Side branch FFR after provisional stenting: simplified approach based on OCT frame count

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Kini ◽  
N Okamoto ◽  
N Barman ◽  
Y Vengrenyuk ◽  
K Yasumura ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Functional Significance ◽  
Area Under The Curve ◽  
Side Branch ◽  
Funding Source ◽  
Fractional Flow ◽  
Simplified Approach ◽  
Main Vessel ◽  
Bifurcation Lesions ◽  
Provisional Stenting

Abstract Background/Introduction Treatment of bifurcation coronary artery lesions remains a major challenge in interventional cardiology. Side branch (SB) stenoses are frequently observed after stent implantation in bifurcation lesions, although angiographically narrowed SBs may not be functionally significant. Fractional flow reserve (FFR), a pressure-derived index of the hemodynamic significance of a coronary artery stenosis, may be useful in determining whether additional intervention is required in jailed SBs. Angiography and intravascular ultrasound (IVUS) derived parameters have showed poor diagnostic accuracy in predicting the functional significance of jailed SBs. Purpose The aim of the present study was to use high resolution optical coherence tomography (OCT) imaging to predict functionally significant SB stenoses after provisional stenting defined as SB FFR ≤0.80. Methods Seventy-one patients with 71 calcified bifurcation lesions with angiographically intermediate SB stenoses undergoing provisional stenting were enrolled in the prospective study. OCT pullbacks were performed before and after stent placement, and SB FFR was measured after main vessel stenting. SB ostium area (SBOA) was assessed using three-dimensional OCT cut-plane analysis off-line. In addition, we developed a simplified approach to SB ostium assessment based on SB ostium frame count using two-dimensional OCT pullback not requiring off-line 3D reconstruction. For the analysis, consecutive frames were counted between the most distal and most proximal take-off of the SB frames. Results Similar to previous studies, quantitative coronary angiography findings were not associated with the functional significance of SBs after main vessel stenting. In contrast, SBOA assessed by 3D-OCT after provisional stenting strongly correlated with post-procedure SB FFR. The optimal cut-off value for the SBOA area to predict a SB FFR ≤0.80 was 0.76 mm2 (sensitivity 82%, specificity 89% and area under the curve of 0.92 (95% CI: 0.84–0.99). A simplified approach to SB ostium assessment using OCT frame count yielded a sensitivity of 82%, specificity 89% and area under the curve 0.92 (95% CI: 0.84 to 0.99) with a cut-off of 4.5 frames allowing detection of functionally significant SB stenoses during the procedure in real time. Figure 1 shows a receiver-operating characteristic curve for SB FFR ≤0.8 and a representative case with SB FFR = 0.66 after provisional stenting and SB ostium frame count equal 3 (Frame 1 to 3) Conclusion(s) Assessment of SB using either 3D OCT off-line reconstruction or a simplified approach based on OCT frame count can detect SB branches with FFR ≤0.80 with high sensitivity and specificity. The developed approaches may represent a useful tool to assess provisional stent outcomes. Figure 1 Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific; St. Jude Medical

Side branch long lesion with main vessel vulnerable plaques by optical coherence tomography predict target-vessel myocardial infarction after provisional stenting in patients with coronary bifurcation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S.L Chen
Keyword(s):  
Side Branch ◽  
Lesion Group ◽  
Lesion Length ◽  
Coronary Bifurcation ◽  
Coronary Bifurcation Lesions ◽  
Vulnerable Plaques ◽  
Main Vessel ◽  
Bifurcation Lesions ◽  
Provisional Stenting ◽  
One Year

