瞬时无波形比值和定量血流分数评价冠状动脉临界病变准确性的对比研究

目的以血流储备分数(FFR)为标准,比较定量血流分数(QFR)和瞬时无波形比值(iFR)评估冠状动脉临界病变的准确性,并分析QFR与iFR的相关性及诊断一致率。方法回顾性纳入北京大学第三医院2015年5月至2020年6月因冠心病进行冠状动脉造影(CAG)并接受FFR和iFR检测的62例患者,收集患者的临床和CAG病变解剖学资料、靶血管iFR和FFR值,并测量同一靶血管的QFR值。以FFR≤0.80为判断心肌缺血的临界值,比较QFR和iFR与FFR评估冠状动脉临界病变的准确性,并分析QFR与iFR的相关性及诊断一致率。结果62例患者中,有53例(85.5%)靶血管为左前降支,基线直径狭窄率为48.0%(41.1%,55.7%)。iFR、QFR与FFR均具有较好的相关性[r=0.773(95%CI 0.649~0.857)、r=0.626(95%CI 0.445~0.757),均P<0.001]。QFR、iFR预测FFR≤0.80的受试者工作特征曲线下面积(AUC)比较,差异无统计学意义[0.859(95%CI 0.748~0.935)比0.875(95%CI 0.766~0.945),P=0.801];二者与FFR诊断一致率的差异无统计学意义(74.2%比79.0%,P=0.615)。QFR与iFR的相关性较弱(r=0.396,95%CI 0.162~0.587,P=0.0015)。QFR对应iFR≤0.89的AUC为0.663(95%CI 0.524~0.801,P=0.028)。QFR、iFR联合诊断策略可以与FFR达到88.7%的诊断一致率,同时减少58.1%的压力导丝使用。结论iFR与QFR评估冠状动脉临界病变具有相似的诊断准确率,但二者相关性较弱。二者联合诊断策略可进一步提高诊断准确率。     

定量冠状动脉造影参数与心肌血流储备分数的相关性分析

目的 探讨定量冠状动脉造影（QCA）参数与心肌血流储备分数（FFR）的相关性.方法 共纳入231例患者325处临界病变,根据FFR值分为两组,FFR＞0.80组（n=177）及FFR≤0.80组（n=148）.结果 两组患者冠状动脉直径狭窄[（58.7±13.4）％比（68.2±11.6）％,P＜0.001]、面积狭窄[（80.9±11.7）％比（88.4±8.0）％,P＜0.001]差异有统计学意义,上述指标与FFR值呈负相关（相关系数分别为r=-0.352,P＜0.001,r=-0.347,P＜0.001）.最小管腔直径两组差异有统计学意义[（1.18 ±0.46）mm比（0.83 ±0.39）mm,P＜0.001],与FFR值呈正相关（r=0.374,P＜0.001）.ROC曲线分析提示,冠状动脉最小管腔直径ROC曲线下面积为0.721,最小管腔面积≥1.05 mm时,预测病变无功能学意义（FFR ＞0.80）的敏感度为62.7％,特异度为73.6％.结论 QCA中冠状动脉直径狭窄百分比、面积狭窄百分比、最小管腔直径与FFR值存在相关性,但预测病变是否为心肌缺血相关靶病变的敏感度和特异度不高,仍应尽量推广功能性心肌缺血指标FFR的使用.     

