Prognostic Implications of Fractional Flow Reserve After Coronary Stenting:A Systematic Review and Meta-analysis

IMPORTANCE: Fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) is generally considered to reflect residual disease. Yet the clinical relevance of post-PCI FFR after drug-eluting stent (DES) implantation remains unclear. OBJECTIVE: To evaluate the clinical relevance of post-PCI FFR measurement after DES implantation. DATA SOURCES: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant published articles from inception to June 18, 2022. STUDY SELECTION: Published articles that reported post-PCI FFR after DES implantation and its association with clinical outcomes were included. DATA EXTRACTION AND SYNTHESIS: Patient-level data were collected from the corresponding authors of 17 cohorts using a standardized spreadsheet. Meta-estimates for primary and secondary outcomes were analyzed per patient and using mixed-effects Cox proportional hazard regression with registry identifiers included as a random effect. All processes followed the Preferred Reporting Items for Systematic Review and Meta-analysis of Individual Participant Data. MAIN OUTCOMES AND MEASURES: The primary outcome was target vessel failure (TVF) at 2 years, a composite of cardiac death, target vessel myocardial infarction (TVMI), and target vessel revascularization (TVR). The secondary outcome was a composite of cardiac death or TVMI at 2 years. RESULTS: Of 2268 articles identified, 29 studies met selection criteria. Of these, 28 articles from 17 cohorts provided data, including a total of 5277 patients with 5869 vessels who underwent FFR measurement after DES implantation. Mean (SD) age was 64.4 (10.1) years and 4141 patients (78.5%) were men. Median (IQR) post-PCI FFR was 0.89 (0.84-0.94) and 690 vessels (11.8%) had a post-PCI FFR of 0.80 or below. The cumulative incidence of TVF was 340 patients (7.2%), with cardiac death or TVMI occurring in 111 patients (2.4%) at 2 years. Lower post-PCI FFR significantly increased the risk of TVF (adjusted hazard ratio [HR] per 0.01 FFR decrease, 1.04; 95% CI, 1.02-1.05; P < .001). The risk of cardiac death or MI also increased inversely with post-PCI FFR (adjusted HR, 1.03; 95% CI, 1.00-1.07, P = .049). These associations were consistent regardless of age, sex, the presence of hypertension or diabetes, and clinical diagnosis. CONCLUSIONS AND RELEVANCE: Reduced FFR after DES implantation was common and associated with the risks of TVF and of cardiac death or TVMI. These results indicate the prognostic value of post-PCI physiologic assessment after DES implantation

A háromér-betegség kezelése a FAME-3 vizsgálat eredményeinek tükrében

A korábbi randomizált vizsgálatok rendre azt igazolták, hogy a coronariabypass-műtét előnyösebb a percutan coro- nariaintervencióval szemben a súlyos, kiterjedt koszorúér-betegség kezelésében. Ezt elsősorban az ismételt revascu- larisatio ritkább igényével magyarázzák, sőt bizonyos alcsoportokban még mortalitási előnyt és kevesebb szívinfarctust is regisztráltak az operáltak között. A közelmúltban publikált multicentrikus, randomizált FAME (Fractional Flow Reserve Versus Angiography in Multivessel Evaluation)-3 tanulmány 1500 beteg bevonásával azt kutatta, hogy a frakcionált „flow reserve” méréssel vezérelt, újgenerációs gyógyszerkibocsátó stent implantációjával végzett percutan coronariaintervenció non-inferior-e a modern koszorúérbypass-műtéttel szemben az egyéves halálozás, a szívinfarctus, a stroke és az ismételt revascularisatiós igény szempontjából. A FAME-3 vizsgálatban aktívan részt vevő szerzők ismertetik a vizsgálatok, a vizsgált populáció és az elvégzett beavatkozások jellemzőit, illetve az eredményeket. A FAME-3 vizsgálatban nem sikerült igazolni a percutan coronariaintervenció non-inferior voltát a bypassműtéttel szemben a háromér-betegség kezelésében. A szerzők részletesen elemzik ennek lehetséges okait, illetve a vizsgálatból származó egyéb fontos következtetéseket. Idetartozik a „kemény végpontok” tekintetében a szignifikáns különbség hiánya a két kar között, illetve az, hogy a perioperatív morbiditás tekintetében a percutan revascularisatio szignifikánsan jobbnak bizonyult. Bár a primer végpont értékelése meghatározó a klinikai döntéshozatalban, a másodlagos szempontok figyelembevétele is elengedhetetlen a részletes betegfelvilágosításnál és az egyéni revascularisatiós stratégia meghatározásában

Remote ischaemic postconditioning protects the heart during acute myocardial infarction in pigs

Ischaemic preconditioning results in a reduction in ischaemic-reperfusion injury to the heart. This beneficial effect is seen both with direct local preconditioning of the myocardium and with remote preconditioning of easily accessible distant non-vital limb tissue. Ischaemic postconditioning with a comparable sequence of brief periods of local ischaemia, when applied immediately after the ischaemic insult, confers benefits similar to preconditioning

Prognostic Value of Fractional Flow Reserve Measured Immediately After Drug-Eluting Stent Implantation.