Abstract Background Provisional side branch (SB) stenting is correlated with target-vessel myocardial infarction (TVMI) in patients with coronary bifurcation lesions. However, the underlying mechanisms remain unknown. Objectives We aimed to determine the correlation of SB lesion length with vulnerable plaques using optical coherence tomography (OCT) and TVMI in patients with coronary bifurcation lesions treated by a provisional approach. Methods A total of 405 patients with 405 bifurcation lesions who underwent pre-PCI OCT imaging of both main vessel (MV) and SB was prospectively enrolled. Patients were defined as Long-SB lesion (SB lesion length ≥10 mm) and Short-SB lesion (SB lesion length <10 mm) groups according to quantitative coronary analysis and were also stratified by the presence of vulnerable plaques based on OCT findings. The primary endpoint was the occurrence of TVMI after provisional stenting at one-year follow-up. Results 178 (43.9%) patients had long SB lesions. Vulnerable plaques predominantly localized in the main vessel (MV) and more frequently in the Long-SB lesion group (42.7%) compared to 24.2% in the Short-SB lesion group (p<0.001). At one-year follow-up after provisional stenting, there were 31 (8.1%) TVMIs, with 11.8% in the Long-SB lesion group and 4.4% in the Short-SB lesion group (p=0.009), leading to significant difference in target lesion failure between two groups (15.2% vs. 6.6%, p=0.007). The rate of cardiac death, revascularization, and stent thrombosis was comparable between study groups. By multivariate regression analysis, long SB lesion length (p=0.011), presence of vulnerable plaques in the polygon of confluence (p=0.001), and true coronary bifurcation lesions (p=0.004) were three independent factors of TVMI. Conclusions Long-SB lesion length with MV vulnerable plaques predict increased TVMI after provisional stenting in patients with true coronary bifurcation lesions. Further study is warranted to identify the better stenting techniques for coronary bifurcation lesions with long lesion in the SB Kaplan-Meier survival curve Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): NSFC

scholarly journals Provisional Stenting for Left Main Bifurcation Disease under IVUS guidance: A Case Series

2021 ◽  
Vol 02 (01) ◽  
pp. 015-018
Author(s):  
Rohit Mody
Keyword(s):  
Imaging Techniques ◽  
Case Series ◽  
Side Branch ◽  
Heart Team ◽  
Left Main ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Procedural Complications ◽  
Bifurcation Lesions ◽  
Provisional Stenting

Around 15-20% of coronary lesions include bifurcation, and among which left main (LM) bifurcation lesions are critical and complex to manage. Though the two-stent strategy is the preferred option for complex LM bifurcation lesions, the provisional strategy should be considered if the side branch is disease-free to avoid peri- and post-procedural complications. Thus, precise anatomical and physiological assessment of LM lesion should be made using intravascular imaging techniques for appropriate decision making. Here, we report three cases of successfully managed LM bifurcation lesions using the provisional stenting technique with the guidance of intravascular ultrasound, fractional flow reserve, and heart team. All three patients were doing well and were ischemia-free on stress echocardiography at three months follow-up.

Comparison of fractional flow reserve and instantaneous wave-free ratio for the hemodynamic assessment of jailed side branches in bifurcation stenting

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
J.M Altstidl ◽  
M Marwan ◽  
M Troebs ◽  
S Achenbach ◽  
L Gaede
Keyword(s):  
Coronary Artery ◽  
Right Coronary Artery ◽  
Balloon Angioplasty ◽  
Functional Significance ◽  
Side Branch ◽  
Fractional Flow ◽  
High Reproducibility ◽  
Flow Reserve ◽  
Hemodynamic Assessment ◽  
The Right

Abstract Background Provisional side-branch stenting strategy is one of the preferred strategies for treatment of bifurcation lesions. Whereas using fraction flow reserve (FFR) for the physiologic assessment of jailed side branches is well studied, the reliability of resting indices such as instantaneous wave free ratio (iFR) is unknown. Methods Consecutive patients with provisional stenting of a bifurcation and a jailed side branch were enrolled in this study. FFR and iFR were measured and, after assuring absence of baseline shift and drift, both measurements were repeated after 3 minutes. Hyperemia was induced by intra-coronary adenosine with a dose of 48μg for the right coronary artery and 96μg for the left coronary artery. Cut-off for the assumed functional significance of a stenosis was 0.80 for FFR and 0.89 for iFR. The decision to treat the side branch was left to the interventionalist's discretion. Results 37 jailed side branches in 36 patients (age 68.4±8.2; male 81% (n=29)) were consecutively enrolled in the study. The main vessel was the left main in 3% (n=1), the left anterior descending (LAD) in 65% (n=24), the diagonal branch (D1) in 3% (n=1), the left circumflex artery (LCX) in 24% (n=9) and the right coronary artery (RCA) in 5% (n=2). The Medina classification revealed true bifurcation stenosis defined as Medina 1–1-1 prior to treatment in 35% (n=13). FFR showed 35% (n=13) of the stenosis to be functionally significant with a high reproducibility of the results (r=0.986). FFR showed a low correlation with angiographic assessment (r=−0.477). iFR indicated hemodynamic relevance in 38% of lesions (n=14) with a high reproducibility (r=0.967) and also correlated poorly with angiographic assessment (r=−0.271). iFR was found to closely correlate with FFR in jailed side branches (r=0.720, Figure 1A). Bland-Altman analysis showed iFR and FFR agreed with a mean difference between FFR and iFR of −0.054±0.146. In 81% (n=30) FFR and iFR showed the same results regarding functional significance. In 8% (n=3) FFR was ≤0.80 and iFR >0.89, in 11% (n=4) FFR was >0.80 and iFR was ≤0.89 (Figure 1B). Side branch treatment was performed in 32% (n=12). All of these lesions showed functional significance in FFR or iFR. Stent implantation was performed in 8% (n=3), balloon angioplasty in 19% (n=7) and balloon angioplasty with a drug-eluting balloon in 5% (n=2). Conclusions The results of this study confirm the poor correlation of angiographic and functional assessment of coronary artery stenoses. Our data show close agreement of iFR and FFR in stent-jailed side branches. Therefore, iFR can be considered as a reliable technique for guidance of provisional side branch stenting. Figure 1 Funding Acknowledgement Type of funding source: None

