Virtual (Computed) Fractional Flow Reserve: Future Role in Acute Coronary Syndromes

Haley, Hazel Arfah; Ghobrial, Mina; Morris, Paul D; Gosling, Rebecca; Williams, Gareth; Mills, Mark T; Newman, Tom; Rammohan, Vignesh; Pederzani, Giulia; Lawford, Patricia; Hose, Rodney; Gunn, Julian

doi:10.3389/fcvm.2021.735008

Cited by 6 publications

(7 citation statements)

References 82 publications

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“…The presented findings, although preliminary, constitute another step forward in the development of virtual PCI planning tools. Our study extends prior observations from computed tomography coronary angiography (CCTA) based FFRCT PCI planning software [ 27 ] and other angiography-derived residual FFR indices [ 25 , 28 , 29 , 30 ]. These tools have the potential to improve treatment qualification by better predicting which patients end with proper functional PCI outcomes as well as those with a lower likelihood of functionally satisfactory outcome, and thus, a risk of a futile invasive procedure.…”

Section: Discussionsupporting

confidence: 81%

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Diagnostic Accuracy of Coronary Angiography-Based Vessel Fractional Flow Reserve (vFFR) Virtual Stenting

Tomaniak

Neleman

Plantes

et al. 2022

JCM

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3D coronary angiography-based vessel fractional flow reserve (vFFR) proved to be an accurate diagnostic alternative to invasively measured pressure wire based fractional flow reserve (FFR). The ability to compute post-PCI vFFR using pre-PCI vFFR virtual stent analysis is unknown. We aimed to assess the feasibility and diagnostic accuracy of pre-PCI vFFR virtual stenting analysis (residual vFFR) with post-PCI FFR as a reference. This is an observational, single-center retrospective cohort study including consecutive patients from the FFR-SEARCH registry. We blindly calculated residual vFFR from pre-PCI angiograms and compared them to invasive pressure-wire based post-PCI FFR. Inclusion criteria involved presentation with either stable or unstable angina or non-ST elevation myocardial infarction (NSTEMI), ≥1 significant stenosis in one of the epicardial coronary arteries (percentage diameter stenosis of >70% by QCA or hemodynamically relevant stenosis with FFR ≤0.80) and pre procedural angiograms eligible for vFFR analysis. Exclusion criteria comprised patients with ST elevation myocardial infarction (STEMI), coronary bypass grafts, cardiogenic shock or severe hemodynamic instability. Eighty-one pre-PCI residual vFFR measurements were compared to post-PCI FFR and post-PCI vFFR measurements. Mean residual vFFR was 0.91 ± 0.06, mean post-PCI FFR 0.91 ± 0.06 and mean post-PCI vFFR was 0.92 ± 0.05. Residual vFFR showed a high linear correlation (r = 0.84) and good agreement (mean difference (95% confidence interval): 0.005 (−0.002–0.012)) with post-PCI FFR, as well as with post-PCI-vFFR (r = 0.77, mean difference −0.007 (−0.015–0.0003)). Residual vFFR showed good accuracy in the identification of lesions with post-PCI FFR < 0.90 (sensitivity 94%, specificity 71%, area under the curve (AUC) 0.93 (95% CI: 0.86–0.99), p < 0.001). Virtual stenting using vFFR provided an accurate estimation of post-PCI FFR and post-PCI vFFR. Further studies are needed to prospectively validate a vFFR-guided PCI strategy.

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Section: Discussionsupporting

confidence: 81%

“…As a next step, the ability to predict the functional outcomes of PCI is gaining increased attention [ 27 , 28 , 29 , 30 ]. Recent developments in the vFFR software allowed us to simulate the effect of ‘virtual’ PCI and estimate post-PCI FFR (residual vFFR).…”

Section: Introductionmentioning

confidence: 99%

Diagnostic Accuracy of Coronary Angiography-Based Vessel Fractional Flow Reserve (vFFR) Virtual Stenting

Tomaniak

Neleman

Plantes

et al. 2022

JCM

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“…We included in our study 40 patients affected by ACS at the time of revascularization confirming the usefulness of vFFR in ACS patients. 25 The rate of RIMA graft occlusion in our study was higher than the reported rate in the literature (68 vs. 89%, respectively) that could be explained by differences in surgical technique (such as Y-grafting). 26 In our previous study, we studied 70 consecutive patients treated with CABG who underwent clinically indicated ICA after surgery with the aim of investigating the functional progression of CAD in native vessels and assessing the relationship between the preoperative angiography-derived FFR value and graft occlusion.…”

Section: Discussioncontrasting

confidence: 75%

“…Identifying the lesions which are physiologically significant in ACS patients can be challenging. We included in our study 40 patients affected by ACS at the time of revascularization confirming the usefulness of vFFR in ACS patients 25 …”

