Long-Term Clinical Outcome After Fractional Flow Reserve–Guided Treatment in Patients With Angiographically Equivocal Left Main Coronary Artery Stenosis

Abstract

Background-Significant left main coronary artery stenosis is an accepted indication for surgical revascularization. The potential of angiography to evaluate the hemodynamic severity of a stenosis is limited. The aims of the present study were to assess the long-term clinical outcome of patients with an angiographically equivocal left main coronary artery stenosis in whom the revascularization strategy was based on fractional flow reserve (FFR) and to determine the relationship between quantitative coronary angiography and FFR. Methods and Results-In 213 patients with an angiographically equivocal left main coronary artery stenosis, FFR measurements and quantitative coronary angiography were performed. When FFR was Ն0.80, patients were treated medically or another stenosis was treated by coronary angioplasty (nonsurgical group; nϭ138). When FFR was Ͻ0.80, coronary artery bypass grafting was performed (surgical group; nϭ75). The 5-year survival estimates were 89.8% in the nonsurgical group and 85.4% in the surgical group (Pϭ0.48). The 5-year event-free survival estimates were 74.2% and 82.8% in the nonsurgical and surgical groups, respectively (Pϭ0.50). Percent diameter stenosis at quantitative coronary angiography correlated significantly with FFR (rϭϪ0.38, PϽ0.001), but a very large scatter was observed. In 23% of patients with a diameter stenosis Ͻ50%, the left main coronary artery stenosis was hemodynamically significant by FFR. Conclusions-In patients with equivocal stenosis of the left main coronary artery, angiography alone does not allow appropriate individual decision making about the need for revascularization and often underestimates the functional significance of the stenosis. The favorable outcome of an FFR-guided strategy suggests that FFR should be assessed in such patients before a decision is made "blindly" about the need for revascularization. (Circulation. 2009;120:1505-1512.)

Comparing treatment outcomes of fractional flow reserve-guided and angiography-guided percutaneous coronary intervention in patients with multi-vessel coronary artery diseases: a systematic review and meta-analysis

“…Although coronary angiography often underestimates or overestimates the functional severity of a lesion, it is still the standard technique for guiding PCI in patients with multivessel CAD [26]. Coronary pressure-derived FFR is an invasive index used to identify stenosis responsible for reversible ischemia, and is well validated [21,27,28]. An FFR of 0.80 discriminates coronary stenosis responsible for ischemia with an accuracy >90% [29,30].…”

Staging of multivessel percutaneous coronary interventions: An expert consensus statement from the Society for Cardiovascular Angiography and Interventions

“…An FFR of >0.75 or >0.80 correlates with excellent long-term outcomes if PCI is deferred [40,43,[51][52][53]. FFR has also been shown to predict physiologic significance of left main coronary lesions, although the data are not as robust [54][55][56].…”

Myocardial perfusion with single-photon emission computed tomography, multidetector computed tomography, or neither?

“…More recently, the development of high-resolution multidetector computed tomography (MDCT) scanners has reignited the interest of practicing physicians in the anatomy rather than the functional significance of luminal obstruction. Nonetheless, the importance of an abnormality in myocardial blood flow and tissue perfusion over mere anatomy has been reinforced in invasive clinical trials 1,2 The significance of tissue perfusion has therefore promoted an interest in developing CT protocols that may allow a ''one stop shop'' assessment of anatomical severity and physiological significance of obstructive CAD. [3][4][5][6][7] The assessment of myocardial ischemia with computed tomography is based on a comparison of myocardial enhancement after the infusion of a vasodilator agent, such as adenosine, to myocardial enhancement during rest.…”