冠状动脉临界病变血管内超声检查参数与定量血流分数的相关性研究

目的探讨冠状动脉临界病变血管内超声(IVUS)检查参数与定量血流分数(QFR)的相关性。方法前瞻性连续入选2018年9月至2019年9月于同济大学附属东方医院接受QFR和IVUS检查的116例患者(117处冠状动脉临界病变)。根据QFR评估结果,将患者分为QFR≤0.80组(25处病变)和QFR>0.80组(92处病变),比较两组IVUS检查参数的差异。应用Poisson线性相关性分析以及受试者工作特征(ROC)曲线评估IVUS与QFR的相关性,应用logistic多元回归分析QFR≤0.80的预测因素。结果IVUS检查发现,QFR≤0.80组最小管腔面积(MLA)[(3.1±0.8)mm²比(3.6±1.1)mm²,P=0.040]、最小管腔直径(MLD)[(1.8±0.3)mm比(2.0±0.3)mm,P=0.012]显著小于QFR>0.80组,而斑块负荷[(73.5±5.6)%比(68.0±8.4)%,P=0.002]、面积狭窄率[(69.8±8.8)%比(63.8±9.8)%,P=0.007]、斑块偏心指数[(0.83±0.12)比(0.73±0.19),P=0.008]及回声消减斑块比例(52.0%比23.9%,P=0.003)显著高于QFR>0.80组,差异均有统计学意义。Poisson线性相关分析显示,MLA(r=0.259,P=0.005)、MLD(r=0.300,P=0.001)与QFR正相关,而斑块负荷(r=–0.357,P<0.001)以及斑块偏心指数(r=–0.247,P=0.008)与QFR负相关。logistic多因素回归分析表明斑块负荷>70%(OR 4.531,95%CI 1.443~14.222,P=0.010)和斑块偏心指数(OR 1.066,95%CI 1.014~1.121,P=0.012)为QFR≤0.80的独立预测因素。结论冠状动脉临界病变IVUS检查结果中斑块负荷>70%以及斑块偏心指数是QFR≤0.80的独立预测因子。     

静息全周期比值与冠脉血流储备分数的一致性

目的 评价静息全周期比值(resting full-cycle ratio,RFR)与金标准冠脉血管储备分数(fractional flow reserve,FFR)的一致性。方法 纳入2021年9月～2022年9月在沧州市中心医院接受侵入性生理学检查的冠心病患者。以RFR≤0.89作为参考值与FFR≤0.80作为参考值进行比较,评价RFR与FFR一致性,RFR的敏感性、特异性、阳性预测值、阴性预测值等指标。结果 本研究共纳入138例患者,共189支血管。以RFR≤0.89作为参考值与FFR≤0.80作为参考值比较,两种方法 一致性达81.5%,并具有统计学意义(R²=0.629,P<0.01),RFR≤0.89作为参考值其敏感度70.1%,特异度87.7%,阳性预测值75.8%,阴性预测值84.3%,准确率81.5%,ROC曲线下AUC面积为0.889(95%CI:0.842～0.937,P<0.01),RFR的cutoff值：0.915。约登指数为0.609。结论 RFR与金标准FFR具有良好的相关性,是冠脉生理学评估方法 的选择之一。     

定量血流分数与血流储备分数诊断错配的影响因素研究

目的 探讨定量血流分数（QFR）与血流储备分数(FFR)检查诊断错配的预测因素。方法 回顾性选取2018年6月1日至2023年2月1日就诊于阜外华中心血管病医院行FFR检查的患者进行离线QFR分析,分别以0.80为临界值将符合纳入标准的337例患者分为四组：FFR(+)QFR（+）、FFR(+)QFR（-）、FFR(-)QFR（+）、FFR(-)QFR（-）。比较四组间基线数据、实验室及影像学检查,多因素logistic回归分析探究QFR和FFR诊断错配的预测因素。结果 离线QFR和FFR功能分类的一致率为81.01%,273例病变分类一致,64例病变分类不一致。多因素logistic回归分析显示,FFR≤0.80时QFR错配预测因素为较小的直径狭窄百分比（DS%）(OR=0.837,95%CI 0.774～0.904,P<0.01)和较短的病变长度（LL）(OR=0.931,95%CI 0.893～0.971,P=0.001);FFR>0.80时QFR错配预测因素为较大的年龄（OR=1.055,95%CI 1.003～1.111,P=0.039）、较大的DS%(OR=1....     

