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Multicenter Study
. 2014 Nov;168(5):739-48.
doi: 10.1016/j.ahj.2014.06.022. Epub 2014 Jul 21.

Real-time use of instantaneous wave-free ratio: results of the ADVISE in-practice: an international, multicenter evaluation of instantaneous wave-free ratio in clinical practice

Ricardo Petraco  1 , Rasha Al-Lamee  1 , Matthias Gotberg  2 , Andrew Sharp  3 , Farrel Hellig  4 , Sukhjinder S Nijjer  1 , Mauro Echavarria-Pinto  5 , Tim P van de Hoef  6 , Sayan Sen  1 , Nobuhiro Tanaka  7 , Eric Van Belle  8 , Waldemar Bojara  9 , Kunihiro Sakoda  10 , Martin Mates  11 , Ciro Indolfi  12 , Salvatore De Rosa  12 , Christian J Vrints  13 , Steven Haine  13 , Hiroyoshi Yokoi  14 , Flavio L Ribichini  15 , Martjin Meuwissen  16 , Hitoshi Matsuo  17 , Luc Janssens  18 , Ueno Katsumi  17 , Carlo Di Mario  19 , Javier Escaned  5 , Jan Piek  6 , Justin E Davies  20
Affiliations
Multicenter Study

Real-time use of instantaneous wave-free ratio: results of the ADVISE in-practice: an international, multicenter evaluation of instantaneous wave-free ratio in clinical practice

Ricardo Petraco et al. Am Heart J. 2014 Nov.

Abstract

Objectives: To evaluate the first experience of real-time instantaneous wave-free ratio (iFR) measurement by clinicians.

Background: The iFR is a new vasodilator-free index of coronary stenosis severity, calculated as a trans-lesion pressure ratio during a specific period of baseline diastole, when distal resistance is lowest and stable. Because all previous studies have calculated iFR offline, the feasibility of real-time iFR measurement has never been assessed.

Methods: Three hundred ninety-two stenoses with angiographically intermediate stenoses were included in this multicenter international analysis. Instantaneous wave-free ratio and fractional flow reserve (FFR) were performed in real time on commercially available consoles. The classification agreement of coronary stenoses between iFR and FFR was calculated.

Results: Instantaneous wave-free ratio and FFR maintain a close level of diagnostic agreement when both are measured by clinicians in real time (for a clinical 0.80 FFR cutoff: area under the receiver operating characteristic curve [ROC(AUC)] 0.87, classification match 80%, and optimal iFR cutoff 0.90; for a ischemic 0.75 FFR cutoff: iFR ROC(AUC) 0.90, classification match 88%, and optimal iFR cutoff 0.85; if the FFR 0.75-0.80 gray zone is accounted for: ROC(AUC) 0.93, classification match 92%). When iFR and FFR are evaluated together in a hybrid decision-making strategy, 61% of the population is spared from vasodilator while maintaining a 94% overall agreement with FFR lesion classification.

Conclusion: When measured in real time, iFR maintains the close relationship to FFR reported in offline studies. These findings confirm the feasibility and reliability of real-time iFR calculation by clinicians.

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Figures

None
Graphical abstract
Figure 1
Figure 1
Pressure normalization, temporal alignment, and iFR calculation using the hemodynamic console.
Figure 2
Figure 2
Importance of ECG detection for accurate iFR measurement.
Figure 3
Figure 3
Frequency distribution of FFR and percentage diameter stenosis values in the study.
Figure 4
Figure 4
Diagnostic agreement between iFR and FFR.
Figure 5
Figure 5
Decision-making strategies of revascularization, using iFR only (bottom panel) and a hybrid iFR-FFR approach (top panel). FFR gray zone (0.75-0.80) refers to a region within which is known to be safe to defer and treat stenoses with equivalent clinical outcomes.
Figure 6
Figure 6
Screenshots of measurements of iFR and FFR. A, An example of interrogation in the left circumflex artery (horizontal arrow), in which both iFR and FFR were negative, above their respective cutoffs of 0.90 and 0.80; revascularization was deferred. B, An example in which both iFR and FFR revealed a functionally significant stenosis in the proximal segment of the left anterior descending artery (oblique arrow); percutaneous revascularization was performed. Because iFR is performed without the need for vasodilator administration, the time of lesion interrogation is typically reduced to around 5 to 10 seconds, from 60 to 120 seconds for FFR.
Figure 7
Figure 7
The FLAIR trial will evaluate the clinical merits of iFR guided revascularization.
See this image and copyright information in PMC

References

    1. Sen S., Escaned J., Malik I.S. Development and validation of a new adenosine-independent index of stenosis severity from coronary wave-intensity analysis: results of the ADVISE (ADenosine Vasodilator Independent Stenosis Evaluation) study. J Am Coll Cardiol. 2012;59(15):1392–1402. - PubMed
    1. Petraco R., Escaned J., Sen S. Classification performance of instantaneous wave–free ratio (iFR) and fractional flow reserve in a clinical population of intermediate coronary stenoses: results of the ADVISE registry. Eurointervention. 2013;9(1):91–101. - PubMed
    1. Park J.J., Petraco R., Nam C.W. Clinical validation of the resting pressure parameters in the assessment of functionally significant coronary stenosis; results of an independent, blinded comparison with fractional flow reserve. Int J Cardiol. 2013;168(4):4070–4075. - PubMed
    1. Jeremias A., Maehara A., Genereux P. Multicenter core laboratory comparison of the instantaneous wave–free ratio and resting P/P with fractional flow reserve: the RESOLVE study. J Am Coll Cardiol. 2013;63(13):1253–1261. - PubMed
    1. Sen S., Asrress K.N., Nijjer S. Diagnostic classification of the instantaneous wave–free ratio is equivalent to fractional flow reserve and is not improved with adenosine administration: results of CLARIFY (Classification Accuracy of Pressure-Only Ratios Against Indices Using Flow Study) J Am Coll Cardiol. 2013;61(13):1409–1420. - PubMed

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