Assessment Of Non-culprit Lesions Research Articles

Quantitative flow ratio for non culprit lesions in ST elevation myocardial infarction and multi vessel disease - a direct comparison with fractional flow reserve

Abstract Objectives In acute myocardial infarction and multivessel disease (MVD), current guidelines recommend treatment of the culprit lesion followed by staged full revascularization of functionally relevant stenoses. We sought to analyze the hemodynamic relevance of intermediate stenoses using quantitative flow ratio (QFR, an angiography-derived fractional flow reserve [FFR]) in a population presenting with ST elevation myocardial infarction (STEMI) and MVD on index procedure. Methods We retrospectively analyzed 36 coronary lesions in 34 Patients presenting with STEMI and MVD from January 2017 to September 2022. 31 (86%) patients were male, mean age 63 ± 7, mean ejection fraction (EF %) 50 ± 8, arterial hypertension 30 (88%), diabetes 13 (38%). The non culprit lesion location was left anterior descending (LAD) in 24 (67%), circumflex artery (RCX) in 8 (22%) and right coronary artery (RCA) in 4 (11%). All patients received an invasive assessment of non culprit lesions using FFR within 3 months after STEMI. A QFR assessment of non culprit lesions in an acute invasive coronary angiography has been compared with FFR results in a staged procedure. Results QFR showed an excellent accuracy in ruling out functionally relevant stenosis with no false negative results (sensitivity 100% compared to FFR). Three coronary lesions (8,3%) were graded false positive (functionally relevant). Due to poor image acquisition, we were unable to perform QFR analysis in ten coronary lesions (28%). Overall specificity (56,5%) was lower than reported in previous trials. After excluding the lesions that could not be analyzed due to poor acquisition we achieved specificity of 81,2% (Fig. 1). Concusion: QFR showed an excellent correlation with FFR (Fig. 1). Performing QFR in STEMI Patients with MVD could reduce the need of repeated invasive coronary angiographies and optimize the clinical therapy management in this high-risk population. Further studies on diagnostic performance and outcomes are needed.Fig. 1: Correlation plot

Diagnostic Performance of On-Site Computed Tomography Derived Fractional Flow Reserve on Non-Culprit Coronary Lesions in Patients with Acute Coronary Syndrome.

The role of coronary computed tomography angiography (CCTA) derived fractional flow reserve (CT-FFR) in the assessment of non-culprit lesions (NCL) in patients with acute coronary syndrome (ACS) is debated. In this prospective clinical study, a total of 68 ACS patients with 89 moderate (30-70% diameter stenosis) NCLs were enrolled to evaluate the diagnostic accuracy of on-site CT-FFR compared to invasive fractional flow reserve (FFRi) and dobutamine stress echocardiography (DSE) as reference standards. CT-FFR and FFRi values ≤ 0.80, as well as new or worsening wall motion abnormality in ≥2 contiguous segments on the supplying area of an NCL on DSE, were considered positive for ischemia. Sensitivity, specificity, positive, and negative predictive value of CT-FFR relative to FFRi and DSE were 51%, 89%, 75%, and 74% and 37%, 77%, 42%, and 74%, respectively. CT-FFR value (β = 0.334, p < 0.001) and CT-FFR drop from proximal to distal measuring point [(CT-FFR drop), β = -0.289, p = 0.002)] were independent predictors of FFRi value in multivariate linear regression analysis. Based on comparing their receiver operating characteristics area under the curve (AUC) values, CT-FFR value and CT-FFR drop provided better discriminatory power than CCTA-based minimal lumen diameter stenosis to distinguish between an NCL with positive and negative FFRi [0.77 (95% Confidence Intervals, CI: 0.67-0.86) and 0.77 (CI: 0.67-0.86) vs. 0.63 (CI: 0.52-0.73), p = 0.029 and p = 0.043, respectively]. Neither CT-FFR value nor CT-FFR drop was predictive of regional wall motion score index at peak stress (β = -0.440, p = 0.441 and β = 0.403, p = 0.494) or was able to confirm ischemia on the territory of an NCL revealed by DSE (AUC = 0.54, CI: 0.43-0.64 and AUC = 0.55, CI: 0.44-0.65, respectively). In conclusion, on-site CT-FFR is superior to conventional CCTA-based anatomical analysis in the assessment of moderate NCLs; however, its diagnostic capacity is not sufficient to make it a gatekeeper to invasive functional evaluation. Moreover, based on its comparison with DSE, CT-FFR might not yield any information on the microvascular dysfunction in the territory of an NCL.