影响冠状动脉左前降支近段临界病变血流储备分数的相关因素分析

目的探讨可能对冠状动脉左前降支近段临界病变血流储备分数(FFR)产生影响的因素。方法纳入2017年9月至2020年1月首都医科大学附属北京安贞医院167例冠状动脉左前降支近段临界病变的患者,行左前降支FFR检查,根据FFR值分为FFR≥0.75组(105例)及FFR<0.75组(62例),比较两组患者相关临床指标的差异,探讨FFR值与病变狭窄程度之间的关系。进行logistic多因素回归分析与FFR值相关的因素。结果两组患者性别、年龄、吸烟史、合并高血压病、合并糖尿病、体重指数、左心室射血分数、最小管腔直径、直径狭窄率、空腹血糖、总胆固醇、高密度脂蛋白胆固醇以及糖化血红蛋白水平等比较,差异均无统计学意义(均P>0.05);FFR<0.75组病变长度[(20.17±7.42)mm比(16.98±6.01)mm,P=0.045]及分支血管积分[(3.36±1.38)分比(2.71±1.04)分,P=0.023]显著大于FFR≥0.75组,差异有统计学意义。Pearson相关分析显示,FFR值与直径狭窄率无相关关系(r=0.371,P=0.067)。logistic多因素回归分析显示,病变长度(OR 2.197,95%CI 1.608~3.372,P=0.017)、分支血管积分(OR 2.101,95%CI 1.079~3.035,P=0.020)与FFR<0.75相关。结论左前降支近段临界病变冠状动脉狭窄的病变长度及病变以远的分支血管积分可能对FFR值产生影响。     

血管内超声在冠状动脉临界病变诊断和介入治疗中的应用

目的:探讨血管内超声(IVUS)在冠状动脉(冠脉)造影显示的临界病变诊断和介入治疗中的应用价值.方法:对经选择性冠脉造影提示临界病变的96例患者的110处病变进行IVUS检查,根据IVUS测定的最小管腔面积≤4.0 mm2作为冠脉介入治疗的标准,分为干预组和未干预组,分析病变的狭窄程度及粥样硬化斑块性质.结果:110处临界病变的平均最小管腔面积为(4.83±2.24)mm2,46处最小管腔面积≤4.0 mm2 的病变成功置入冠脉支架;IVUS显示干预组的最小管腔面积小于未干预组(3.47±0.44)mm2 比(5.69±1.57)mm2,(P<0.05);同时干预组的斑块负荷大于未干预组,但差异无统计学意义(68.50±5.98)%比(62.89±7.69)%,(P>0.05).两组的定性结果差异无统计学意义(P>0.05).结论:对冠脉造影显示的临界病变行IVUS检查可进一步明确临界病变的狭窄程度和病变的性质,指导下一步治疗.     

稳定性冠心病患者半乳糖凝集素-3与血流储备分数相关性研究

目的:探讨稳定性冠心病患者血清Galectin-3与血流储备分数(FFR)之间的关系。方法:连续入选2011-08-2014-12行FFR检测的单支病变稳定性冠心病274例,分为FFR0.80组和FFR≤0.80组,ELISA检测患者血清Galectin-3表达水平。结果:FFR≤0.80组平均年龄58.9±8.3岁,男性比例、高血压患病率高于FFR0.80组,入院前口服ACEI/ARB比例低于FFR0.80组;FFR≤0.80组Galectin-3表达高于FFR0.80组;Galectin-3独立于性别、吸烟、入院前口服阿司匹林和尿酸,是稳定性冠心病患者FFR≤0.80的独立预测因子(比值比:3.961,95%的置信区间为1.769~8.870,P=0.001)。线性回归分析FFR值与Galectin-3独立相关。结论:稳定性冠心病患者,Galectin-3与FFR明显相关,是反映冠状动脉狭窄血管功能的重要指标。     

