Angio-Based Fractional Flow Reserve, Functional Pattern of Coronary Artery Disease, and Prediction of Percutaneous Coronary Intervention Result: a Proof-of-Concept Study

Simone Biscaglia, Barry F Uretsky, Matteo Tebaldi, Andrea Erriquez, Salvatore Brugaletta, Enrico Cerrato, Giorgio Quadri, Giosafat Spitaleri, Iginio Colaiori, Domenico Di Girolamo, Alessandra Scoccia, Ottavio Zucchetti, Emanuele D'Aniello, Marco Manfrini, Rita Pavasini, Emanuele Barbato, Gianluca Campo, Simone Biscaglia, Barry F Uretsky, Matteo Tebaldi, Andrea Erriquez, Salvatore Brugaletta, Enrico Cerrato, Giorgio Quadri, Giosafat Spitaleri, Iginio Colaiori, Domenico Di Girolamo, Alessandra Scoccia, Ottavio Zucchetti, Emanuele D'Aniello, Marco Manfrini, Rita Pavasini, Emanuele Barbato, Gianluca Campo

Abstract

Purpose: Wire-based coronary physiology pullback performed before percutaneous coronary intervention (PCI) discriminates coronary artery disease (CAD) distribution and extent, and is able to predict functional PCI result. No research investigated if quantitative flow ratio (QFR)-based physiology assessment is able to provide similar information.

Methods: In 111 patients (120 vessels) treated with PCI, QFR was measured both before and after PCI. Pre-PCI QFR trace was used to discriminate functional patterns of CAD (focal, serial lesions, diffuse disease, combination). Functional CAD patterns were identified analyzing changes in the QFR virtual pullback trace (qualitative method) or after computation of the QFR virtual pullback index (QVPindex) (quantitative method). QVPindex calculation was based on the maximal QFR drop over 20 mm and the length of epicardial coronary segment with QFR most relevant drop. Then, the ability of the different functional patterns of CAD to predict post-PCI QFR value was tested.

Results: By qualitative method, 51 (43%), 20 (17%), 15 (12%), and 34 (28%) vessels were classified as focal, serial focal lesions, diffuse disease, and combination, respectively. QVPindex values >0.71 and ≤0.51 predicted focal and diffuse patterns, respectively. Suboptimal PCI result (post-PCI QFR value ≤0.89) was present in 22 (18%) vessels. Its occurrence differed across functional patterns of CAD (focal 8% vs. serial lesions 15% vs. diffuse disease 33% vs. combination 29%, p=0.03). Similarly, QVPindex was correlated with post-PCI QFR value (r=0.62, 95% CI 0.50-0.72).

Conclusion: Our results suggest that functional patterns of CAD based on pre-PCI QFR trace can predict the functional outcome after PCI.

Clinical trial registration: ClinicalTrials.gov , number NCT02811796. Date of registration: June 23, 2016.

Keywords: Angio-based fractional flow reserve; Functional pattern of coronary artery disease; Percutaneous coronary intervention; Pressure pullback gradient; Quantitative flow ratio.

Conflict of interest statement

SiB received research grant from Medis, SMT, Siemens. GC received research grant from Boston Scientific, Medis, SMT, Siemens. MT received research grant from Boston Scientific. EB received speaker’s fees from Abbott Vascular, Boston Scientific, GE. BFU received research grant from Opsens. PWS received personal fees from Sino Medical Sciences Technology, Philips/Volcano, and Xeltis. SaB received speaker fee from Abbott Vascular, Advisory board fee from Boston Scientific & i Vascular. research grant to his Institution from Astrazeneca. All other authors have nothing to disclose.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Study flow chart. PCI, percutaneous coronary intervention; sec, seconds; QFR, quantitative flow ratio
Fig. 2
Fig. 2
Distribution of functional patterns of CAD in tertiles of QVPindex. The colors indicate the functional patterns of CAD (as assessed by qualitative method) in QVPindex tertiles (lowest tertiles ≤0.54, intermediate tertile 0.55–0.71, highest tertile >0.71). No., number; CAD, coronary artery disease; QFR, quantitative flow ratio; QVPindex, QFR virtual pullback index
Fig. 3
Fig. 3
Examples of successful PCI in vessels with intermediate-high QVPindex. QFR, quantitative flow ratio; MaxQFR20mm, maximal drop of QFR value in 200 mm; ΔQFRvessel, difference in the QFR values from the beginning to the end of the vessel; LFD, length of the vessel with functional disease; TVL, total vessel length; QVPindex, QFR virtual pullback index; PCI, percutaneous coronary intervention. Yellow arrows indicate the presence of coronary lesions before or after PCI, whereas green lines indicate stented segments in post-PCI images
Fig. 4
Fig. 4
Examples of suboptimal PCI in vessels with intermediate-low QVPindex. QFR, quantitative flow ratio; MaxQFR20mm, maximal drop of QFR value in 200 mm; ΔQFRvessel, difference in the QFR values from the beginning to the end of the vessel; LFD, length of the vessel with functional disease; TVL, total vessel length; QVPindex, QFR virtual pullback index; PCI, percutaneous coronary intervention. Yellow arrows indicate the presence of coronary lesions before or after PCI, whereas green lines indicate stented segments in post-PCI images

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