Fractional flow reserve in clinical practice: from wire-based invasive measurement to image-based computation

Tu, Shengxian; Westra, Jelmer; Adjedj, Julien; Ding, Daixin; Liang, Fuyou; Xu, Bo; Holm, Niels Ramsing; Reiber, Johan H. C.; Wijns, William

doi:10.1093/eurheartj/ehz918

Cited by 73 publications

(50 citation statements)

References 40 publications

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“…In addition to the cost of disposable pressure wire and the discomfort caused by hyperemia, it was reported that a major obstacle to the adoption of coronary physiological assessment in the catheterization laboratory lies in physician's confidence in visual assessment of angiographic images alone 3 . Thus, image‐based computational FFR could potentially contribute to wider adoption of coronary physiological assessment 21 . However, the feasibility and efficiency of computational FFR is crucial for it to be widely adopted in routine use in the catheterization laboratory.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic accuracy of quantitative flow ratio for assessment of coronary stenosis significance from a single angiographic view: A novel method based on bifurcation fractal law

Ding

Chang³

et al. 2021

Cathet Cardio Intervent

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102

138

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Objectives We aimed to evaluate the diagnostic accuracy of computation of fractional flow reserve (FFR) from a single angiographic view in patients with intermediate coronary stenosis. Background Computation of quantitative flow ratio (QFR) from a single angiographic view might increase the feasibility of routine use of computational FFR. In addition, current QFR solutions assume a linear tapering of the reference vessel size, which might decrease the diagnostic accuracy in the presence of the physiologically significant bifurcation lesions. Methods An artificial intelligence algorithm was proposed for automatic delineation of lumen contours of major epicardial coronary arteries including their side branches. A step‐down reference diameter function was reconstructed based on the Murray bifurcation fractal law and used for QFR computation. Validation of this Murray law‐based QFR (μQFR) was performed on the FAVOR II China study population. The μQFR was computed separately in two angiographic projections, starting with the one with optimal angiographic image quality. Hemodynamically significant coronary stenosis was defined by pressure wire‐derived FFR ≤0.80. Results The μQFR was successfully computed in all 330 vessels of 306 patients. There was excellent correlation (r = 0.90, p < .001) and agreement (mean difference = 0.00 ± 0.05, p = .378) between μQFR and FFR. The vessel‐level diagnostic accuracy for μQFR to identify hemodynamically significant stenosis was 93.0% (95% CI: 90.3 to 95.8%), with sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of 87.5% (95% CI: 80.2 to 92.8%), 96.2% (95% CI: 92.6 to 98.3%), 92.9% (95% CI: 86.5 to 96.9%), 93.1% (95% CI: 88.9 to 96.1%), 23.0 (95% CI: 11.6 to 45.5), 0.13 (95% CI: 0.08 to 0.20), respectively. Use of suboptimal angiographic image view slightly decreased the diagnostic accuracy of μQFR (AUC = 0.97 versus 0.92, difference = 0.05, p < .001). Intra‐ and inter‐observer variability for μQFR computation was 0.00 ± 0.03, and 0.00 ± 0.03, respectively. Average analysis time for μQFR was 67 ± 22 s. Conclusions Computation of μQFR from a single angiographic view has high feasibility and excellent diagnostic accuracy in identifying hemodynamically significant coronary stenosis. The short analysis time and good reproducibility of μQFR bear potential of wider adoption of physiological assessment in the catheterization laboratory.

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Section: Discussionmentioning

confidence: 99%

Diagnostic accuracy of quantitative flow ratio for assessment of coronary stenosis significance from a single angiographic view: A novel method based on bifurcation fractal law

Ding

Chang³

et al. 2021

Cathet Cardio Intervent

Self Cite

102

138

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“…QFR also had a good diagnostic correlation with FFR in assessing non-culprit lesions in patients with acute coronary syndrome and multivessel disease ( 14 , 15 ). Although QFR and vFFR are both angiography-derived FFR, they are computed using different fluid dynamics models ( 16 ). Data on the diagnostic performance of vFFR remains to be further explored.…”

Section: Discussionmentioning

confidence: 99%

Agreement Between Invasive Wire-Based and Angiography-Based Vessel Fractional Flow Reserve Assessment on Intermediate Coronary Stenoses

Chang

Lee

Chuang

et al. 2021

Front. Cardiovasc. Med.