P5632Different impact of lesion length on fractional flow reserve in intermediate coronary lesions between each coronary artery

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
H Shibutani ◽  
K Fujii ◽  
K Matsumura ◽  
M Otagaki ◽  
S Morishita ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Functional Significance ◽  
Roc Analysis ◽  
Area Under The Curve ◽  
Lesion Length ◽  
Fractional Flow ◽  
Optimal Cutoff ◽  
Cutoff Value ◽  
Flow Reserve ◽  
The Mean

Abstract Background Previous studies reported that lesion length was an important geometric parameter in addition to the degree of stenosis in the determinant of functional significance of coronary artery stenosis. Nevertheless, the optimal cutoff value of lesion length for predicting functional significance for each coronary artery has not yet been evaluated, though previous studies revealed that the cutoff value of minimum lumen diameter measured on coronary angiography (CAG) to predict fractional flow reserve (FFR) <0.80 is different for each coronary artery Purpose This study evaluated whether the impact of lesion length on functional significance is similar between each coronary artery for lesions with intermediate stenosis. Methods Patients with suspected coronary artery disease who had at least one intermediate coronary lesion (luminal diameter stenosis of 70 to 80% by visual estimation on CAG) and underwent FFR measurement for the evaluation of myocardial ischemia were evaluated. Quantitative coronary angiography analysis including percent diameter stenosis and lesion length was performed. FFR was measured as the ratio of the mean distal coronary artery pressure to the mean aortic pressure during maximal hyperemia induced by intravenous infusion of adenosine triphosphate (150 μg /kg/min). The area under the receiver operating characteristics (ROC) curve was estimated for the best cutoff value as a predictor of FFR value of ≤0.80 for each coronary artery. Results A total of 221 de novo lesions that underwent FFR measurement were enrolled. The average FFR value was 0.81±0.07. Although lesion length was similar among the lesions with an FFR >0.80 at different locations, the mean lesion length was significantly longer for lesions in the right coronary artery (RCA) with an FFR ≤0.80 than for those in the left anterior descending artery (LAD) and left circumflex artery (13.4±3.4 versus 8.6±3.1 versus 12.0±3.7 mm, p<0.001). ROC analysis demonstrated that the optimal cutoff value of lesion length for predicting an FFR ≤0.80 was 10.0 mm in the LAD (0.56 area under the curve, 48% sensitivity, 76% specificity), whereas 13.1 mm in the RCA (0.84 area under the curve, 67% sensitivity, 93% specificity) (Figure). ROC analysis of LL for FFR≤0.80 Conclusions A longer lesion length is required to achieve FFR<0.80 in the RCA than in the other arteries. This may suggest the low possibility of an FFR ≤0.80 when stenosis is focal and short in the RCA with stenosis of 70 to 80% by visual estimation on CAG.

scholarly journals Correlations between fractional flow reserve and a novel non-hyperemic index: resting full-cycle ratio in patients with an ambiguous coronary artery stenosis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
P Szolc ◽  
L Niewiara ◽  
B Guzik ◽  
G Horszczaruk ◽  
J Podolec ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Fractional Flow Reserve ◽  
Coronary Artery Stenosis ◽  
Invasive Coronary Angiography ◽  
Area Under The Curve ◽  
Left Ventricular ◽  
Artery Stenosis ◽  
Funding Source ◽  
Fractional Flow ◽  
Flow Reserve