Instantaneous wave-free ratio for the assessment of nonculprit lesions in patients with acute coronary syndrome

Abstract Background A physiological assessment with the fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) is strongly recommended by the European Guidelines of Revascularization to guide percutaneous coronary intervention (PCI) decision making in intermediate coronary stenosis. However, data supporting its use in the pro-inflammatory setting of ACS is weak. Purpose To analyze the usefulness of a physiological coronary evaluation with iFR of nonculprit lesions in patients with ACS. Methods Retrospective multicenter study including patients with ACS and underwent successful revascularization of the culprit vessel and had other nonculpritlesions physiologically evaluated with the iFR between January 2017 and December 2019. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction, stent thrombosis and new revascularization (MACEs). Results A total of 356 patients with 472 nonculprit lesions were included. The mean age was 66±11 years. The clinical presentation was non-ST-segment elevation myocardial infarction (NSTEMI) in 235 patients and ST-segment elevation myocardial infarction (STEMI) in 121 patients. After a mean follow-up period of 22±10 months, the primary endpoint occurred in 32 patients (9%). There were no differences in outcomes regarding iFR induced treatment strategy (patients with all lesions revascularized vs. patients with at least one lesion deferred for revascularization, 10.5 vs 8.4%, p=0.476). Conclusion The use of the iFR to guide percutaneous coronary intervention decision making in nonculprit lesions seems to be safe, with an acceptable percentage of MACEs at the mid-term follow-up. Funding Acknowledgement Type of funding sources: None. FlowchartSurvival curves by iFR and ACS group

Vessel fractional flow reserve in assessment of non-culprit lesions in ST elevation myocardial infarction

ObjectivesWe sought to evaluate the physiology of non-culprit lesions by using vessel fractional flow reserve (vFFR) among patients with ST elevation myocardial infarction (STEMI) and multivessel disease (MVD).MethodsFrom January 2017...

Feasibility and diagnostic reliability of quantitative flow ratio in the assessment of non-culprit lesions in acute coronary syndrome

Several studies have demonstrated the feasibility and safety of hemodynamic assessment of non-culprit coronary arteries in setting of acute coronary syndromes (ACS) using fractional flow reserve (FFR) measurements. Quantitative flow ratio (QFR), recently introduced as angiography-based fast FFR computation, has been validated with good agreement and diagnostic performance with FFR in chronic coronary syndromes. The aim of this study was to assess the feasibility and diagnostic reliability of QFR assessment during primary PCI. A total of 321 patients with ACS and multivessel disease, who underwent primary PCI and were planned for staged PCI of at least one non-culprit lesion were enrolled in the analysis. Within this patient cohort, serial post-hoc QFR analyses of 513 non-culprit vessels were performed. The median time interval between primary and staged PCI was 49 [42–58] days. QFR in non-culprit coronary arteries did not change between acute and staged measurements (0.86 vs 0.87, p = 0.114), with strong correlation (r = 0.94, p ≤ 0.001) and good agreement (mean difference -0.008, 95%CI -0.013–0.003) between measurements. Importantly, QFR as assessed at index procedure had sensitivity of 95.02%, specificity of 93.59% and diagnostic accuracy of 94.15% in prediction of QFR ≤ 0.80 at the time of staged PCI. The present study for the first time confirmed the feasibility and diagnostic accuracy of non-culprit coronary artery QFR during index procedure for ACS. These results support QFR as valuable tool in patients with ACS to detect further hemodynamic relevant lesions with excellent diagnostic performance and therefore to guide further revascularisation therapy.

Instantaneous wave-free ratio-guided revascularization of non-culprit lesion in patients with ST-segment elevation myocardial infarction and multivessel coronary disease: design and rationale of the WAVE registry.

