生理分布与冠状动脉疾病的局部严重程度及其经皮冠状动脉介入治疗后的结果。
Physiological Distribution and Local Severity of Coronary Artery Disease and Outcomes After Percutaneous Coronary Intervention.
机构信息
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China.
出版信息
JACC Cardiovasc Interv. 2021 Aug 23;14(16):1771-1785. doi: 10.1016/j.jcin.2021.06.013.
OBJECTIVES
The aim of this study was to evaluate prognostic implications of physiological 2-dimensional disease patterns on the basis of distribution and local severity of coronary atherosclerosis determined by quantitative flow ratio (QFR) virtual pull back.
BACKGROUND
The beneficial effect of percutaneous coronary intervention (PCI) is determined by physiological distribution and local severity of coronary atherosclerosis.
METHODS
The study population included 341 patients who underwent angiographically successful PCI and post-PCI fractional flow reserve (FFR) measurement. Using pre-PCI virtual pull backs of QFR, physiological distribution was determined by pull back pressure gradient index, with a cutoff value of 0.78 to define predominant focal versus diffuse disease. Physiological local severity was assessed by instantaneous QFR gradient per unit length, with a cutoff value of ≥0.025/mm to define a major gradient. Suboptimal post-PCI physiological results were defined as both post-PCI FFR ≤0.85 and percentage FFR increase ≤15%. Clinical outcome was assessed by target vessel failure (TVF) at 2 years.
RESULTS
QFR pull back pressure gradient index was correlated with post-PCI FFR (R = 0.423; P < 0.001), and instantaneous QFR gradient per unit length was correlated with percentage FFR increase (R = 0.370; P < 0.001). Using the 2 QFR-derived indexes, disease patterns were classified into 4 categories: predominant focal disease with and without major gradient (group 1 [n = 150] and group 2 [n = 21], respectively) and predominant diffuse disease with and without major gradient (group 3 [n = 115] and group 4 [n = 55], respectively). Proportions of suboptimal post-PCI physiological results were significantly different according to the 4 disease patterns (18.7%, 23.8%, 22.6%, and 56.4% from group 1 to group 4, respectively; P < 0.001). Cumulative incidence of TVF after PCI was significantly higher in patients with predominant diffuse disease (8.1% in group 3 and 9.9% in group 4 vs 1.4% in group 1 and 0.0% in group 2; overall P = 0.024).
CONCLUSIONS
Both physiological distribution and local severity of coronary atherosclerosis could be characterized without pressure-wire pull backs, which determined post-PCI physiological results. After successful PCI, TVF risk was determined mainly by the physiological distribution of coronary atherosclerosis. (Automated Algorithm Detecting Physiologic Major Stenosis and Its Relationship With Post-PCI Clinical Outcomes [Algorithm-PCI], NCT04304677; Influence of FFR on the Clinical Outcome After Percutaneous Coronary Intervention [PERSPECTIVE], NCT01873560).
目的
本研究旨在评估基于定量血流比（QFR）虚拟回撤确定的冠状动脉粥样硬化分布和局部严重程度的生理二维疾病模式对预后的影响。
背景
经皮冠状动脉介入治疗（PCI）的获益取决于冠状动脉粥样硬化的生理分布和局部严重程度。
方法
本研究纳入了 341 例接受经皮冠状动脉介入治疗且术后行血流储备分数（FFR）测量的患者。通过术前 QFR 虚拟回撤，使用回撤压力梯度指数来确定生理分布，以 0.78 作为分界值，定义主要为局灶性或弥漫性病变。生理局部严重程度通过瞬时 QFR 梯度/单位长度进行评估，以 0.025/mm 作为分界值，定义主要梯度。将术后即刻 FFR≤0.85 和 FFR 增加百分比≤15%定义为术后即刻不理想的生理结果。通过 2 年时的靶血管失败（TVF）评估临床结局。
结果
QFR 回撤压力梯度指数与术后即刻 FFR 呈正相关（R=0.423，P<0.001），瞬时 QFR 梯度/单位长度与 FFR 增加百分比呈正相关（R=0.370，P<0.001）。根据这 2 个 QFR 衍生指标，将疾病模式分为 4 类：伴有或不伴有主要梯度的局灶性病变（第 1 组[n=150]和第 2 组[n=21]）和伴有或不伴有主要梯度的弥漫性病变（第 3 组[n=115]和第 4 组[n=55]）。根据 4 种疾病模式，术后即刻不理想的生理结果比例存在显著差异（第 1 组至第 4 组分别为 18.7%、23.8%、22.6%和 56.4%，P<0.001）。PCI 后 TVF 的累积发生率在弥漫性病变患者中明显更高（第 3 组为 8.1%，第 4 组为 9.9%，而第 1 组为 1.4%，第 2 组为 0.0%；总体 P=0.024）。
结论
在无需压力导丝回撤的情况下，可对冠状动脉粥样硬化的生理分布和局部严重程度进行特征描述，这决定了术后即刻的生理结果。成功 PCI 后，TVF 风险主要取决于冠状动脉粥样硬化的生理分布。（自动算法检测生理主要狭窄及其与术后临床结局的关系[Algorithm-PCI]，NCT04304677；FFR 对经皮冠状动脉介入治疗后临床结局的影响[PERSPECTIVE]，NCT01873560）。
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