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Doctoral Thesis
DOI
https://doi.org/10.11606/T.98.2019.tde-27072020-111909
Document
Author
Full name
Mateus Veloso e Silva
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2019
Supervisor
Committee
Sousa, Amanda Guerra de Moraes Rego (President)
Devito, Fernando Stucchi
Alves, Claudia Maria Rodrigues
Costa Junior, José de Ribamar
Title in Portuguese
Análise do estudo da reserva de fluxo por meio da angiografia quantitativa tridimensional e de recursos computacionais no diagnóstico e tratamento da doença arterial coronária
Keywords in Portuguese
Estenose Coronária
Índice de Gravidade da Doença
Isquemia Miocárdica
Reprodutibilidade dos Testes
Valor Preditivo dos Testes
Abstract in Portuguese
A doença arterial coronária (DAC) permanece como a principal causa de mortalidade no mundo e o exame padrão-ouro para seu diagnóstico é a angiografia coronária invasiva. Habitualmente, este diagnóstico é realizado por meio do percentual de estenose de forma visual ou quantitativa. Entretanto, estes métodos apresentam elevada variabilidade interobservador e baixa correlação com desfechos clínicos em ensaios clínicos randomizados que compararam tratamento clinico com angioplastia coronária. Os métodos de avaliação funcional, tais como a Fractional Flow Reserve (FFR) e a Instantaneous wave-free Ratio (iFR), melhoraram a acurácia diagnóstica. A Quantitative Flow Reserve (QFR) é uma nova modalidade de avalição fisiológica baseada na reconstrução tridimensional dos vasos e na estimativa da velocidade de fluxo. Objetivo: Avaliar a acurácia diagnóstica da QFR e sua correlação com os métodos de referência para avaliação fisiológica, a FFR e a iFR. em lesões intermediárias. Métodos: Foram incluídos pacientes portadores de DAC estável submetidos à angiografia coronária invasiva entre fevereiro de 2018 e janeiro de 2019 e que exibiam estenoses de gravidade intermediária. AFFR, iFR e QFR foram realizadas nas lesões elegíveis. AFFR, medida em hiperemia máxima, foi considerada o método-padrão. Resultados: Foram avaliadas 41 lesões de 32 pacientes, com idade entre 41 e 82anos. Dezenove (46,3%) lesões apresentaram FFR menor que 0,80. As médias da FFR. iFR, contrast QFR (cQFR), fixed-flow QFR (ffQFR) e do porcentual do diâmetro de estenose pela Angiografia Coronária Quantitativa (ACQ) e pela estimativa visual foram: 0,79±0,12, 0,88±0,12, 0,78±0,10, 0,79±0,10 e 51,91±10,26% e 57,58±13,00%, respectivamente. A acurácia diagnóstica da iFR, cQFR, ffQFR e do porcentual do diâmetro de estenose pela (ACQ) e pela estimativa visual foram 85,0% (95%intervalodeconfiança[IC]:69,5-93,8%), 95,1% (95%IC88,2-99,2%), 80,5% (95%IC:64,6-90,6%), 80,5% (95%IC:64,6-90,6) e 65,9% (95%IC:49,3-79,4%). Entre a ffQFR e a FFR, houve boa correlação (rc=0,83) e concordância (diferençamédia:0,01±0,12). Esta correlação foi ainda melhor entre a cQFR e a FFR, com ótima correlação (rc=0,92) e concordância (diferençamédia:0±0,09). Uma boa concordância intra e interobservador foi observada nas avaliações da cQFR, com diferença média de 0±0,03. Conclusão: A avaliação da QFR apresenta boa reprodutibilidade e boa correlação com a FFR e aumenta a acurácia diagnóstica em relação ao diâmetro de estenose.
Title in English
Analysis of coronary flow reserve by using quantitative three dimensional angiography and computational resources in the diagnosis of coronary artery disease
Keywords in English
Coronary Stenosis
Myocardial Ischemia
Predictive Value of Tests
Quantitative Flow Reserve
Reproduc ibility of Results
Sever it y of Illness Index
Abstract in English
Coronary Artery Disease (CAD) remains the leading cause of death worldwide and the gold standard diagnostic procedure for CAD is coronary angiography. Usually, this diagnostic method evaluates the percentual diameter stenosis by visual or quantitative estimation. However, this method shows high interobserver variability and low correlation with clinical outcomes in randomized clinical trials comparing optimized medical treatment with percutaneous coronary intervention. Methods that evaluate the functional significance of stenoses, such as Fractional Flow Reserve (FFR) and Instantaneous Wave-free Ratio (iFR), present high diagnostic accuracy. The Quantitative Flow Reserve (QFR) is a new modality of physiological assessment based on three-dimensional reconstruction of vessels and estimation of flow velocity. Objective: To evaluate the diagnostic accuracy of the QFR and its correlation with referential methods for physiological evaluation, such as FFR and iFR, in intermediate lesions. Methods: We included patients with stable CAD who underwent coronary angiography between February 2018 and January 2019 and presented intermediate stenoses. FFR, iFR, and QFR were performed on eligible lesions. FFR, measured in maximal hyperemia, was considered the gold standard method. Results: The patients aged 41 to 82 years. From the 41 lesions e valuated,19 (46.3%) presented a FFR lower than 0.80. The averages of FFR, iFR, QFR (cQFR), fixed-flow QFR (ffQFR), and percentual stenosis diameter by quantitative coronary angiography (QCA) andby visual estimation were 0.79±0.12, 0.88±0.12, 0.78±0.10, 0.79±0.10 and 51.91±10.26% and 57.58±13.00%, respectively. The diagnostic accuracy of iFR, cQFR, ffQFR and percentual stenosis diameter by QCA and visual estimation was 85.0% (95%,[CI]:69.5-93.8%), 95 (95%[CI]88.2-99.2%), 80.5% (95%[CI]:64.6-90.6%), 80.5% (95%[CI]:64.6-90,6) and 65.9% (95%[CI]:49.3-79.4%). There was a good correlation (rc=0.83) and concordance (mean difference:0.01±0.12) between ffQFR and FFR. The correlation was even stronger between cQFR and FFR (rc=0.92) with optimal agreement (meandifference:0±0.09). A good intra and interobserver agreement were observed in the cQFR evaluations, with a mean difference of 0±0.03. Conclusion: The QFR evaluation presented good correlation and reproducibility when compared to FFR and increased the diagnostic accuracy related to the evaluation of percentual stenosis diameter.
 
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Publishing Date
2020-08-10
 
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