Off Target: Optimum Post-PCI FFR In general Missed

Optimization of fractional drift reserve (FFR) after angiographically worthwhile percutaneous coronary intervention (PCI) did now not affect clinical outcomes but severely diminished the proportion of patients leaving the cath lab with an FFR of 0.80 or much less in a single-heart randomized trial.

After odd-of-care PCI, most productive 32% of patients finished a put up-PCI FFR of at the least 0.90, which has been proven to be related to a decrease likelihood for repeat PCI and predominant unfavorable cardiovascular occasions.

Most certainly more relating to, 29% of patients had a final FFR at or below the guideline-suggested revascularization threshold of 0.80, said look creator Damien Collison, MD, Golden Jubilee National Clinic and College of Glasgow, United Kingdom.

The TARGET-FFR trial concerned 260 patients with coronary artery illness, at the side of genuine angina and non-ST-segment myocardial infarction, who had been randomly assigned after angiographically worthwhile PCI to blinded put up-PCI coronary physiology assessment or to a physiology-guided incremental optimization approach (PIOS).

If a patient within the PIOS neighborhood had a suboptimal FFR lower than 0.90, the physiology results had been disclosed to the operator and additional optimization knowledgeable in step with the results of FFR pullback assessment.

Namely, if the FFR pullback indicated diffuse illness pattern with out a focal step-americaand the hyperemic trans-stent gradient (HTG) used to be lower than 0.05 fashions, the case used to be deemed whole, Collison said.

If the HTG used to be at the least 0.05, postdilatation with a increased noncompliant balloon to 18 atm used to be knowledgeable, and if a focal step-up of at the least 0.05 used to be acknowledged launch air the stented segment, an additional stent used to be suggested. In a roundabout diagram, FFR pullback used to be repeated and if both of the two earlier requirements had been existing, operators could well mark additional postdilatation or deploy one additional stent.

Essentially based on FFR pullback assessment, a substrate for additional optimization used to be existing in 60 of 131 (46%) PIOS patients. Operators felt it appropriate to mark additional put up-dilatation and/or stenting in 66% of these patients.

Amongst these 40 conditions, both FFR and coronary drift reserve (CFR) increased from strategy of 0.76 to 0.82 (P <.001) and from 3.0 to 4.0 (P = .02), respectively, Collison reported in a leisurely-breaking session at the digital Transcatheter Cardiovascular Therapeutics (TCT) 2020.

The percentage of patients with a final FFR of at the least 0.90 — the look’s predominant discontinue point — increased from 28.1% to 38.1% with PIOS, but this did now not enact statistical significance in step with a hypothesized 20% between-neighborhood disagreement (P = .09).

The PIOS approach, on the different hand, did severely cleave the proportion of patients with a final FFR of 0.80 or much less (18.6% vs 29.8%; P = .045).

No longer all straight away, this came at the associated price of severely longer course of (94 vs 67 minutes) and fluoroscopy (23 vs 16 minutes) times, apart from as increased radiation (921 vs 686 mGy) and adenosine (93 vs 62 mg) doses, Collison said.

Procedural issues had been related in every neighborhood (2.5 vs 9.5 with out PIOS; P =.14).

At a median of 105 days, there used to be no disagreement within the alternate within the Seattle Angina Questionaire-7 summary ranking or its particular individual domains between the two groups.

One purpose vessel failure and one cardiac loss of life took place within the PIOS neighborhood, in contrast with out a such occasions among withhold watch over issues over a median of 1.7 years.

In an diagnosis stratified by purpose vessel, there used to be no important disagreement in pre-PCI FFR or CFR. But imply put up-PCI FFR used to be severely decrease within the left anterior descending (LAD) artery than within the left circumflex or upright coronary arteries (0.80 vs 0.92 vs 0.91; P <.001), which helps earlier registry knowledge that an LAD purpose lesion is a fixed predictor of suboptimal put up-PCI FFR results, Collison said.

Discussant Bernard De Bruyne, MD, PhD, OLV Clinic, Aalst, Belgium, said the look lacked energy to train PIOS could well give a procure to patient outcomes or enact increased FFR values but highlights the necessity for diversified FFR cutoffs in diversified vessels.

“The LAD is de facto a diversified animal through put up-PCI FFR and, in actuality even pre-PCI FFR,” and can possess an FFR already within the jam of 0.8 with out stenosis first of all, “which is now not often ever the case within the upright coronary artery,” he said. “So doubtlessly within the long plug we can ought to conceive reviews focusing on diversified thresholds, especially the upright and the LAD.”

Collison observed that, presumably confusingly, registry knowledge has already proposed that the LAD ought to smooth possess both a increased or decrease optimum threshold than diversified vessels. “Between you and I and the world, within the event you like to ought to enact FFRs of 0.90, you ought to smooth alternate your practice to good stent upright coronaries and left circumflex,” he quipped.

Discussant Allen Jeremias, MD, St. Francis Clinic, Roslyn, Unique York, said TARGET-FFR is an possess-opening look.

“I’m a tiny bit disturbed that residual ischemia is even greater than we saw in DEFINE-PCI and in actuality most productive a third of these possess an optimum kill result with an FFR of more than 0.90 with angiographic steering by myself,” he said. “So I mediate it in actuality reinforces the importance of doing physiology sooner than and after to recordsdata PCI to procure to greater outcomes.”

The implications also underline the importance of FFR pullback assessment, which is underutilized, Jeremias suggested. “We bolt away barely a pair of knowledge on the desk.”

In a TCT wrap-up video, Roxana Mehran, MD, Icahn School of Medication at Mount Sinai, Unique York Metropolis, said she also used to be disturbed that so few patients met the 0.90 requirements but expressed some hesitancy about the FFR thresholds put up-PCI.

“We good offered Xience knowledge with this kind of low event rate and, take into consideration me, they don’t seem like doing FFR at the discontinue of every individual of these procedures,” she said. “So if that is the case, then we ought to smooth possess had diagram more occasions. So I non-public now not mediate that an FFR of 0.80 in actuality holds exquisite for clinical occasions postprocedure because it does preprocedure of whether you ought to smooth bolt forward to realize something or now not. And I mediate you might want to to well attain injury within the event you good withhold going.”

The look used to be subsidized by the NHS National Ready Events Centre Board. Collison reported consulting expenses/honoraria from Abbott Clinical and MedAlliance.

Transcatheter Cardiovascular Therapeutics (TCT) 2020. Equipped October 16, 2020.

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