State-of-the-Art Review
Invasive Coronary Physiology After Stent Implantation: Another Step Toward Precision Medicine

https://doi.org/10.1016/j.jcin.2020.10.055Get rights and content
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Highlights

  • Physiology assessment post-PCI predicts outcome but is rarely used in clinical practice.

  • Pullback can identify stent-related issues, overlooked lesions, and diffuse disease.

  • Focal drops at pullback indicate the need of post-dilation or stent implantation.

  • Diffuse disease demands aggressive medical therapy.

  • Powered trials comparing physiology- and angio-guided PCI optimization are warranted.

Abstract

Intracoronary physiology is routinely used in setting the indication for percutaneous coronary intervention (PCI) but seldom in assessing procedural results. This attitude is increasingly challenged by accumulated evidence demonstrating the value of post-PCI functional assessment in predicting long-term patient outcomes. Besides fractional flow reserve, a number of new indexes recently incorporated to clinical practice, including nonhyperemic pressure and functional angiographic indexes, provide new opportunities for the physiological assessment of PCI results. Largely, the benefit of these tools is derived from longitudinal analysis of the treated vessel, which allows precise identification of the vessel segment accounting for a suboptimal functional result and enabling operators to perform accurate PCI optimization. In this document the authors review available evidence supporting why physiological assessment should be extended to immediate post-PCI with the aim of improving patient outcomes. A step-by-step guide on how available physiological tools can be used for such purpose is provided.

Key Words

coronary physiology
fractional flow reserve
instantaneous wave-free ratio
outcome
percutaneous coronary intervention
precision medicine
quantitative flow ratio

Abbreviations and Acronyms

CAD
coronary artery disease
FFR
fractional flow reserve
FFRangio
angiographic fractional flow reserve
iFR
instantaneous wave-free ratio
PCI
percutaneous coronary intervention
Pd/Pa
ratio of resting distal to aortic coronary pressure
PPG
pull back pressure gradient
QFR
quantitative flow ratio
vFFR
vessel fractional flow reserve

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