Background The optimal management of patients with ST-elevation acute coronary syndromes and multivessel coronary artery disease is challenging. There is a growing body of evidence supporting invasive functional evaluation of multivessel disease with FFR or iFR has been added to the literature. In this regard, the WAVE study recently demonstrated the diagnostic accuracy of iFR functional assessment of non-culprit lesions in multivessel patients with STEMI. However, no studies have still verified the long-term clinical impact of an iFR-guided revascularization in this setting of patients. Methods Patients undergoing primary PCI for STEMI and presenting multivessel disease will be enrolled. After the treatment of the culprit lesion, an iFR-guided functional assessment of non-culprit lesions will be done: if iFR ≤ 0.89 PCI will be performed during the index procedure or staged. Conversely, iFR> 0.89 will be direct the patient towards a conservative approach. Results The study start date was May 1, 2018. The enrollement phase was completed on March 30, 2020. The primary endpoint is the occurrence of Target Lesion Failure (TLF), a composite of cardiovascular death, non-fatal myocardial infarction, and ischemia-driven revascularization of the vessel previously assessed with iFR. Secondary end points include MACE (Cardiovascular death, non-fatal MI, any revascularization). Conclusions The aim of the present study is to evaluate the long-term clinical impact of an iFR-guided revascularization of the non-culprit lesions in STEMI patients with multivessel coronary artery disease.

Quantitative flow ratio to predict non-target-vessel-related events at 5 years in STEMI patients undergoing angiography-guided revascularization

Abstract Background In patients with ST-segment-elevation myocardial infarction (STEMI), angiography-based complete revascularization is associated with superior outcomes compared with culprit-lesion-only percutaneous coronary intervention (PCI). Quantitative Flow Ratio (QFR) is a novel, non-invasive, vasodilator-free method to assess the hemodynamic significance of coronary stenoses. Purpose To investigate the incremental value of QFR over angiography alone in the assessment of non-culprit lesions (NCL) in STEMI patients undergoing primary PCI. Methods In the randomized, multicenter COMFORTABLE AMI trial, STEMI patients underwent angiography-guided complete revascularization. QFR was determined in untreated non-target vessels by assessors blinded for clinical outcomes. Results Out of 1161 STEMI patients, 946 vessels in 617 patients could be analyzed by QFR. At 5-year follow-up, the rate of the primary endpoint cardiac death, non-target vessel myocardial infarction (non-TV-MI) and clinically indicated, non-target vessel revascularization (non-TVR) was significantly higher in patients with QFR ≤0.80 compared with QFR >0.80 (62.9% vs. 12.7%, HR 7.20, 95% CI 4.46–11.62, p<0.001), driven by higher rates of non-TV-MI (15.4% vs. 3.6%, HR 4.59, 95% CI 1.72–12.23, p=0.002) and non-TVR (58.6% vs. 7.7%, HR 10.99, 95% CI 6.39–18.91, p<0.001). No significant differences for cardiac death were observed. Multivariate analysis identified QFR ≤0.80, MI SYNTAX score and left ventricular function as independent predictors of the primary endpoint. QFR ≤0.80 showed an accuracy of 86.1%, sensitivity of 23.2%, specificity of 97.5%, positive predictive value of 62.9% and negative predictive value of 87.5% for the prediction of the primary endpoint. Conclusions Our study results suggest incremental value of QFR over angiography-guided PCI for NCL among STEMI patients undergoing primary PCI. Kaplan-Meier curves of primary endpoint Funding Acknowledgement Type of funding source: None

ST-elevation Myocardial Infarction and Multivessel Coronary Artery Disease - A Critical Review of Current Practice, Evidence and Meta-analyses.

In recent years, practice and guidelines for patients with ST-elevation myocardial infarction (STEMI) have evolved from a 'culprit-only approach' to complete revascularisation; however, several issues remain, particularly regarding assessment of non-culprit lesions and timing of their revascularisation. Complete revascularisation should be performed in patients presenting with STEMI; however, available studies often present contradictory results regarding the optimal timing of non-culprit lesion percutaneous coronary intervention (PCI). The aim of this review is to provide a practical approach for the assessment of patients presenting with STEMI and multivessel coronary artery disease by analysing randomised trials, meta-analyses and our clinical experience. We recommend multivessel revascularisation at the time of primary PCI for simple cases, while we suggest deferring treatment of complex lesions; the optimal timing of staged PCI should be individualised according to clinical judgement.