腔内斑块强度对血管内超声诊断冠状动脉狭窄的准确性研究

目的冠状动脉狭窄与血管内超声显像(IVUS)下的腔内斑块强度(IBS)存在一定关联,本研究旨在探讨IBS对IVUS诊断冠状动脉狭窄的准确性。方法选取2016年9月—2017年8月海南省第三人民医院与泰达国际心血管病医院收治的冠状动脉狭窄病人54例,经冠状动脉血流储备分数(FFR)测量及IVUS检查共发现57处冠状动脉病变,使用IVUS对IBS进行分析,ΔIBS=(远端血管IBS)-(病变近端管腔IBS)。结果 FFR与ΔIBS(r=-0.50,P=0.000)和最小管腔面积(MLA)(r=0.55,P=0.000)显著相关。右冠状动脉和左下前降支冠状动脉的FFR与ΔIBS之间存在显著相关性(r=-0.60,P=0.02;r=-0.58,P=0.000)。MLA与FFR具有显著关联性(r=0.55,P=0.000)。ROC曲线分析显示,ΔIBS预测FFR≤0.80:曲线下面积=0.82,P=0.007,最佳截止值为6.78;MLA预测FFR:曲线下面积=0.83,P=0.006,最佳截止值为2.38;FFR降低与ΔIBS≥6.78且MLA≤2.38显著相关,且当二者组合时达极低值。结论右冠状动脉和左下前降支冠状动脉中,IBS与FFR显著相关,IVUS可为冠状动脉疾病病人提供准确的诊断。     

血管内超声在无保护左主干病变介入治疗中的应用

目的:评价血管内超声(IVUS)指导下的无保护左主干病变介入治疗的临床疗效。方法:纳入2012年1月至2015年12月入住我院的368例经冠状动脉(冠脉)造影证实无保护左主干狭窄超过50%的冠心病患者为研究对象,除外急性ST段抬高的急性心肌梗死患者,按倾向匹配得分法,1∶2分为IVUS组和常规造影介入(CAG)组,最终36例患者入选IVUS组,72例患者入选CAG组,比较2组患者的临床特征、住院期间和1年随访期间的主要心脏不良事件(MACE)(包括死亡、心绞痛复发及因缺血所致的再次血运重建等)。结果:2组患者年龄、性别构成、吸烟、高血压、糖尿病、高血脂、脑卒中、陈旧性心肌梗死、既往经皮冠脉介入术(PCI)史和外周血管疾病史无明显差异(均P0.05)。2组患者在最小管腔直径[(1.06±0.42)mm比(1.01±0.39)mm,P=0.697]、管腔直径狭窄百分比(83.9%±10.4%比87.6%±9.0%,P=0.064)、死亡率(0%比2.8%,P=0.551)、心绞痛复发率(8.3%比25%,P=0.071)、再次靶血管血运重建率(5.6%比13.9%,P=0.330)也无明显差异,但与CAG组相比,IVUS组的参考血管直径[(3.53±0.52)mm比(3.29±0.47)mm,P=0.018]、植入支架直径[(3.72±0.34)mm比(3.44±0.41)mm,P=0.001]、高压后扩球囊直径[(3.99±0.43)mm比(3.54±0.47)mm,P=0.000]及术后最小管腔直径[(3.88±0.40)mm比(3.49±0.42)mm,P=0.000]均明显大,MACE的发生率(8.3%比27.8%,P=0.038)明显降低。结论:IVUS指导下的无保护左主干病变介入治疗安全、有效,可明显改善此类患者的临床预后。     

Discordance between fractional flow reserve and instantaneous wave-free ratio in patients with severe aortic stenosis: A retrospective cohort study

