Impact of intravascular ultrasound findings in patients with a post PCI fractional flow reserve ≤0.85 on 2 year clinical outcome

doi:10.1016/j.ijcard.2020.05.027

International Journal of Cardiology

Volume 317, 15 October 2020, Pages 33-36

https://doi.org/10.1016/j.ijcard.2020.05.027 Get rights and content

Highlights

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IVUS may help reveal residual disease or suboptimal stent implantation to understand a low post PCI FFR.
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These specific IVUS findings may impact long-term clinical outcome.
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Patients with impaired post PCI FFR values and IVUS derived anomalies might warrant further treatment.

Abstract

Background

Patients with a low post PCI fractional flow reserve (FFR) are at increased risk for future adverse cardiac events. The aim of the present study was to assess the impact of specific intravascular ultrasound (IVUS) findings in patients with a low post percutaneous coronary intervention (PCI) FFR on long-term clinical outcome.

Methods

In a subgroup analysis, 100 vessels with an FFR value ≤0.85 underwent post PCI IVUS to further assess the potential determinants for low post PCI FFR. No further action was taken to improve post PCI FFR. The primary endpoint of this study was the event free survival of target vessel failure (TVF) at two years in patients with a post PCI FFR ≤0.85, which was defined as a composite of cardiac death, target vessel myocardial infarction or target vessel revascularization.

Results

In patients with a post PCI FFR ≤0.85, TVF free survival rates were 88.5% vs. 95.5% for patients with versus without residual proximal lesions and 88.2% vs. 95.5% for patients with versus without residual distal lesions respectively (HR = 2.53, 95% confidence interval (CI) 0.52–12.25, p = .25 and HR = 2.60, 95% CI 0.54–12.59, p = .24 respectively). TVF free survival was 92.8% vs. 93.5% in patients with versus without stent underexpansion >20% (HR = 1.01, 95% CI 0.21–4.88, p = .99) and 89.3% vs. 97.8% in patients with versus without any residual focal lesion including lumen compromising hematoma (HR = 4.64, 95% CI 0.55–39.22, p = .18).

Conclusion

Numerically higher TVF rates were observed in patients with a post PCI FFR ≤0.85 and clear focal residual disease as assessed with IVUS.

Section snippets

Background

FFR after stenting proved to be a strong and independent predictor for MACE [1]. Unfortunately, the exact rationale behind this observation remains elusive based on angiographic findings alone let alone the impact on clinical follow-up. Fractional flow reserve (FFR) has proven to be a useful technique to address coronary physiology and the haemodynamic significance of coronary segments both pre- and post-intervention [2].

In the intravascular ultrasound (IVUS) sub-study of the FFR SEARCH

Patient selection

The FFR SEARCH (Stent Evaluated at Rotterdam Cardiology Hospital) study is a prospective single center registry in which 1000 consecutive patients underwent FFR evaluation after angiographic successful PCI with a primary endpoint to study the impact of post PCI FFR on major adverse cardiac event rates at 2 years. In a subgroup analysis, 95 consecutive patients (100 vessels) with a post PCI FFR value ≤0.85 and 20 patients (20 vessels) with a post PCI FFR >0.85 underwent post PCI IVUS to further

Results

Baseline characteristics and IVUS findings are depicted in Table 1.

In the dedicated IVUS analyses, in patients with a post PCI FFR ≤0.85, significant focal lesions proximal or distal to the treated segment were found in 29% and 30% of the vessels respectively. Underexpansion >20% was present in 50% of the vessels. In 54% of the vessels clear focal signs of luminal narrowing were found due to residual focal lesions or lumen compromising hematoma (3%). In 87% of the vessels, either a focal

Discussion

Low post PCI FFR proved to be associated with higher rates of TVF [1]. However, the practical implications of low post PCI FFR remain debated since little is known about the exact mechanisms behind the low FFR and potential consequences of further intravascular treatment.

In the FFR SEARCH IVUS study we found a high proportion of IVUS detected anomalies including focal lesions, stent underexpansion and malapposition in vessels with a post PCI FFR ≤0.85; findings that were not readily apparent on

Limitations

The sample size in this sub-study of the FFR SEARCH is registry is limited. Although clear clinical trends were observed, the limited number of patients with a persistent low post PCI FFR and subsequent IVUS withheld us from providing significant hazard ratios. The current study is hypothesis generating and large randomized trials are warranted to further investigate the relation between IVUS detected anomalies and hard clinical endpoints in patients with persistent low post PCI FFR.

