Enhancing quantitative coronary angiography (QCA) with advanced artificial intelligence: comparison with manual QCA and visual estimation

Artificial intelligence-based quantitative coronary angiography (AI-QCA) was introduced to address manual QCA's limitations in reproducibility and correction process. The present study aimed to assess the performance of an updated AI-QCA solution (MPXA-2000) in lesion detection and quantification using manual QCA as the reference standard, and to demonstrate its superiority over visual estimation. This multi-center retrospective study analyzed 1,076 coronary angiography images obtained from 420 patients, comparing AI-QCA and visual estimation against manual QCA as the reference standard. A lesion was classified as 'detected' when the minimum lumen diameter (MLD) identified by manual QCA fell within the boundaries of the lesion delineated by AI-QCA or visual estimation. The detected lesions were evaluated in terms of diameter stenosis (DS), MLD, and lesion length (LL). AI-QCA accurately detected lesions with a sensitivity of 93% (1705/1828) and showed strong correlations with manual QCA for DS, MLD, and LL (R² = 0.65, 0.83 and 0.71, respectively). In views targeting the major vessels, the proportion of undetected lesions by AI-QCA was less than 4% (56/1492). For lesions in the side branches, AI-QCA also demonstrated high sensitivity (> 92%) in detecting them. Compared to visual estimation, AI-QCA showed significantly better lesion detection capability (93% vs. 69%, p < 0.001), and had a higher probability of detecting all lesions in images with multiple lesions (86% vs. 33%, p < 0.001). The updated AI-QCA demonstrated robust performance in lesion detection and quantification without operator intervention, enabling reproducible vessel analysis. The automated process of AI-QCA has the potential to optimize angiography-guided interventions by providing quantitative metrics.