JACC: Cardiovascular Interventions
September 2018 DOI: 10.1016/j.jcin.2018.09.023
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Angiography-derived Fractional Flow Reserve in the SYNTAX II Trial: Feasibility, Diagnostic Performance of QFR and Clinical Prognostic Value of Functional SYNTAX Score Derived from QFR in Patients with Three-vessel Disease

Taku Asano, Yuki Katagiri, Chun Chin Chang, Norihiro Kogame, Ply Chichareon, Kuniaki Takahashi, Rodrigo Modolo, Erhan Tenekecioglu, Carlos Collet, Hans Jonker, Clare Appleby, Azfar Zaman, Nicolas van Mieghem, Neal Uren, Javier Zueco, Jan J. Piek, Johan H.C. Reiber, Vasim Farooq, Javier Escaned, Adrian P. Banning, Patrick W. Serruys and Yoshinobu Onuma

Author + information

DOI: 
https://doi.org/10.1016/j.jcin.2018.09.023
Published By: 
JACC: Cardiovascular Interventions
Print ISSN: 
1936-8798
Online ISSN: 
1876-7605
History: 
  • Received June 11, 2018
  • Revision received September 3, 2018
  • Accepted September 17, 2018
  • Published online September 22, 2018.

Article Versions

Copyright & Usage: 
© 2018

Author Information

  1. Taku Asano, MD1,2,
  2. Yuki Katagiri, MD1,
  3. Chun Chin Chang, MD3,
  4. Norihiro Kogame, MD1,
  5. Ply Chichareon, MD1,
  6. Kuniaki Takahashi, MD1,
  7. Rodrigo Modolo, MD1,
  8. Erhan Tenekecioglu, MD3,
  9. Carlos Collet, MD1,4,
  10. Hans Jonker, BSc5,
  11. Clare Appleby, MD6,
  12. Azfar Zaman, MD7,
  13. Nicolas van Mieghem, MD, PhD3,
  14. Neal Uren, MD8,
  15. Javier Zueco, MD9,
  16. Jan J. Piek, MD, PhD1,
  17. Johan H.C. Reiber, MD, PhD10,
  18. Vasim Farooq, MD, PhD11,
  19. Javier Escaned, MD, PhD12,
  20. Adrian P. Banning, MD13,
  21. Patrick W. Serruys, MD, PhD;3,∗ (patrick.w.j.c.serruys{at}gmail.com) and
  22. Yoshinobu Onuma, MD, PhD3,6
  1. 1Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
  2. 2Department of Cardiology, St. Luke’s International Hospital, Tokyo, Japan
  3. 3ThoraxCenter, Erasmus Medical Center, Rotterdam, the Netherlands
  4. 4Department of Cardiology, Universitair Ziekenhuis Brussel, Brussel, Belgium
  5. 5Cardialysis, Rotterdam, the Netherlands
  6. 6Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
  7. 7Department of Cardiology, Freeman Hospital Newcastle, Newcastle upon Tyne, United Kingdom
  8. 8Department of Cardiology, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
  9. 9Department of Cardiology, Hospital Universitario Valdecilla, Cantabria, Spain
  10. 10Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
  11. 11. Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals, Manchester, United Kingdom
  12. 12Hospital Cliinico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
  13. 13Department of Cardiology, John Radcliffe Hospital, Cardiology, Oxford, United Kingdom
  1. ↵∗Address for correspondence: Prof. P.W. Serruys, MD, PhD ThoraxCenter Erasmus Medical Center Rotterdam, the Netherlands Tel: +31-10-4635260 Fax: +31-10-4369154.

Abstract

Objectives the current study investigated the applicability of quantitative flow ratio (QFR) in patients with three-vessel disease (3VD) and aimed to demonstrate the impact of functional SYNTAX score derived from QFR (fSSQFR) on clinical outcomes.

Background the applicability of QFR in patients with 3VD and feasibility of fSSQFR have not yet been investigated.

Methods all the lesions interrogated with instantaneous wave-free ratio (iFR) and/or fractional flow reserve (FFR) in the SYNTAX II trial were retrospectively screened and analyzed for QFR. The diagnostic performance of QFR was investigated with hybrid wire-derived pressure assessment (iFR/FFR) utilized in the trial as a reference. Patients with analyzable QFR in three vessels were stratified according to fSSQFR to evaluate its clinical prognostic value based on 2-year patient-oriented composite endpoint (POCE).

Results QFRs were analyzable in 71.0% of the lesions (836 lesions). The diagnostic performance of QFR to predict binary wire-based ischemia was substantial (area under a curve [AUC] 0.81, accuracy 73.8%) with a positive predictive value of 85.9%. Independent predictors for diagnostic discordance were lesions in side branches, involvement of bifurcation/trifurcation and small vessel. According to 2-year POCE, fSSQFR reclassified 26.1% (36/138) of the patients in high/intermediate risk group into low risk group appropriately (net reclassification improvement 0.32, P<0.001). AUC of fSSQFR predicting 2-year POCE was higher than that of classic anatomical SYNTAX score (0.68 vs 0.56, P=0.002).

Conclusions QFR demonstrated substantial applicability in patients with 3VD. The fSSQFR has the potential to further refine prognostic risk estimation as compared with classic anatomical SYNTAX score.

Key Words

Footnotes

  • Disclosures:

  • Johan H.C. Reiber is the CEO of Medis medical imaging systems and has a part-time appointment at Leiden University Medical Center as Professor of Medical Imaging.

  • Javier Escaned is consultant Philips/Volcano and Boston Scientific.

  • Adrian P. Banning receives lecture fees and grant support from Boston Scientific.

  • The other authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

  • Received June 11, 2018.
  • Revision received September 3, 2018.
  • Accepted September 17, 2018.
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