Section: Discussionmentioning

confidence: 79%

Preoperative angiography-derived fractional flow reserve may predict coronary artery bypass grafting occlusion and disease progression

Mushtaq,

Gigante,

Conte

et al. 2023

Journal of Cardiovascular Medicine

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Background Graft occlusion after coronary artery bypass grafting (CABG) has been associated with competitive flow of native coronary arteries. Objectives To assess with coronary computed tomography angiography (CCTA) graft occlusion and coronary artery disease (CAD) progression of native vessels after CABG and their relationship with angiography-derived vessel fractional flow reserve (vFFR) performed before surgery. Methods Between 2006 and 2018, serial vFFR analyses were obtained before CABG in each major native coronary vessel from two institutions. All patients underwent follow-up CCTA. Results In 171 consecutive patients, serial preoperative angiograms were suitable for vFFR analysis of 298 grafted and 59 nongrafted vessels. Median time between CABG and CCTA was 2.1 years. Preoperative vFFR was assessed in 131 left anterior descending artery (LAD), 132 left circumflex artery (LCX) and 94 right coronary aretry (RCA) and was less than 0.80 in 255 of 298 bypassed vessels. Graft occlusion was observed at CCTA in 28 of 298 grafts. The median preoperative vFFR value of native coronaries was higher in occluded compared with patent grafts (0.75 vs. 0.60, P < 0.001) and was associated with graft. The best vFFR cut-off to predict graft occlusion was 0.67. Progression of CAD was higher in grafted than in nongrafted vessels (89.6 vs. 47.5%, P < 0.001). Pre-CABG vFFR predicted disease progression of grafted native vessels (AUC = 0.83). Conclusion Preoperative vFFR derived from invasive coronary angiography was able to predict graft occlusion and CAD progression of grafted coronary arteries.

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“…Correct calculation of angiography-derived FFR critically depends on the operator's experience. It is demonstrated that when an expert reanalysis previous 3D reconstruction of casual users, it may result in a change in the treatment decision in as much as 37% of cases ( 52 ).…”

Section: Limitations Of Fractional Flow Reserve Derived From Invasive...mentioning

confidence: 99%

Current status and future perspectives of fractional flow reserve derived from invasive coronary angiography

Dobrić,

Furtula,

Tešić

et al. 2023

Front. Cardiovasc. Med.

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Assessment of the functional significance of coronary artery stenosis using invasive measurement of fractional flow reserve (FFR) or non-hyperemic indices has been shown to be safe and effective in making clinical decisions on whether to perform percutaneous coronary intervention (PCI). Despite strong evidence from clinical trials, utilization of these techniques is still relatively low worldwide. This may be to some extent attributed to factors that are inherent to invasive measurements like prolongation of the procedure, side effects of drugs that induce hyperemia, additional steps that the operator should perform, the possibility to damage the vessel with the wire, and additional costs. During the last few years, there was a growing interest in the non-invasive assessment of coronary artery lesions, which may provide interventionalist with important physiological information regarding lesion severity and overcome some of the limitations. Several dedicated software solutions are available on the market that could provide an estimation of FFR using 3D reconstruction of the interrogated vessel derived from two separated angiographic projections taken during diagnostic coronary angiography. Furthermore, some of them use data about aortic pressure and frame count to more accurately calculate pressure drop (and FFR). The ideal non-invasive system should be integrated into the workflow of the cath lab and performed online (during the diagnostic procedure), thereby not prolonging procedural time significantly, and giving the operator additional information like vessel size, lesion length, and possible post-PCI FFR value. Following the development of these technologies, they were all evaluated in clinical trials where good correlation and agreement with invasive FFR (considered the gold standard) were demonstrated. Currently, only one trial (FAVOR III China) with clinical outcomes was completed and demonstrated that QFR-guided PCI may provide better results at 1-year follow-up as compared to the angiography-guided approach. We are awaiting the results of a few other trials with clinical outcomes that test the performance of these indices in guiding PCI against either FFR or angiography-based approach, in various clinical settings. Herein we will present an overview of the currently available data, a critical review of the major clinical trials, and further directions of development for the five most widely available non-invasive indices: QFR, vFFR, FFRangio, caFFR, and AccuFFRangio.

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Virtual (Computed) Fractional Flow Reserve: Future Role in Acute Coronary Syndromes

Cited by 6 publications

References 82 publications

Diagnostic Accuracy of Coronary Angiography-Based Vessel Fractional Flow Reserve (vFFR) Virtual Stenting

Diagnostic Accuracy of Coronary Angiography-Based Vessel Fractional Flow Reserve (vFFR) Virtual Stenting

Preoperative angiography-derived fractional flow reserve may predict coronary artery bypass grafting occlusion and disease progression

Current status and future perspectives of fractional flow reserve derived from invasive coronary angiography

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