BackgroundDiscordance between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) occurs in approximately 20 % of cases. However, no studies have reported the discordance in patients with severe aortic stenosis (AS). We aimed to evaluate the diagnostic discordance between FFR and iFR in patients with severe AS.MethodsWe examined 140 consecutive patients with severe AS (164 intermediate coronary artery stenosis vessels). FFR and iFR were calculated in four quadrants based on threshold FFR and iFR values of ≤0.8 and ≤0.89, respectively (Group 1: iFR >0.89, FFR >0.80; Group 2: iFR ≤0.89, FFR >0.80; Group 3: iFR >0.89, FFR ≤0.80; and Group 4: iFR ≤0.89, FFR ≤0.80). Concordant groups were Groups 1 and 4, and discordant groups were Groups 2 and 3. Positive and negative discordant groups were Groups 3 and 2, respectively.ResultsThe median (Q1, Q3) FFR and iFR were 0.84 (0.76, 0.88) and 0.85 (0.76, 0.91), respectively. Discordance was observed in 48 vessels (29.3 %). In the discordant group, negative discordance (Group 2: iFR ≤0.89 and FFR >0.80) was predominant (45 cases, 93.6 %). Multivariate analysis showed that the left anterior descending artery [odds ratio (OR), 3.88; 95 % confidence interval (CI): 1.54–9.79, p = 0.004] and peak velocity ≥5.0 m/s (OR, 3.21; 95%CI: 1.36–7.57, p = 0.008) were independently associated with negative discordance (FFR >0.8 and iFR ≤0.89).ConclusionsIn patients with severe AS, discordance between FFR and iFR was predominantly negative and observed in 29.3 % of vessels. The left anterior descending artery and peak velocity ≥5.0 m/s were independently associated with negative discordance.     

Association Between FFRCT and Instantaneous Wave-Free Ratio (iFR) of Intermediate Lesions on Coronary Computed Tomography Angiography

BackgroundNew data suggests long term outcomes of coronary revascularization based on instantaneous wave free ratio (iFR) are equivalent to invasive fractional flow reserve (FFR). We aimed to evaluate the correlation between non-invasive FFR derived from cardiac CT (FFR_CT) and iFR.MethodsData from 21 patients with 26 vessels, who underwent both FFR_CT computation and invasive iFR measurement, were analysed. We evaluated diagnostic performance of FFR_CT according to two cut-off values of ≤0.80 and ≤0.70 with iFR ≤0.89 as the reference standard.ResultsIn a per vessel analysis, the average diameter stenosis was 59%, mean FFR_CT was 0.81 while mean iFR was 0.90. Using an FFR_CT cut-off of 0.80, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy for FFR_CT were 86%, 84%, 67%, 94%, and 85% respectively. When the cut-off was lowered to 0.70, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy for FFR_CT were 57%, 100%, 100%, 86% and 88% respectively.ConclusionFFR_CT correlates well with iFR in this small retrospective study. Larger studies are required to confirm this finding.     

El cociente de flujo cuantitativo en pacientes con estenosis aórtica grave y lesiones coronarias intermedias

Introduction and objectivesQuantitative flow ratio (QFR) is a novel noninvasive method for evaluating coronary physiology. However, data on the QFR in patients with aortic stenosis (AS) and coronary artery disease are scarce. Thus, we compared the diagnostic performance of the QFR with that of the resting distal to aortic coronary pressure (Pd/Pa) ratio, fractional flow reserve (FFR), and instantaneous wave-free ratio (iFR), as well as angiographic indices.MethodsA total of 221 AS patients with 416 vessels undergoing FFR/iFR measurements were enrolled in the study.ResultsThe mean percent diameter stenosis (%DS) was 58.6% ± 13.4% and the mean Pd/Pa ratio, FFR, iFR, and QFR were 0.95 ± 0.03, 0.85 ± 0.07, 0.90 ± 0.04, and 0.84 ± 0.07, respectively. A FFR ≤ 0.80 was noted in 26.0% of interrogated vessels, as well as an iFR ≤ 0.89 in 33.2% and QFR ≤ 0.80 in 31.7%. The QFR had better agreement with FFR (intraclass correlation coefficient [ICC], 0.96; 95% confidence interval [95%CI], 0.95-0.96) than with the iFR (ICC, 0.79; 95%CI, 0.75-0.82) and Pd/Pa ratio (ICC, 0.52; 95%CI, 0.44-0.58). In addition, the QFR showed better diagnostic accuracy (98.6% vs 94.2%; P < .001) and discriminant function (area under the curve = 0.996 vs 0.988; P < .001) when the iFR was used as the reference instead of FFR.ConclusionsIn patients with AS, the QFR has good agreement with both FFR and iFR. However, the agreement appears to be even better when the iFR is used as the reference, presumably due to the complex nature of the coronary physiology in the assessment of coronary artery disease in patients with severe AS.     