Abstract Background Fractional flow reserve (FFR) measurement has been the gold standard for invasive assessment of coronary ischemia. Resting full cycle ratio (RFR) is a new non-hyperemic index used to define physiologic significance of coronary artery stenosis. However, there are limited data available to establish optimal cut-off value of RFR for decision making on revascularization. Aim The aim of our study was to assess optimal cut-off value of RFR at which to predict FFR of 0.8. Methods The RFR and FFR values were recorded during invasive coronary angiography in vessels with angiographic stenosis 40–70% according to visual assessment. Maximum hyperemia for FFR measurement was achieved with adenosine iv. infusion at 140 μg/kg/min. Left main disease, acute myocardial infarction and systolic left ventricular dysfunction (EF &lt;40%) were the main exclusion criteria. Results We evaluated 332 vessels, including 189 (56.9%) left anterior descending arteries, 77 (23.2%) left circumflex arteries and 66 (19.9%) right coronary arteries. Median diameter stenosis as assed by QCA was 45% (IQR 40; 50). Median RFR and FFR values were 0.90 [IQR 0.85; 0.94] and 0.86 [IQR 0.81; 0.92] respectively, with significant correlation (p&lt;0.001, Figure 1, panel A). Optimal cut-off value for RFR to detect FFR 0.80 was 0.90 with area under the curve of 90.3%, sensitivity of 81.4% and specificity 88.0% (Figure 1, panel B). Conclusions Our data confirm RFR cut-off value ≤0.90 as an optimal threshold to detect ischemic lesions with good sensitivity and specificity in comparison to FFR assessment. Further research is necessary to assess outcomes of RFR-guided revascularization strategy. Figure 1. RFR–FFR correlation and ROC analysis Funding Acknowledgement Type of funding source: Other. Main funding source(s): Jagiellonian University statutory grant

Abstract 17162: Prediction of Functional Severity of Coronary Bifurcation Lesions by Means of Angiographically-Derived Score

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Dobirn Vassilev ◽  
Niya Mileva ◽  
Pavel Nikolov ◽  
Georgi Dimitrov ◽  
Kiril Karamfiloff ◽  
...  
Keyword(s):  
Functional Significance ◽  
Hemodynamic Instability ◽  
Side Branch ◽  
Lesion Length ◽  
Syntax Score ◽  
Fractional Flow ◽  
St Segment Elevation ◽  
Flow Reserve ◽  
Bifurcation Lesion ◽  
Bifurcation Lesions

Background: There is uncertainty about relation between clinical and angiographic characteristics and functional significance of bifurcation stenosis. Methods: We analysed patients from FIESTA registry (ClinicalTrials.gov:NCT01724957). Subjects (>18 years) with stable angina, bifurcation lesions with diameter ≥2.5mm and ≤4.5 mm, SB diameter≥2.0 mm were included. We excluded patients with ST-segment elevation myocardial infarction, left main disease, hemodynamic instability. Provisional stenting was the default strategy in all patients. Fractional flow reserve(FFR) was performed using the PrimeWire or PrimeWire Prestige(Volcano Corp., USA). Bifurcation lesion with FFR above 0.80 were deferred from PCI. Results: A total of 171 patients, mean age 67±10 years, 66% males were included in the analysis. Of them 78(46%) had functionally significant bifurcation lesion (FSL) versus 93(54%) with non-significant lesion (nFSL). There were no differences (FSLvs.nFSL) in baseline characteristics: dyslipidemia(88%vs96%), diabetes(44%vs.32%), smoking (52%vs40%), past MI (24%vs15%), previous PCI(54%vs49%), atrial fibrillation (17%vs29%), peripheral artery disease (10%vs9%), renal failure(29%vs31%) –all p>0.05. On logistic-regression analysis independent predictors of functional significance were: SYNTAX score≥11 (OR=5.523,CI:1.666-18.311,p=.005), lesion length≥25mm (OR=21.737,CI:4.963-95.202,p<.001),MV%DS≥55%(OR=9.535,CI:2.508-34.883,p=.001) and MB%DS≥65% (OR=12.927,CI:3.015-55.418,p=.001). We created score for prediction of functional significance of bifurcation lesion with the following parameters: SYNTAX ≥11 gives 1 point, SB BARI≥12%- 1 point, MV%DS ≥55%- 1.5 point, MB%DS≥65%- 2 points, lesion length ≥25 mm – 3 points. The overall performance of the score was excellent with AUC=.960, p<.001. With a cut-off value ≥4.5 points it has sensitivity of 90%, specificity 91%, accuracy 90%, p<.001. Conclusion: Different degree of stenosis in proximal main vessel and distal side branch, lesion length, SB myocardium territory and SYNTAX score are significant predictors of functional severity of bifurcation lesion. A score based on those parameters was developed with excellent discriminatory ability.

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