FFR / Lindstaedt

How good are experienced interventional cardiologists at predicting the functional significance of intermediate or equivocal left main coronary artery stenoses?

Lindstaedt M, Spiecker M, Perings C, Lawo T,
Yazar A, Holland-Letz T, Muegge A, Bojara W,
Germing A. Int J Cardiol. 2007 Aug 21; 120(2):254-61.

OBJECTIVES:

Assess the accuracy of visual angiographic assessment of intermediate or equivocal left main coronary artery (LMCA) stenoses by experienced interventional cardiologists when taking fractional flow reserve (FFR) measurements as the gold standard.

METHODS:

• 51 patients
• Intermediate lesions (40 - 80 % diameter stenosis by angiography) and equivolcal LMCA disease
• Eveluation of all lesions by FFR
• Angiograms were reviewed by 4 experienced interventionalists blinded to FFR results
• Lesion significance had to be classified as 'significant', 'not significant', or 'unsure' by observer

SUMMARY:

• Results were compared with two different FFR cutoff values (< 0.75 and hemodynamically significant lesions.
• The 4 reviewers achieved correct lesion classification in no more than approximately 50 % of cases each, regardless of FFR threshold.
• The interobserver agreement between two reviewers in excess of the agreement expected due to chance was outperformed on average by only 16 %.
• The iinterobserver variability was large resulting in unanimously correct lesion classification in only 29 % of all cases.

CONCLUSIONS:

The evaluation of the functional significance of intermediate or equivocal LMCA stenoses should not be based on visual assessment, even when performed by experienced interventional cardiologists. The study is a strong plea to be prudent and self-critical with respect to one's own ability to appraise the functional significance of left main lesions correctly. Increased application of FFR measurements in this patient population should be recommended.

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