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Original article
DOI: 10.1016/j.rec.2021.04.008
Available online 21 May 2021
Quantitative flow ratio for evaluation of borderline coronary lesions in patients with severe aortic stenosis
El cociente de flujo cuantitativo en pacientes con estenosis aórtica grave y lesiones coronarias intermedias
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Pawel Kleczynskia,
Corresponding author
kleczu@interia.pl

Corresponding author: Department of Interventional Cardiology, Jagiellonian University Medical College, 80 Pradnicka St., 31-501 Krakow, Poland.
, Artur Dziewierzb, Lukasz Rzeszutkob, Dariusz Dudekb, Jacek Legutkoa
a Department of Interventional Cardiology, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
b 2nd Department of Cardiology, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, University Hospital, Krakow, Poland
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Table 1. Baseline characteristics
Table 2. Lesion characteristics
Table 3. Comparison of the diagnostic performance and discriminant function of QFR with FFR and iFR used as reference standards
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Abstract
Introduction and objectives

Quantitative 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.

Methods

A total of 221 AS patients with 416 vessels undergoing FFR/iFR measurements were enrolled in the study.

Results

The 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.

Conclusions

In 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.

Keywords:
Aortic stenosis
Coronary artery disease
Coronary physiology
Quantitative flow ratio
Abbreviations:
%DS
AVS
CAD
iFR
QFR
TAVR
Resumen
Introducción y objetivos

El cociente de flujo cuantitativo (quantitative flow ratio [QFR]) es un método novedoso y no invasivo para evaluar la fisiología coronaria. Sin embargo, los datos sobre QFR en pacientes con estenosis aórtica (EA) y enfermedad coronaria son escasos. Por lo tanto, se evaluó el rendimiento diagnóstico del QFR contra la relación del cociente de presión coronaria en reposo distal/aórtica (Pd/Pa), la reserva fraccional de flujo (FFR) y el índice diastólico instantáneo sin ondas (iFR), así como índices angiográficos.

Métodos

Se incluyó un total de 221 pacientes con EA con 416 vasos en los que se midieron los valores de FFR/iFR.

Resultados

El porcentaje medio de estenosis del diámetro (%DS) fue 58,6±13,4% y las medias de Pd/Pa, FFR, iFR y QFR, 0,95±0,03, 0,85±0,07, 0,90±0,04 y 0,84±0,07 respectivamente. Se observó una FFR ≤ 0,80 en el 26,0% de los vasos evaluados, iFR ≤ 0,89 en el 33,2% y QFR ≤ 0,80 en el 31,7%. El QFR tuvo mejor correlación con la FFR (coeficiente de correlación intraclase [ICC]=0,96; intervalo de confianza del 95% [IC95%], 0,95-0,96) que con el iFR (ICC=0,79; IC95%, 0,75-0,82) y la Pd/Pa (ICC=0.52; IC95%, 0,44-0,58). Además, el QFR mostró una mejor precisión diagnóstica (el 98,6 frente al 94,2%; p <0,001) y la función discriminatoria (área bajo la curva, 0,996 frente a 0,988; p <0,001) al utilizar como referencia el iFR en lugar de la FFR.

Conclusiones

En pacientes con EA, el QFR muestra una buena correlación con la FFR y el iFR. Sin embargo, esta podría ser aún mejor utilizando el iFR como referencia, presumiblemente debido a la naturaleza compleja de la fisiología coronaria en la evaluación de la enfermedad coronaria de pacientes con EA grave.

Palabras clave:
Estenosis aórtica
Enfermedad coronaria
Fisiología coronaria
Cociente de flujo cuantitativo

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