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iFR, FFR, and IVUS in Intermediate Left Main Coronary Artery Stenosis
Quick Takes
- Among patients with intermediate left main coronary artery (LMCA) stenosis, concordance between FFR and iFR was moderate (80%).
- In case of discordance, IVUS tended to be more similar to FFR to classify stenosis significance.
- Deferral of LMCA revascularization based on iFR (combined with IVUS in cases of FFR and iFR discordance) appears to be safe.
Study Questions:
What is the concordance between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in intermediate left main coronary artery (LMCA) lesions, and the safety of deferring revascularization based on a hybrid decision-making strategy combining iFR and intravascular ultrasound (IVUS)?
Methods:
The iLITRO - EPIC07 study investigators conducted a prospective, observational, multicenter registry with 300 consecutive patients with intermediate LMCA stenosis who underwent FFR and iFR and, in case of discordance, IVUS and minimal lumen area (MLA) measurements. The primary clinical endpoint was a composite of cardiovascular death, LMCA lesion-related nonfatal myocardial infarction, or unplanned LMCA revascularization. Concordance between functional and imaging techniques was conducted using Cohen’s kappa coefficient. Also, sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic (ROC) curve for the tests were estimated.
Results:
FFR and iFR had an agreement of 80% (both positive in 67 and both negative in 167 patients); in case of disagreement (31 FFR+ / iFR– and 29 FFR– / iFR+), MLA was ≥6 mm2 in 8.7% of patients with FFR+ and 14.6% with iFR+. Among the 300 patients, 105 (35%) underwent revascularization and 181 (60%) were deferred according to iFR and IVUS. At a median follow-up of 20 months, major adverse cardiac event (MACE) incidence was 8.3% in the defer group and 13.3% in the revascularization group (hazard ratio, 0.71; 95% confidence interval, 0.30-1.72; p = 0.45).
Conclusions:
The authors concluded that in patients with intermediate LMCA stenosis, a physiology-guided treatment decision is feasible either with FFR or iFR with moderate concordance between both indices.
Perspective:
This prospective registry study showed that among patients with intermediate LMCA stenosis, concordance between FFR and iFR was moderate (80%). Furthermore, in case of discordance, IVUS tended to be more similar to FFR to classify stenosis significance. Finally, deferral of LMCA revascularization based on iFR (combined with IVUS in cases of FFR and iFR discordance) appears to be safe, with similar MACE rate as compared with patients in whom LMCA revascularization was performed. Overall, from a clinician perspective, an approach based on a combination of IVUS and physiology in intermediate LMCA lesions appears optimal to define whether revascularization can be safely deferred.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Echocardiography/Ultrasound
Keywords: Cardiac Surgical Procedures, Constriction, Pathologic, Coronary Stenosis, Diagnostic Imaging, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Secondary Prevention, TCT22, Transcatheter Cardiovascular Therapeutics, Ultrasonography, Interventional, Vascular Diseases
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