Finally,

Conclusion

At two years, the cumulative survival free of TVF in patients with a post PCI FFR ≤0.85 was 93.5%. Numerically higher TVF rates were observed in patients with clear focal residual disease as assessed with IVUS.

The following are the supplementary data related to this article.

. Baseline characteristic and IVUS findings in vessels with and without proximal lesions, distal lesions underexpansion or any lesion (post PCI FFR ≤0.85.

Funding

The Erasmus Medical centre received institutional support from ACIST medical Inc.

Declaration of Competing Interest

LvZ received institutional research support from ACIST medical Inc.

TN received institutional research support from ACIST medical Inc.

JD reports to have received institutional research support from Pie Medical, ACIST Medical Inc., PulseCath, Medtronic, Boston Scientific, Abbott Vascular and speaker and consultancy fees from PulseCath, Medtronic, ReCor Medical, Acist Medical Inc.

All other co-authors have no relevant conflict of interests to declare.

Acknowledgments

N/A.

References (5)

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Impact of impaired fractional flow reserve after coronary interventions on outcomes: a systematic review and meta-analysis
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B. De Bruyne et al.
Fractional flow reserve-guided PCI for stable coronary artery disease
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Cited by (4)

Validation of Segmental Post-PCI Physiological Gradients With IVUS-Detected Focal Lesions and Stent Underexpansion
2023, JACC: Cardiovascular Interventions
Segmental postpercutaneous coronary intervention (PCI) pressure gradients may detect residual disease and potential targets for optimization. However, universal definitions of relevant segmental gradients are lacking.
This study sought to evaluate the diagnostic performance of post-PCI fractional flow reserve (FFR), distal coronary pressure-to-aortic pressure ratio (Pd/Pa), and diastolic pressure ratio (dPR) gradients to detect residual focal lesions and stent underexpansion as observed by intravascular ultrasound (IVUS).
Patients from the IVUS-guided optimization arm of the FFR REACT (FFR-guided PCI Optimization Directed by High-Definition IVUS Versus Standard of Care) trial with complete IVUS and FFR pullback data were included. Patients with angiographically successful PCI and post-PCI FFR <0.90 underwent FFR, Pd/Pa, and IVUS pullbacks. dPR was calculated offline using dedicated software. Segmental pressure gradients (distal, in stent, and proximal) in segments ≥5 mm were evaluated against IVUS-detected residual disease (distal or proximal focal lesions and stent underexpansion).
A total of 139 vessels were included (mean post-PCI FFR: 0.83 ± 0.05, range 0.56-0.89). Focal distal and proximal lesions were detected by IVUS in 23 (17.4%) of 132 and 14 (12.6%) of 111 vessels, respectively, whereas stent underexpansion was present in 86 (61.9%) vessels. Diagnostic ability of segmental FFR gradients to predict IVUS-detected distal and proximal lesions was moderate-to-good (area under the curve [AUC]: 0.69 and 0.84, respectively) and poor to moderate for segmental Pd/Pa and dPR gradients (AUC ranging from 0.58 to 0.69). In-stent gradients had no discriminative ability to detect stent underexpansion (FFR AUC: 0.52; Pd/Pa AUC: 0.54; dPR AUC: 0.55).
In patients with post-PCI FFR <0.90, segmental post-PCI pressure gradients have moderate discriminative ability to identify IVUS-detected focal lesions but no discriminative ability to identify IVUS-detected stent underexpansion.
Prognostic value of optical flow ratio for cardiovascular outcomes in patients after percutaneous coronary stent implantation
2023, Frontiers in Cardiovascular Medicine
Prognostic Value of Coronary Angiography-Derived Fractional Flow Reserve Immediately After Stenting
2022, Frontiers in Cardiovascular Medicine
Physiological assessment after percutaneous coronary intervention: The hard truth
2021, Panminerva Medica

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Short communicationImpact of intravascular ultrasound findings in patients with a post PCI fractional flow reserve ≤0.85 on 2 year clinical outcome

Highlights

Abstract

Background

Methods

Results

Conclusion

Section snippets

Background

Patient selection

Results

Discussion

Limitations

Conclusion

Funding

Declaration of Competing Interest

Acknowledgments

Impact of impaired fractional flow reserve after coronary interventions on outcomes: a systematic review and meta-analysis

BMC Cardiovasc. Disord.

Fractional flow reserve-guided PCI for stable coronary artery disease

N Engl J Med.

Short communication
Impact of intravascular ultrasound findings in patients with a post PCI fractional flow reserve ≤0.85 on 2 year clinical outcome