Prediction of the true fractional flow reserve of left main coronary artery stenosis with concomitant downstream stenoses: in vitro and in vivo experiments

Yamamoto, Etsuhide; Saito, Naritatsu; Matsuo, Hitoshi; Kawase, Yoshiaki; Watanabe, Shin; Bao, Bingyuan; Watanabe, Hiroki; Higami, Hirooki; Nakatsuma, Kenji; Kimura, Takeshi

doi:10.4244/eijv11i11a246

Cited by 20 publications

(12 citation statements)

References 11 publications

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“…When concomitant to a LMCA stenosis, a significant stenosis is present in only one downstream branch, measuring the true FFR is still potentially confounded. As described earlier, the practice of measuring LMCA FFR by using a disease-free daughter vessel (figure 5) has been shown to be a relatively reliable with only minimal interference from downstream disease in the diseasedbranch (unless this is severe: >90% diameter stenosis or FFR<0.45) [44][45][46] .…”

Section: 'Isolated' Left Main Stenosismentioning

confidence: 87%

“…The main findings of this study are: The unique benefits of precisely controlling lesion geometry with 3D-printing have enabled us to overcome many limitations of previous work in the field, where stenoses were created with external ties and clamps 27,77 . This has enabled us to show that the factors that most influence the error when predicting individual lesion significance in serial disease are total vessel FFR, average % diameter stenosis of the tandem stenoses and ∆P across the lesion is question.…”

Section: Discussionmentioning

confidence: 99%

“…Whilst potential interaction is recognized, the practice of measuring LMCA FFR by placing the wire in the disease-free daughter vessel has been shown to be a reliable method in in vitro studies with only minimal interference from downstream disease in the diseased-branch [44][45][46] . Fearon et al went on to demonstrate this in their in vivo study by interrogating LMCA stenoses in 25 patients following PCI of the LAD+/-LCx.…”

Section: Theoretical Challenges To Physiological Assessment Of the Lmcamentioning

confidence: 99%

“…Whilst this method has theoretical flaws, based on the inconsistent volume of subtended myocardium, previous data suggests it is reliable method of assessing the ∆FFRtrue of the LMCA stenosis. This method was initially validated in animal studies 41,45,46 . Fearon et al then demonstrated this in a clinical study of 91 LMCA lesions following PCI of the LAD, LCx, or both.…”

Section: Limitations Of No 'Gold Standard' For Invasive Physiologicalmentioning

confidence: 99%

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3 Optimising physiology guided management of serial coronary artery disease

Modi

Perera

2018

Abstracts

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BackgroundPhysiology-guided coronary revascularisation is associated with better outcomes however it is unclear if pressure-derived indices, such as FFR, can reliably assess individual lesions in serial disease.Methods3D printed serial disease phantoms were assessed in vitro. FFR of a lesion was predicted from the size of step up on pressure-wire pullback in the presence of serial lesions (FFR app ) and compared to phantoms with no accompanying lesion (FFR true ). Mathematical models to minimise error in predicting FFR true were developed in 32 phantoms and validated in 15 patients and another 20 phantoms. In 43 serial disease patients we compared how different indices (FFR, iFR, Pd/Pa) predict true values, after isolation by PCI or disease-free sidebranch. In a subset of 21 we measured flow to calculate Hyperaemic Stenosis Resistance (hSR).ResultsFFR app underestimated FFR true in 85% of phantoms, with discrepancy proportional to total FFR. 4.5% of lesions were misclassified (FFR <0.8 threshold); with mathematical models this fell to 1.5% (figure 1). Clinically, FFR, iFR and Pd/Pa significantly underestimated true values; hSR is least affected (p<0.01).Abstract 3 Figure 1Scatterplots of difference between FFRapp of a stenosis in presence of accompanying lesion and FFRtrue, when stenosis present in isolation. Within the validation cohort, discrepancy was 5% (0.036±0.048), which improved to 0.6% (0.005±0.037) and 0.8% (0.006±0.023) using empirical and theoretical solutions respectively (P<0.01). In the clinical cohort, discrepancy was 6.6% (0.041±0.03), which improved to 2.2% (0.019±0.026) and 2.0% (0.016±0.023) (P<0.01)ConclusionPressure-derived indices underestimate stenosis significance in serial disease. Pressure pullback data can be mathematically analysed to minimise this. Pressure-flow based resistance indices are less prone to this error.

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Section: 'Isolated' Left Main Stenosismentioning

confidence: 87%

Section: Discussionmentioning

confidence: 99%

Section: Theoretical Challenges To Physiological Assessment Of the Lmcamentioning

confidence: 99%

Section: Limitations Of No 'Gold Standard' For Invasive Physiologicalmentioning

confidence: 99%

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3 Optimising physiology guided management of serial coronary artery disease

Modi

Perera

2018

Abstracts

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“…Tandem lesions exist when there are two lesions of possible angiographic significance in the same coronary artery, separated by an angiographically normal segment . The correct approach requires measuring the Δ P to determine the relative importance of each lesion's contribution to flow resistance . FFR is measured beyond the distal lesion (FFR summed ).…”

Section: Clinical Utility Of Translesional Measurementsmentioning

confidence: 99%

Focused update of expert consensus statement: Use of invasive assessments of coronary physiology and structure: A position statement of the society of cardiac angiography and interventions

Lotfi

Davies

Fearon

et al. 2018

Cathet Cardio Intervent

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Physiology-Guided Management of Serial Coronary Artery Disease

et al. 2018

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Serial coronary artery disease is common, and physiological assessment is prone to errors. The future, whether it be in improving the interpretation of fractional flow reserve, using resting indices such as instantaneous wave-free ratio, or examining novel flow-based resistance indices, will hopefully improve our management of this common yet unresolved clinical conundrum. In the meantime, revascularisation decisions in this challenging scenario should focus on clinical presentation and physiologic evaluation using a pressure-wire pullback maneuver and left main disease-free side branch where appropriate.

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Prediction of the true fractional flow reserve of left main coronary artery stenosis with concomitant downstream stenoses: in vitro and in vivo experiments

Abstract: Two novel equations which predict the true FFR of LMCA stenosis were demonstrated to be correct. The study also revealed that the functional impact of downstream stenoses on the LMCA stenosis became stronger when the downstream stenoses became more severe.

Cited by 20 publications

References 11 publications

3 Optimising physiology guided management of serial coronary artery disease

3 Optimising physiology guided management of serial coronary artery disease

Focused update of expert consensus statement: Use of invasive assessments of coronary physiology and structure: A position statement of the society of cardiac angiography and interventions

Physiology-Guided Management of Serial Coronary Artery Disease

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