P116On-site coronary CT - derived FFR for the assessment of non-culprit lesions in patients who suffered myocardial infarction

P116On-site coronary CT - derived FFR for the assessment of non-culprit lesions in patients who suffered myocardial infarction

TCT-621 Comparison of Quantitative Flow Ratio and Instantaneous Wave-Free Ratio for Immediate Assessment of Non-Culprit Lesions in Patients With ST-Segment Elevation Myocardial Infarction An iSTEMI Substudy

BACKGROUND: Quantitative flow ratio (QFR) is an angiography-based approach for in-procedure functional evaluation of coronary artery lesions. We evaluated the diagnostic performance of QFR with ins ...

Atherosclerotic plaque composition and significance of nonculprit intermediate coronary lesions. Intravascular ultrasound and quantitative coronary angiography study in acute coronary syndrome

Background Detection of potentially vulnerable plaques inducing acute coronary syndrome (ACS) improves prevention of cardiovascular events. We aimed at using intravascular ultrasound (IVUS) for morphological assessment, anatomical significance of atherosclerotic plaques of nonculprit intermediate coronary lesions and correlation with quantitative coronary angiography (QCA) in ACS. Patients and methods 2IVUS was performed on 61 nonculprit intermediate coronary lesions in 28 patients diagnosed with non-ST-elevation ACSs. Percent area stenosis more than 70% was the cutoff value for intervention. Results The mean age was 53.2±9.1 years, men=20 (71.4%). Culprit vessels represent 42% of affected vessels. Higher lipid content was found in lesions of culprit vessels (P Conclusion IVUS might be valuable for the assessment of nonculprit lesions in ACS. There is high vulnerability for plaque rupture in intermediate lesions of culprit vessels. MLA and plaque burden are the main predictors for lesion anatomical significance. QCA is a reliable tool for detecting severity of coronary artery disease.

TCT-416 Rationale and design of COMBINE (OCT–FFR) assessment of non-culprit lesions to better predict adverse event outcomes in diabetes mellitus patients.

Fractional flow reserve (FFR) is a widely used tool for the identification of ischaemia-generating stenoses and to guide decisions on coronary revascularisation. However, the safety of FFR-based decisions in high-risk subsets, such as patients with Diabetes Mellitus (DM) or vulnerable stenoses

P5867COMBINE OCT and FFR assessment of non culprit lesions to better predict adverse event outcomes in diabetes mellitus patients. Rationale, design and initial OCT results

P5867COMBINE OCT and FFR assessment of non culprit lesions to better predict adverse event outcomes in diabetes mellitus patients. Rationale, design and initial OCT results

Intracoronary Thermography: Does It Help Us in Clinical Decision Making?

The concept of the "vulnerable" plaque has recently emerged to explain how quiescent atherosclerotic lesions evolve to cause clinical events. The morphologic and immunologic determinants specific for the vulnerable plaque have been reported: a large lipid core (>or=40% plaque volume) composed of free cholesterol crystals, cholesterol esters, and oxidized lipids impregnated with tissue factor; a thin fibrous cap depleted of smooth muscle cells and collagen; an outward (positive) remodeling; inflammatory cell infiltration of fibrous cap and adventitia (mostly monocyte-macrophages, some activated T cells, and mast cells); and increased neovascularity. Despite the large amount of information regarding the morphological characteristics of remote lesions, we lack studies with functional assessment of non-culprit lesions. Coronary thermography is a technique for functional assessment of coronary atherosclerotic plaques. Several catheter designs have been proposed. There are catheters with thermistor(s) and wires with thermal sensors at the distal tip. All designs have several advantages and disadvantages. Despite the current limitations of coronary thermography, we gained important pathophysiological and clinical information regarding the vulnerability of atheromatic plaques. It has been documented both experimentally and clinically that increased heat generation is associated with increased macrophage concentration within the plaque. The correlation between local inflammatory involvement and local heat generation has also been observed with the peripheral inflammatory markers such as C-reactive protein. Whether systemic treatment, with agents such as statins or interventional techniques, such as drug-eluting stents, will have an impact on stabilizing vulnerable plaques need to be determined in future studies. In conclusion, although there are several techniques for evaluating morphologically atheromatic plaques, thermography is a promising method for the functional assessment of vulnerable plaque and has been introduced into clinical practice, with a good predictive value for clinical events in patients with increased temperature in the atherosclerotic plaque.