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Background: Angiography-based functional assessment of coronary stenoses emerges as a novel approach to assess coronary physiology. We sought to investigate the agreement between invasive coronary wire-based fractional flow reserve (FFR), resting full-cycle ratio (RFR), and angiography-based vessel FFR (vFFR) for the functional assessment of coronary stenoses in patients with coronary artery disease.Materials and Methods: Between Jan 01, 2018, and Dec 31, 2020, 298 patients with 385 intermediate lesions received invasive coronary wire-based functional assessment (FFR, RFR or both) at a single tertiary medical center. Coronary lesions involving ostium or left main artery were excluded. vFFR analysis was performed retrospectively based on aortic root pressure and two angiographic projections.Results: In total, 236 patients with 291 lesions were eligible for vFFR analysis. FFR and RFR were performed in 258 and 162 lesions, respectively. The mean FFR, RFR and vFFR value were 0.84 ± 0.08, 0.90 ± 0.09, and 0.83 ± 0.10. vFFR was significantly correlated with FFR (r = 0.708, P < 0.001) and RFR (r = 0.673, P < 0.001). The diagnostic performance of vFFR vs. FFR was accuracy 81.8%, sensitivity 77.4%, specificity 83.9%, positive predictive value 69.9%, and negative predictive value 88.5%. The discriminative power of vFFR for FFR ≤ 0.80 or RFR ≤ 0.89 was excellent. Area under the receiver operating characteristic curve (AUC) was 0.87 (95% CI:0.83–0.92) for FFR and 0.80 (95% CI:0.73–0.88) for RFR.Conclusion: Angiography-based vFFR has a substantial agreement with invasive wire-based FFR and RFR in patients with intermediate coronary stenoses. vFFR can be utilized to assess coronary physiology without a pressure wire in a post hoc manner.

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“…These findings indicate that there is an association between low FFR values and high-risk plaque The present study examined for the first time the combined value of computationally-derived FFR and plaque morphology in predicting events. We analysed data from the PROSPECT and IBIS-4 studies and used an established software that is capable of retrospectively processing angiographic imaging data to derive FFR [7]. We found that QFR provided additional prognostic information to plaque morphology and enabled more accurate prediction of MACE.…”

Section: Discussionmentioning

confidence: 99%

“…Quantitative flow ratio (QFR), a wire-free, hyperaemia-free method has been recently introduced to overcome these limitations and derive FFR from models reconstructed from 3-dimensional quantitative coronary angiography (3D-QCA) [3]. Recent clinical studies have supported the potential clinical value of QFR showing that it enables not only accurate detection of flow limiting lesions but also identification of patients at risk from cardiovascular events [4][5][6][7].…”

Section: Introductionmentioning

confidence: 99%

Predictive value of the QFR in detecting vulnerable plaques in non-flow limiting lesions: a combined analysis of the PROSPECT and IBIS-4 study

Safi

Bourantas

Ramasamy

et al. 2020

Int J Cardiovasc Imaging

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Studies have shown that the quantitative flow ratio (QFR), recently introduced to assess lesion severity from coronary angiography, provides useful prognostic information; however the additive value of this technique over intravascular imaging in detecting lesions that are likely to cause events is yet unclear. We analysed data acquired in the PROSPECT and IBIS-4 studies, in particular the baseline virtual histology-intravascular ultrasound (VH-IVUS) and angiographic data from 17 non-culprit lesions with a presumable vulnerable phenotype (i.e., thin or thick cap fibroatheroma) that caused major adverse cardiac events or required revascularization (MACE) at 5-year follow-up and from a group of 78 vulnerable plaques that remained quiescent. The segments studied by VH-IVUS were identified in coronary angiography and the QFR was estimated. The additive value of 3-dimensional quantitative coronary angiography (3D-QCA) and of the QFR in predicting MACE at 5 year follow-up beyond plaque characteristics was examined. It was found that MACE lesions had a greater plaque burden (PB) and smaller minimum lumen area (MLA) on VH-IVUS, a longer length and a smaller minimum lumen diameter (MLD) on 3D-QCA and a lower QFR compared with lesions that remained quiescent. By univariate analysis MLA, PB, MLD, lesion length on 3D-QCA and QFR were predictors of MACE. In multivariate analysis a low but normal QFR (> 0.80 to < 0.97) was the only independent prediction of MACE (HR 3.53, 95% CI 1.16-10.75; P = 0.027). In non-flow limiting lesions with a vulnerable phenotype, QFR may provide additional prognostic information beyond plaque morphology for predicting MACE throughout 5 years.

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Fractional flow reserve in clinical practice: from wire-based invasive measurement to image-based computation

Cited by 73 publications

References 40 publications

Diagnostic accuracy of quantitative flow ratio for assessment of coronary stenosis significance from a single angiographic view: A novel method based on bifurcation fractal law

Diagnostic accuracy of quantitative flow ratio for assessment of coronary stenosis significance from a single angiographic view: A novel method based on bifurcation fractal law

Agreement Between Invasive Wire-Based and Angiography-Based Vessel Fractional Flow Reserve Assessment on Intermediate Coronary Stenoses

Predictive value of the QFR in detecting vulnerable plaques in non-flow limiting lesions: a combined analysis of the PROSPECT and IBIS-4 study

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