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Published on: April 13, 2015
Three-dimensional QCA-based vessel fractional flow reserve (vFFR) in Heart Team decision-making: a multicentre,
Mariusz Tomaniak1,2, Kaneshka Masdjedi1, Tara Neleman1
1Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands.
Insights
Three-dimensional quantitative coronary angiography (3D QCA)-based fractional flow reserve (FFR) is feasible in about 40% of Heart Team patients, with significant discordance found in 29.8% of cases. This highlights potential discrepancies in revascularization strategies.
Area of Science:
- Cardiovascular medicine
- Interventional cardiology
- Medical imaging
Background:
- Heart Team decision-making relies on coronary angiography, but functional significance of lesions is not always clear.
- Three-dimensional quantitative coronary angiography (3D QCA)-based fractional flow reserve (FFR) offers a non-invasive method to assess lesion significance.
Purpose of the Study:
- To evaluate the feasibility of 3D QCA-based FFR (vFFR) in Heart Team patients.
- To assess the concordance between vFFR-confirmed lesion significance and the Heart Team's revascularization strategy.
Main Methods:
- Retrospective cohort study involving 416 patients from six institutions.
- Three-vessel vFFR was computed by blinded analysts.
- Discordance between vFFR and revascularization strategy was the primary outcome; major adverse cardiac events (MACE) were secondary outcomes.
Main Results:
- vFFR computation was feasible in 416/1003 (41.5%) of screened patients, with insufficient angiogram quality being the main limitation (43%).
- Discordance between vFFR and revascularization strategy occurred in 124/416 patients (29.8%).
- Discordant patients had a higher incidence of MACE (29.7%) compared to concordant patients (18.5%) over a median follow-up of 962 days (p=0.031).
Conclusions:
- Three-vessel vFFR is feasible in a subset of Heart Team patients, though limited by angiogram quality.
- A significant proportion of patients (29.8%) showed discordance between vFFR-confirmed lesion significance and the proposed revascularization strategy.
- These findings suggest vFFR could refine revascularization decisions and potentially improve patient outcomes.
Objectives:
To evaluate the feasibility of three-vessel three-dimensional (3D) quantitative coronary angiography (QCA)-based fractional flow reserve (FFR) computation in patients discussed within the Heart Team in whom the treatment decision was based on angiography alone, and to evaluate the concordance between 3D QCA-based vessel FFR (vFFR)-confirmed functional lesion significance and revascularisation strategy as proposed by the Heart Team.
Design:
Retrospective, cohort.
Setting:
3D QCA-based FFR indices have not yet been evaluated in the context of Heart Team decision-making; consecutive patients from six institutions were screened for eligibility and three-vessel vFFR was computed by blinded analysts.
Participants:
Consecutive patients with chronic coronary syndrome or unstable angina referred for Heart Team consultation. Exclusion criteria involved: presentation with acute myocardial infarction (MI), significant valve disease, left ventricle ejection fraction <30%, inadequate quality of angiogram precluding vFFR computation in all three epicardial coronary arteries (ie, absence of a minimum of two angiographic projections with views of at least 30° apart, substantial foreshortening/overlap of the vessel, poor contrast medium injection, ostial lesions, chronic total occlusions).
Primary And Secondary Outcome Measures:
Discordance between vFFR-confirmed lesion significance and revascularisation was assessed as the primary outcome measure. Rates of major adverse cardiac events (MACE) defined as cardiac death, MI and clinically driven revascularisation were reported.
Results:
Of a total of 1003 patients were screened for eligibility, 416 patients (age 65.6±10.6, 71.2% male, 53% stable angina) were included. The most important reason for screening failure was insufficient quality of the angiogram (43%). Discordance between vFFR confirmed lesion significance and revascularisation was found in 124/416 patients (29.8%) corresponding to 149 vessels (46/149 vessels (30.9%) were reclassified as significant and 103/149 vessels (69.1%) as non-significant by vFFR). Over a median of 962 days, the cumulative incidence of MACE was 29.7% versus 18.5% in discordant versus concordant patients (p=0.031).
Conclusions:
vFFR computation is feasible in around 40% of the patients referred for Heart Team discussion, a limitation that is mostly based on insufficient quality of the angiogram. Three vessel vFFR screening indicated discordance between vFFR confirmed lesion significance and revascularisation in 29.8% of the patients.
