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Resumen Introduccion y objetivos La valoracion angiografica visual sigue utilizandose para decidir la revascularizacion de lesiones coronarias dudosas. Multiples factores, distintos del grado de estenosis, se han asociado con la repercusion funcional de una lesion coronaria. El objetivo de este estudio es analizar la capacidad de predecir visualmente la repercusion funcional de una lesion coronaria y los condicionantes clinicos y angiograficos asociados con el error en la prediccion. Metodos Estudio de concordancia entre la prediccion de repercusion funcional realizada por intervencionistas expertos y el valor de reserva fraccional de flujo obtenido mediante guia intracoronaria de presion en 665 lesiones intermedias (estenosis del 40–70% del diametro) en 587 pacientes. Se determinaron los factores independientemente asociados a un error en la prediccion. Resultados Se observo una discordancia del 30,1% (sobrestimacion, 11,3%; subestimacion, 18,8%) entre el valor de reserva fraccional de flujo predicho ≤ 0,80 y el observado. La localizacion en el stent, en una arteria distinta de la descendente anterior y en una bifurcacion se asocio a sobrestimacion. El sexo masculino, la calcificacion grave y el mayor territorio miocardico distal a la lesion se asociaron significativamente con importancia funcional de la lesion subestimada. Conclusiones Incluso integrando caracteristicas angiograficas y clinicas, la estimacion visual de la importancia funcional de estenosis coronarias intermedias se asocia a una alta tasa de discrepancias respecto a su determinacion real. Determinadas caracteristicas angiograficas y clinicas se asocian especificamente con mayor tendencia a sobrestimar o subestimar la importancia de la lesion.

Objective: To assess the relationship between lesion length and other angiographic parameters on the functional significance of long coronary lesions with moderate stenosis. Background: Coronary revascularization is usually based on angiographic percent stenosis. Coronary stenosis length is not usually considered in daily clinical practice for revascularization decision-making. The relevance of lesion length might be greater in longer lesions with intermediate stenosis. Methods: All coronary lesions >20 mm and of 40–70% percent stenosis assessed by intracoronary pressure wire between 2007 and 2009 were included. Interventionists performing digital quantification of lesion stenosis were blinded to the result of fractional flow reserve (FFR). Correlations between angiographic data and FFR were analyzed. Results: One hundred and six lesions from 103 patients were included. Reference diameter: 2.9 6 0.56 mm; maximal stenosis: 49.0 6 8.7%; minimal luminal diameter (MinimalLD): 1.48 6 0.4 mm; mean luminal diameter (MeanLD): 2.3 6 0.5 mm; mean lesion length: 28.7 6 10.6 mm. Lesions with FFR 20 mm) with moderate angiographic stenosis, lesion length might be the strongest determinant of functional repercussion. Lesion length should be considered when judging the benefit of revascularization or perform functional functional measures that overcome the limitations of simple stenosis quantification. V C 2012 Wiley Periodicals, Inc.

Introduction and objectives Visual angiographic assessment continues to be used when decisions are made on whether to revascularize ambiguous coronary lesions. Multiple factors, other than the degree of stenosis, have been associated with the functional significance of a coronary lesion. The aim of this study was to investigate the ability of interventionists to visually predict the functional significance of a coronary lesion and the clinical and angiographic characteristics associated with errors in prediction. Methods We conducted a concordance study of the functional significance of coronary lesions predicted by experienced interventionists and fractional flow reserve values measured by intracoronary pressure wire in 665 intermediate lesions (40%-70% diameter stenosis) in 587 patients. We determined which factors were independently associated with errors in prediction. Results There was disagreement between the predicted fractional flow reserve value of ≤ 0.80 and the observed value in 30.1% of the lesions (overestimation: 11.3%; underestimation, 18.8%). Stent location in an artery other than the anterior descending artery or in a bifurcation was associated with overestimation. Male sex, severe calcification, and a greater myocardial territory distal to the lesion were significantly associated with the functional significance of the underestimated lesion. Conclusions Even when taking into account angiographic and clinical characteristics, there is a high rate of disagreement between visual estimation and direct measurement of intermediate coronary stenosis in relation to its functional significance. Specific angiographic and clinical characteristics are associated with an increased tendency to overestimate or underestimate the significance of lesions.

