Carlos Collet1, Yosuke Miyazaki2, Nicola Ryan3, Taku Asano4, Erhan Tenekecioglu2, Jeroen Sonck5, Daniele Andreini6, Manel Sabate7, Salvatore Brugaletta7, Rodney H Stables8, Antonio Bartorelli6, Robbert J de Winter4, Yuki Katagiri4, Ply Chichareon4, Giovanni Luigi De Maria9, Pannipa Suwannasom4, Rafael Cavalcante2, Hans Jonker10, Marie-Angèle Morel10, Bernard Cosyns5, Arie P Kappetein5, David T Taggart9, Vasim Farooq11, Javier Escaned2, Adrian Banning9, Yoshinobu Onuma12, Patrick W Serruys13. 1. Department of Cardiology, Academic Medical Center of Amsterdam, Cardiology, Amsterdam, the Netherlands; Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium. 2. Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands. 3. Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain. 4. Department of Cardiology, Academic Medical Center of Amsterdam, Cardiology, Amsterdam, the Netherlands. 5. Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium. 6. Centro Cardiologico Monzino, University of Milan, Milan, Italy. 7. Hospital Clinic I Provincial de Barcelona, Barcelona, Spain. 8. Liverpool Heart and Chest Hospital, Liverpool, United Kingdom. 9. John Radcliffe Hospital, Cardiology, Oxford, United Kingdom. 10. Cardialysis BV, Rotterdam, the Netherlands. 11. Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals, Manchester, United Kingdom. 12. Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium; Cardialysis BV, Rotterdam, the Netherlands. 13. Department of Cardiology, Imperial College London, London, United Kingdom. Electronic address: patrick.w.j.c.serruys@gmail.com.
Abstract
BACKGROUND: The functional SYNTAX score (FSS) has been shown to improve the discrimination for major adverse cardiac events compared with the anatomic SYNTAX score (SS) while reducing interobserver variability. However, evidence supporting the noninvasive FSS in patients with multivessel coronary artery disease (CAD) is scarce. OBJECTIVES: The purpose of this study was to assess the feasibility of and validate the noninvasive FSS derived from coronary computed tomography angiography (CTA) with fractional flow reserve (FFRCT) in patients with 3-vessel CAD. METHODS: The CTA-SS was calculated in patients with 3-vessel CAD included in the SYNTAX II (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery II) study. The noninvasive FSS was determined by including only ischemia-producing lesions (FFRCT ≤0.80). SS derived from different imaging modalities were compared using the Bland-Altman and Passing-Bablok method, and the agreement on the SS tertiles was investigated with Cohen's Kappa. The risk reclassification was compared between the noninvasive and invasive physiological assessment, and the diagnostic accuracy of FFRCT was assessed by the area under the receiver-operating characteristic curve using instantaneous wave-free ratio as a reference. RESULTS: The CTA-SS was feasible in 86% of patients (66 of 77), whereas the noninvasive FSS was feasible in 80% (53 of 66). The anatomic SS was overestimated by CTA compared with conventional angiography (27.6 ± 6.4 vs. 25.3 ± 6.9; p < 0.0001) whereas the calculation of the FSS yielded similar results between the noninvasive and invasive imaging modalities (21.6 ± 7.8 vs. 21.2 ± 8.8; p = 0.589). The noninvasive FSS reclassified 30% of patients from the high- and intermediate-SS tertiles to the low-risk tertile, whereas invasive FSS reclassified 23% of patients from the high- and intermediate-SS tertiles to the low-risk tertile. The agreement on the classic SS tertiles based on Kappa statistics was slight for the anatomic SS (Kappa = 0.19) and fair for the FSS (Kappa = 0.32). The diagnostic accuracy of FFRCT to detect functional significant stenosis based on an instantaneous wave-free ratio ≤0.89 revealed an area under the receiver-operating characteristics curve of 0.85 (95% CI: 0.79 to 0.90) with a sensitivity of 95% (95% CI: 89% to 98%), specificity of 61% (95% CI: 48% to 73%), positive predictive value of 81% (95% CI: 76% to 86%), and negative predictive value of 87% (95% CI: 74% to 94%). CONCLUSIONS: Calculation of the noninvasive FSS is feasible and yielded similar results to those obtained with invasive pressure-wire assessment. The agreement on the SYNTAX score tertile classification improved with the inclusion of the functional component from slight to fair agreement. FFRCT has good accuracy in detecting functionally significant lesions in patients with 3-vessel CAD. (A Trial to Evaluate a New Strategy in the Functional Assessment of 3-Vessel Disease Using SYNTAX II Score in Patients Treated With PCI; NCT02015832).
