Quantitative Flow Ratio (QFR) Computed FFR based on two angiographic projections Hector M. Garcia-Garcia MD, MSc, PhD, FESC, FACC Director, Angio and IVUS/NIRS corelab Chairman, Clinical Event Committee

Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company None

Functional Assessment of Coronary Stenosis Using Angiography: will you treat it? diameter stenosis (DS): 53% Anatomy: DS = 53% vs. Physiology: FFR = 0.85 Quantitative Coronary Angiography (QCA)

Functional Assessment of Coronary Stenosis Using Angiography: Background Traditional Methods Issues Invasive – need a wire Need for adenosine: Discomfort; Arrythmia Time consuming Pullback device not available For bifurcations, wire in both main vessel and sidebranch Expensive for patient/hospital Worldwide acceptance 7-10% Echavarria-Pinto M, Garcia-Garcia HM et al. Interventional Cardiology. Oct 2015 ,Vol. 7, No. 5, 483 Gonzalvez PA, Garcia-Garcia HM et al. JACC: Cardiovascular Imaging. Vol. 8, No. 11, Nov 2015, 1322.

Functional Assessment of Coronary Stenosis Using Angiography: Background Traditional Methods Computer Tomography Methods Echavarria-Pinto M, Garcia-Garcia HM et al. Interventional Cardiology. Oct 2015 ,Vol. 7, No. 5, 483 Gonzalvez PA, Garcia-Garcia HM et al. JACC: Cardiovascular Imaging. Vol. 8, No. 11, Nov 2015, 1322.

Quantitative Flow Ratio - QFR: One-stop shop?

Quantitative Flow Ratio Relies on 3D QCA 3D vessel modelling is the backbone for the PCI procedure: Allows the calculation of the functional significance parameter QFR Optimal viewing angle for PCI Precise stent sizing Co-registration with OCT or IVUS

In-procedure time: < 5 min Quantitative Flow Ratio - QFR (Quantitative Flow Ratio = Medis’ QCA derived FFR) 3D model reconstructed from 2 angiographic projections with angles ≥ 25º apart, acquired by monoplane or biplane systems. Patient-specific volumetric flow rate (at hyperaemia) calculated using the combination of contrast bolus front frame count and 3D QCA; In-procedure time: < 5 min QFR = 0.87 FFR = 0.85 Based on EuroPCR presentation by Aarhus University Hospital, Skejby, Denmark

Quantitative Flow Ratio Study Results – FAVOR I

Quantitative Flow Ratio Study Results FFRQCA versus FFR FN FP Difference: 0.00 ± 0.06 (p = 0.541) Tu et al. JACC Cardiovasc Interv 2014, 7:768-777

Quantitative Flow Ratio Study Results – FAVOR II Pilot

Functional Assessment of Coronary Stenosis Using Angiography: Background 1. fQFR: a fixed empiric hyperemic flow velocity (HFV) of 0.35 m/s that was derived from previous FFR studies was used for computation. 2. cQFR: frame count (FC) analysis was performed, without pharmacologically induced hyperemia, to derived the HFV. 3. aQFR: FC analysis was performed during hyperemia, induced by intravenous administration of adenosine or adenosine triphosphate. The “real” HFVs were derived and the software calculated 2 new QFR pullbacks. Flow velocity is segment length in 3D QCA divided by dye flow time from FC. Tu S et al. JACC: Cardiovascular Interventions. Vol 9, Issue 19, 10 Oct 2016,2024–2035 .

Functional Assessment of Coronary Stenosis Using Angiography: Background Tu S et al. JACC: Cardiovascular Interventions. Vol 9, Issue 19, 10 Oct 2016,2024–2035 .

QFR analysis in a dedicated offline software (Medis Suite XA) Certified QFR analysis team Vessel QFR = 0.54 Lesion QFR = 0.56 Note: The wire based FFR is 0.57

Functional Assessment of Coronary Stenosis Using Angiography: Background (A) Per patient (73). (B) Per vessel (84). Tu S et al. JACC: Cardiovascular Interventions. Vol 9, Issue 19, 10 Oct 2016,2024–2035 .

Conclusions from Authors Fast computation of FFR from coronary angiography (QFR), acquired with or without pharmacological hyperemia-induction, is feasible. Contrast-flow QFR (cQFR) based on conventional diagnostic coronary angiography provides results similar to QFR based on hyperemic conditions, and is superior to fixed-flow QFR. The favorable results of cQFR bears the potential of a wider adoption of FFR-based lesion assessment, as cQFR might reduce procedure time, risk, and costs (no need to use pressure wire, and no need to induce maximal hyperemia) . The use of QFR is not without a stiff learning curve, which requires that users be certified by the offline software provider (Medis) before being able to start. Current indications: Patients with stable angina; Under investigations: MI, bifurcation lesions, lengthy diffuse disease, etc.

QFR Ongoing Studies FAVOR II study Q2FR trial ALL AMI trial FDA IDE submission ALL AMI trial