Intravenous adenosine is considered the drug of choice to obtain maximum hyperemia in the measurement of the fractional flow reserve (FFR). However, comparative studies performed between intravenous and intracoronary administration have not used high doses of intracoronary adenosine. The present study compared the efficacy and safety of high doses of intracoronary adenosine to intravenous administration when calculating the FFR. Intracoronary bolus doses of 60, 180, 300, and 600 μg adenosine were compared to an intravenous administration of 140 μg/kg/min, 200 μg/kg/min, and 140 μg/kg/min plus an intracoronary bolus of 120 μg. All the cases were performed using the radial approach. FFR was assessed in 102 patients with 108 intermediate lesions by an intracoronary pressure wire. The intracoronary dose of 60 μg was associated with a significantly greater FFR compared to the intravenous infusion (0.02 ± 0.03, p = 0.001). The intracoronary doses of 300 (-0.01 ± 0.00; p = 0.006) and 600 μg (-0.02 ± 0.00; p0.0005) were significantly associated with a smaller FFR compared to the intravenous infusion. An intracoronary dose of 600 μg revealed a significantly greater percentage of lesions with an FFR0.80 compared to intravenous infusion at 140 μg/kg/min (37.6 vs 31.5%; p0.05) and 200 μg/kg/min (37.6 vs 32.4%; p0.05) and compared to intracoronary doses of 60 (26.9%) and 180 μg (31.5%). In conclusion, an intracoronary bolus dose300 μg can be equal to or more effective than an intravenous infusion of adenosine in achieving maximum hyperemia when calculating the FFR. Its use could simplify these procedures without having an effect on safety.

To assess the relationship between lesion length and other angiographic parameters on the functional significance of long coronary lesions with moderate stenosis.Coronary revascularization is usually based on angiographic percent stenosis. Coronary stenosis length is not usually considered in daily clinical practice for revascularization decision-making. The relevance of lesion length might be greater in longer lesions with intermediate stenosis.All coronary lesions20 mm and of 40-70% percent stenosis assessed by intracoronary pressure wire between 2007 and 2009 were included. Interventionists performing digital quantification of lesion stenosis were blinded to the result of fractional flow reserve (FFR). Correlations between angiographic data and FFR were analyzed.One hundred and six lesions from 103 patients were included. Reference diameter: 2.9 ± 0.56 mm; maximal stenosis: 49.0 ± 8.7%; minimal luminal diameter (MinimalLD): 1.48 ± 0.4 mm; mean luminal diameter (MeanLD): 2.3 ± 0.5 mm; mean lesion length: 28.7 ± 10.6 mm. Lesions with FFR0.75 accounted for 33% (n = 35). Weak correlations were obtained between FFR and MinimalLD (r = 0.36; P0.0005), MeanLD (r = 0.24; P = 0.014), maximal stenosis (r = 0.31; P = 0.001), and mean stenosis (r = 0.018; P = 0.85); strong correlations were observed between FFR and lesion length (r = 0.63; P0.0005), lesion length/MinimalLD (r = 0.67; P0.0005), and lesion length/MeanLD (0.72; P0.0005). The predictive values of lesion length, lesion length/MinimalLD, and lesion length/MeanLD for FFR0.75 were 0.86, 0.91, and 0.92, respectively.In long lesions (20 mm) with moderate angiographic stenosis, lesion length might be the strongest determinant of functional repercussion. Lesion length should be considered when judging the benefit of revascularization or perform functional functional measures that overcome the limitations of simple stenosis quantification.