires validation in complex scenarios.
Purpose of the Study:
- To assess the accuracy of invasive FFR pullback and noninvasive FFRCT in evaluating individual stenoses within serial coronary artery disease.
- To introduce and validate a novel FFRCT-derived percutaneous coronary intervention (PCI) planning tool (FFRCT-P).
- To compare the predictive accuracy of FFRCT-P against FFRpullback and conventional FFRCT for lesion-specific stenosis significance.
Main Methods:
- Prospective enrollment of patients with angiographic serial coronary artery disease undergoing PCI.
- Performance of coronary CT angiography with post hoc FFRCT and FFRCT-P calculations.
- Invasive FFR pullback measurements prior to PCI to determine apparent stenosis contribution (FFRpullback).
- Measurement of true FFR (FFRtrue) after individual lesion PCI for validation.
Main Results:
- Conventional FFRCT showed moderate correlation with invasive FFR for overall lesion assessment (R=0.71).
- Both FFRpullback and conventional FFRCT significantly underestimated the true FFR contribution of individual stenoses (42% and 37% error, respectively).
- The novel FFRCT-P tool significantly reduced stenosis underestimation to a 7% error, demonstrating improved accuracy.
Conclusions:
- Invasive FFR pullback and conventional FFRCT methods are limited by significant underestimation of stenosis contribution in serial coronary artery disease.
- A novel noninvasive FFRCT-based PCI planning tool (FFRCT-P) provides more accurate prediction of individual stenosis significance in complex coronary anatomy.
- FFRCT-P represents a promising advancement for noninvasive assessment and planning in patients with serial coronary artery disease.
Background:
Fractional flow reserve (FFR) is commonly used to assess the functional significance of coronary artery disease but is theoretically limited in evaluating individual stenoses in serially diseased vessels. We sought to characterize the accuracy of assessing individual stenoses in serial disease using invasive FFR pullback and the noninvasive equivalent, fractional flow reserve by computed tomography (FFRCT). We subsequently describe and test the accuracy of a novel noninvasive FFRCT-derived percutaneous coronary intervention (PCI) planning tool (FFRCT-P) in predicting the true significance of individual stenoses.
Methods And Results:
Patients with angiographic serial coronary artery disease scheduled for PCI were enrolled and underwent prospective coronary CT angiography with conventional FFRCT-derived post hoc for each vessel and stenosis (FFRCT). Before PCI, the invasive hyperemic pressure-wire pullback was performed to derive the apparent FFR contribution of each stenosis (FFRpullback). The true FFR attributable to individual lesions (FFRtrue) was then measured following PCI of one of the lesions. The predictive accuracy of FFRpullback, FFRCT, and the novel technique (FFRCT-P) was then assessed against FFRtrue. From the 24 patients undergoing the protocol, 19 vessels had post hoc FFRCT and FFRCT-P calculation. When assessing the distal effect of all lesions, FFRCT correlated moderately well with invasive FFR ( R=0.71; P<0.001). For lesion-specific assessment, there was significant underestimation of FFRtrue using FFRpullback (mean discrepancy, 0.06±0.05; P<0.001, representing a 42% error) and conventional trans-lesional FFRCT (0.05±0.06; P<0.001, 37% error). Using FFRCT-P, stenosis underestimation was significantly reduced to a 7% error (0.01±0.05; P<0.001).
Conclusions:
FFR pullback and conventional FFRCT significantly underestimate true stenosis contribution in serial coronary artery disease. A novel noninvasive FFRCT-based PCI planner tool more accurately predicts the true FFR contribution of each stenosis in serial coronary artery disease.
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