Lindstaedt M, Spiecker M, Lawo T, Yazar A, Mügge A, Bojara W, Germing A
Medizinische Klinik II, Universitätsklinik Bergmannsheil, Bochum.
Dtsch Med Wochenschr. 2006 Sep 29;131(39):2134-8. doi: 10.1055/s-2006-951340.
Left main coronary artery disease (LMCA) is still a widely accepted indication for coronary artery bypass surgery. Intermediate LMCA disease, however, often cannot be evaluated reliably on the basis of clinical and angiographic information alone. The deferral of surgical revascularization based on fractional flow reserve (FFR) measurements has been shown to be safe and feasible when taking an FFR value of (3) 0.75 as cutoff. This study was performed to compare the accuracy of visual angiographic assessment of intermediate LMCA stenoses by experienced interventional cardiologists with functional assessment by FFR in a patient population with excellent long-term outcome after deferral of surgery on the basis of FFR measurements.
24 of 51 consecutive patients with intermediate LMCA disease were deferred from surgery based on an FFR value of > or = 0.75. Each angiogram was retrospectively reviewed independently by three experienced interventional cardiologists. Reviewers were blinded to initial FFR results, clinical data, and clinical outcome and asked to classify each lesion as SIGNIFICANT (FFR < 0.75), NOT SIGNIFICANT (FFR > or = 0.75), or UNSURE if the observer was unable to make a decision based on the angiogram.
Mean follow-up was 29 +/- 13.6 months. No death or myocardial infarction was observed, event-free survival was 69 %. When taking the "unsure" classifications into consideration the individual reviewers achieved correct lesion classification with respect to FFR results on average in 58 % to 82 % of cases. Interobserver variability resulted in only 46 % of cases in concordant lesion classification (3 agreements or 2 agreements and 1 "unsure" evaluation). The number of concordant agreements between the individual pairs of reviewers did not exceed the rate of coincidental agreements that could be expected to result from simple guessing (mean KAPPA coefficient 0.04). More than 50 % of patients with excellent long-term outcome after deferral of surgery would potentially have undergone operative revascularization if consensual decision making had been solely based on angiographic lesion assessment.
The functional significance of intermediate or equivocal LMCA lesions should not be based on visual assessment alone, even when performed by experienced interventional cardiologists.
左主干冠状动脉疾病（LMCA）仍是冠状动脉搭桥手术广泛认可的适应症。然而，仅依据临床和血管造影信息，往往无法可靠地评估中度LMCA疾病。当以（3）0.75作为截断值时，基于血流储备分数（FFR）测量结果延迟手术血运重建已被证明是安全可行的。本研究旨在比较经验丰富的介入心脏病专家通过血管造影视觉评估中度LMCA狭窄的准确性与在基于FFR测量结果延迟手术的患者群体中FFR功能评估的准确性，这些患者具有良好的长期预后。
51例连续性中度LMCA疾病患者中，24例基于FFR值≥0.75被延迟手术。三位经验丰富的介入心脏病专家对每例血管造影进行独立回顾性分析。审阅者对初始FFR结果、临床数据及临床结局不知情，并被要求将每个病变分类为“显著”（FFR＜0.75）、“不显著”（FFR≥0.75），若观察者无法根据血管造影做出判断则分类为“不确定”。
平均随访时间为29±13.6个月。未观察到死亡或心肌梗死，无事件生存率为69%。考虑“不确定”分类时，各审阅者平均在58%至82%的病例中对病变分类与FFR结果相符。观察者间变异性导致仅46%的病例病变分类一致（3个一致或2个一致及1个“不确定”评估）。各审阅者对之间的一致意见数量未超过单纯猜测预期的偶然一致率（平均Kappa系数0.04）。如果仅基于血管造影病变评估做出共识性决策，超过50%在延迟手术后具有良好长期预后的患者可能会接受手术血运重建。
即使由经验丰富的介入心脏病专家进行，中度或可疑LMCA病变的功能意义也不应仅基于视觉评估。