Comparison of resting and adenosine-free pressure indices with adenosine-induced hyperemic fractional flow reserve in intermediate coronary lesions

Objective

Fractional flow reserve (FFR) using adenosine has been the gold standard in the functional assessment of intermediate coronary stenoses in the catheterization laboratory. We aim to study the correlation of adenosine-free indices such as whole cycle Pd/Pa [the ratio of mean distal coronary pressure (Pd) to the mean pressure observed in the aorta (Pa)], instantaneous wave-free ratio (iFR), and contrast-induced submaximal hyperemia (cFFR) with FFR.

Diagnostic accuracy of instantaneous wave free‐ratio in clinical practice

Aims

To evaluate the correlation between iFR and FFR in real‐world clinical practice.

Methods and Results

Retrospective, single‐centre study of 229 consecutive pressure‐wire studies (n_p = 158). Real‐time iFR and FFR measurements were performed for angiographically borderline stenoses. Functionally significant stenoses were defined as iFR <0.86 or FFR ≤0.80. An iFR between 0.86 and 0.93 was considered within the grey zone (Hybrid approach). Median iFR and FFR (IQR) were 0.92 (0.87‐0.95) and 0.83 (0.76‐0.89), respectively. Pearson's correlation coefficient was 0.75 (P < 0.001). Bland‐Altman plot showed a mean difference between iFR and FFR that remained consistent throughout the range of values. The optimal iFR cutoff was 0.91—sensitivity 80%, specificity 82% with ROC area under curve of 89%. Using the Hybrid iFR‐FFR strategy, we demonstrated high accuracy of iFR results—sensitivity 95%, specificity 96%, PPV 95%, and NPV 96%. In addition, this method would have avoided adenosine in 56% of patients. Mean follow‐up period was 17.2 (±3.4) months. All‐cause mortality was 3.2% (n_p = 5) and repeat intervention was required in six lesions (2.6%).

Conclusions

This study demonstrates that iFR is a valuable adjunct to FFR using the Hybrid iFR‐FFR strategy in a real‐world population. The use of adenosine may be avoided in about half the cases.

     

血管内超声显像指标对冠状动脉中度狭窄病变功能意义的判断价值

目的:评估血管内超声显像(intravascularultrasound,IVUS)测定的指标对冠状动脉中度狭窄病变功能意义的判断价值。方法:46支冠状动脉造影(coronaryarteryangiography,CAG)显示中度狭窄(直径狭窄率40%～60%)的冠状动脉,压力导丝测定心肌血流储备分数(myocardialfractionalflowreserve,FFRmyo),IVUS测定面积狭窄率及最小管腔面积。以FFRmyo<0.75为界限值,采用受试者工作特征曲线(receiveroperatingcharacteristic,ROC)选择IVUS测量的每个指标的截断点。结果:46支血管病变的直径狭窄率(49±11)%,FFRmyo为(0.83±0.15),显著低于正常组(FFRmyo为0.97±0.02)。14处(30%)病变低于界限值(FFRmyo<0.75)。IVUS面积狭窄率与FFRmyo呈负相关(r=-0.68,P<0.001)。以FFRmyo<0.75为界限值,根据ROC分析,面积狭窄率≥65%为截断点,灵敏度=100%,特异性=72%。最小管腔面积与FFRmyo呈正相关(r=0.63,P<0.001),以最小管腔面积≤4mm2为截断点,灵敏度=93%,特异性=77%。结论:IVUS测定的面积狭窄率≥65%、最小管腔面积≤4mm2,能较准确地判断中度狭窄病变的功能意义。     

Análise comparativa do fractional flow reserve (FFR) e do instantaneous wave‐free ratio (iFR): resultados de um registo de 5 anos

Introduction and Objective

Assessment of coronary lesions by the instantaneous wave free ratio (iFR) has generated significant debate. We aimed to assess the diagnostic performance of iFR and its impact on the decision to use fractional flow reserve (FFR) and on procedural characteristics.