BACKGROUND The predictive value of fractional flow reserve (FFR) measured immediately after percutaneous coronary intervention (PCI) with drug-eluting stent placement has not been prospectively investigated. We investigated the potential of post-PCI FFR measurements to predict clinical outcome in patients from FAME 1 and 2 trials (Fractional Flow Reserve or Angiography for Multivessel Evaluation). METHODS AND RESULTS All patients of FAME 1 and FAME 2 who had post-PCI FFR measurement were included. The primary outcome was vessel-oriented composite end point at 2 years, defined as vessel-related cardiovascular death, vessel-related spontaneous myocardial infarction, and ischemia-driven target vessel revascularization. Eight hundred thirty-eight vessels in 639 patients were analyzed. Baseline FFR values did not differ between vessels with versus without vessel-oriented composite end point (0.66±0.11 versus 0.63±0.14, respectively; P=0.207). Post-PCI FFR was significantly lower in vessels with vessel-oriented composite end point (0.88±0.06 versus 0.90±0.06, respectively; P=0.019). Comparing the 2-year outcome of lower and upper tertiles of post-PCI FFR significant difference was found favoring upper tertile in terms of overall vessel-oriented composite end point (9.2% versus 3.8%, respectively; hazard ratio, 1.46; 95% confidence interval, 1.02-2.08; P=0.037) and target vessel revascularization (7.0% versus 2.4%, respectively; hazard ratio, 1.59; 95% confidence interval, 1.03-2.46; P=0.037). When adjusted to sex, hypertension, diabetes mellitus, target vessel, serial stenosis, and baseline percentage diameter stenosis, a strong trend was preserved in terms of target vessel revascularization (harzard ratio, 1.55; 95% confidence interval, 0.97-2.46; P=0.066), favoring the upper tertile. Post-PCI FFR of 0.92 was found to have the highest diagnostic accuracy; however, the positive likelihood ratio remained low (<1.4). CONCLUSIONS A higher post-PCI FFR value is associated with a better vessel-related outcome. However, its predictive value is too low to advocate its use as a surrogate clinical end point

Short- and Medium-Term Outcomes Comparison of Native- and Valve-in-Valve TAVI Procedures

Background: In high-risk patients with degenerated aortic bioprostheses, valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) has emerged as a less invasive alternative to surgical valve replacement. To compare outcomes of ViV and native valve (NV) TAVI procedures. Methods: 34 aortic ViV-TAVI performed between 2012 and 2022 using self-expanding valves, were included in this retrospective analysis. Propensity score matching (1:2 ratio, 19 criteria) was used to select a comparison NV-TAVI group from a database of 1206 TAVI procedures. Clinical and echocardiographic endpoints, short- and long-term all-cause mortality (ACM) and cardiovascular mortality (CVM) data were obtained. Subgroup analyses were completed according to the true internal diameter, dividing patients into a small (≤19 mm) valve group (SVG) and a large (>19 mm) valve group (LVG). Results: Clinical outcomes of ViV- and NV-TAVI were comparable, including device success [88.2% vs. 91.1%, p = 0.727], major adverse cardiovascular and cerebrovascular events [5.8% vs. 5.8%, p = 1.000], hemodialysis need [5.8% vs. 2.9%, p = 0.599], pacemaker need [2.9% vs. 11.7%, p = 0.265], major vascular complications [2.9% vs. 1.4%, p = 1.000], life-threatening or major bleeding [2.9% vs. 1.4%, p = 1.000] and in-hospital mortality [8.8% vs. 5.9%, p = 0.556]. There was a significant difference in the immediate post-intervention mean residual aortic valve gradient (MAVG) [14.6 ± 8.5 mm Hg vs. 6.4 ± 4.5 mm Hg, p < 0.0001], which persisted at 1 year [p = 0.0002]. There were no differences in 12- or 30-month ACM [11.8% vs. 8.8%, p = 0.588; 23.5% vs. 27.9%, p = 0.948], and CVM [11.8% vs. 7.3%, p = 0.441; 23.5% vs. 16.2%, p = 0.239]. Lastly, there was no difference in CVM at 1 year and 30 months [11.1% vs. 12.5%, p = 0.889; 22.2% vs. 25.0%, p = 0.742]. Conclusions: Analyzing a limited group (n = 34) of ViV-TAVI procedures out of 1206 TAVIs done at a single institution, ViV-TAVI appeared to be an acceptable approach in patients not deemed appropriate candidates for redo valve replacement surgery. Clinical outcomes of ViV-TAVI were comparable to TAVI for native valve stenosis