BACKGROUND: The functional SYNTAX score (FSS) has been shown to improve the discrimination for major adverse cardiac events compared with the anatomic SYNTAX score (SS) while reducing interobserver variability. However, evidence supporting the noninvasive FSS in patients with multivessel coronary artery disease (CAD) is scarce. OBJECTIVES: The purpose of this study was to assess the feasibility of and validate the noninvasive FSS derived from coronary computed tomography angiography (CTA) with fractional flow reserve (FFRCT) in patients with 3-vessel CAD. METHODS: The CTA-SS was calculated in patients with 3-vessel CAD included in the SYNTAX II (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery II) study. The noninvasive FSS was determined by including only ischemia-producing lesions (FFRCT ≤0.80). SS derived from different imaging modalities were compared using the Bland-Altman and Passing-Bablok method, and the agreement on the SS tertiles was investigated with Cohen's Kappa. The risk reclassification was compared between the noninvasive and invasive physiological assessment, and the diagnostic accuracy of FFRCT was assessed by the area under the receiver-operating characteristic curve using instantaneous wave-free ratio as a reference. RESULTS: The CTA-SS was feasible in 86% of patients (66 of 77), whereas the noninvasive FSS was feasible in 80% (53 of 66). The anatomic SS was overestimated by CTA compared with conventional angiography (27.6 ± 6.4 vs. 25.3 ± 6.9; p < 0.0001) whereas the calculation of the FSS yielded similar results between the noninvasive and invasive imaging modalities (21.6 ± 7.8 vs. 21.2 ± 8.8; p = 0.589). The noninvasive FSS reclassified 30% of patients from the high- and intermediate-SS tertiles to the low-risk tertile, whereas invasive FSS reclassified 23% of patients from the high- and intermediate-SS tertiles to the low-risk tertile. The agreement on the classic SS tertiles based on Kappa statistics was slight for the anatomic SS (Kappa = 0.19) and fair for the FSS (Kappa = 0.32). The diagnostic accuracy of FFRCT to detect functional significant stenosis based on an instantaneous wave-free ratio ≤0.89 revealed an area under the receiver-operating characteristics curve of 0.85 (95% CI: 0.79 to 0.90) with a sensitivity of 95% (95% CI: 89% to 98%), specificity of 61% (95% CI: 48% to 73%), positive predictive value of 81% (95% CI: 76% to 86%), and negative predictive value of 87% (95% CI: 74% to 94%). CONCLUSIONS: Calculation of the noninvasive FSS is feasible and yielded similar results to those obtained with invasive pressure-wire assessment. The agreement on the SYNTAX score tertile classification improved with the inclusion of the functional component from slight to fair agreement. FFRCT has good accuracy in detecting functionally significant lesions in patients with 3-vessel CAD. (A Trial to Evaluate a New Strategy in the Functional Assessment of 3-Vessel Disease Using SYNTAX II Score in Patients Treated With PCI; NCT02015832).
Authors: Axel Schmermund; Joachim Eckert; Marco Schmidt; Annett Magedanz; Thomas Voigtländer Journal: Clin Res Cardiol Date: 2018-07-04 Impact factor: 5.460
Authors: Fan Zhou; Chun Xiang Tang; U Joseph Schoepf; Christian Tesche; Maximilian J Bauer; Brian E Jacobs; Chang Sheng Zhou; Jing Yan; Meng Jie Lu; Guang Ming Lu; Long Jiang Zhang Journal: Eur Radiol Date: 2018-10-30 Impact factor: 5.315
Authors: Jagat Narula; Y Chandrashekhar; Amir Ahmadi; Suhny Abbara; Daniel S Berman; Ron Blankstein; Jonathon Leipsic; David Newby; Edward D Nicol; Koen Nieman; Leslee Shaw; Todd C Villines; Michelle Williams; Harvey S Hecht Journal: J Cardiovasc Comput Tomogr Date: 2020-11-20
Authors: G B John Mancini; Jonathan Leipsic; Matthew J Budoff; Cameron J Hague; James K Min; Susanna R Stevens; Harmony R Reynolds; Sean M O'Brien; Leslee J Shaw; Cholenahally N Manjunath; Kreton Mavromatis; Marcin Demkow; Jose Luis Lopez-Sendon; Alexander M Chernavskiy; Gilbert Gosselin; Herwig Schuchlenz; Gerard P Devlin; Anoop Chauhan; Sripal Bangalore; Judith S Hochman; David J Maron Journal: JACC Cardiovasc Imaging Date: 2021-01-13