title: Fractional flow reserve and coronary bifurcation anatomy: a novel quantitative model to assess and report the stenosis severity of bifurcation lesions.
abstract: OBJECTIVE
  The aim of this study was to develop a new model for assessment of stenosis severity in a bifurcation lesion including its core. The diagnostic performance of this model, powered by 3-dimensional quantitative coronary angiography to predict the functional significance of obstructive bifurcation stenoses, was evaluated using fractional flow reserve (FFR) as the reference standard.
  
  
  BACKGROUND
  Development of advanced quantitative models might help to establish a relationship between bifurcation anatomy and FFR.
  
  
  METHODS
  Patients who had undergone coronary angiography and interventions in 5 European cardiology centers were randomly selected and analyzed. Different bifurcation fractal laws, including Murray, Finet, and HK laws, were implemented in the bifurcation model, resulting in different degrees of stenosis severity.
  
  
  RESULTS
  A total of 78 bifurcation lesions in 73 patients were analyzed. In 51 (65%) bifurcations, FFR was measured in the main vessel. A total of 34 (43.6%) interrogated vessels had an FFR≤0.80. Correlation between FFR and diameter stenosis was poor by conventional straight analysis (ρ=-0.23, p<0.001) but significantly improved by bifurcation analyses: the highest by the HK law (ρ=-0.50, p<0.001), followed by the Finet law (ρ=-0.49, p<0.001), and the Murray law (ρ=-0.41, p<0.001). The area under the receiver-operating characteristics curve for predicting FFR≤0.80 was significantly higher by bifurcation analysis compared with straight analysis: 0.72 (95% confidence interval: 0.61 to 0.82) versus 0.60 (95% confidence interval: 0.49 to 0.71; p=0.001). Applying a threshold of ≥50% diameter stenosis, as assessed by the bifurcation model, to predict FFR≤0.80 resulted in 23 true positives, 27 true negatives, 17 false positives, and 11 false negatives.
  
  
  CONCLUSIONS
  The new bifurcation model provides a comprehensive assessment of bifurcation anatomy. Compared with straight analysis, identification of lesions with preserved FFR values in obstructive bifurcation stenoses was improved. Nevertheless, accuracy was limited by using solely anatomical parameters.
authors.affiliation: Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China; Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands. Electronic address: sxtu@sjtu.edu.cn.
authors.forename: Shengxian
authors.initials: S
authors.lastname: Tu
authors.affiliation: Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain.
authors.forename: Mauro
authors.initials: M
authors.lastname: Echavarria-Pinto
authors.affiliation: Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Department of Health Technology and Services Research, MIRA Institute, University of Twente, Enschede, the Netherlands.
authors.forename: Clemens
authors.initials: C
authors.lastname: von Birgelen
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark.
authors.forename: Niels R
authors.initials: NR
authors.lastname: Holm
authors.affiliation: Cardiovascular Centre Aalst, Onze-Lieve-Vrouwziekenhuis Clinic, Aalst, Belgium.
authors.forename: Stylianos A
authors.initials: SA
authors.lastname: Pyxaras
authors.affiliation: Department of Cardiology, Paul Stradins Clinical Hospital, Riga, Latvia.
authors.forename: Indulis
authors.initials: I
authors.lastname: Kumsars
authors.affiliation: Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands.
authors.forename: Ming Kai
authors.initials: MK
authors.lastname: Lam
authors.affiliation: Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands.
authors.forename: Ilona
authors.initials: I
authors.lastname: Valkenburg
authors.affiliation: Cardiovascular Centre Aalst, Onze-Lieve-Vrouwziekenhuis Clinic, Aalst, Belgium.
authors.forename: Gabor G
authors.initials: GG
authors.lastname: Toth
authors.affiliation: Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Yingguang
authors.initials: Y
authors.lastname: Li
authors.affiliation: Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain.
authors.forename: Javier
authors.initials: J
authors.lastname: Escaned
authors.affiliation: Cardiovascular Centre Aalst, Onze-Lieve-Vrouwziekenhuis Clinic, Aalst, Belgium.
authors.forename: William
authors.initials: W
authors.lastname: Wijns
authors.affiliation: Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Johan H C
authors.initials: JH
authors.lastname: Reiber
mesh_terms: D000368:Aged; D019540:Area Under Curve; D017023:Coronary Angiography / Q000379:methods*; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000473:pathology; D003331:Coronary Vessels / Q000033:anatomy & histology* / Q000000981:diagnostic imaging; D005060:Europe; D005069:Evaluation Studies as Topic; D005260:Female; D053805:Fractional Flow Reserve, Myocardial / Q000502:physiology*; D006801:Humans; D021621:Imaging, Three-Dimensional; D008297:Male; D008875:Middle Aged; D011786:Quality Control; D012372:ROC Curve; D011857:Radiographic Image Interpretation, Computer-Assisted; D012720:Severity of Illness Index
keywords: coronary bifurcation; fractional flow reserve; quantitative coronary angiography