Dataset Information

Fractional Flow Reserve-Guided Stent Optimisation in Focal and Diffuse Coronary Artery Disease.

ABSTRACT: Assessing coronary physiology after stent implantation facilitates the optimisation of percutaneous coronary intervention (PCI). Coronary artery disease (CAD) patterns can be characterised by the pullback pressure gradient (PPG) index. The impact of focal vs. diffuse disease on physiology-guided incremental optimisation strategy (PIOS) is unknown. This is a sub-study of the TARGET-FFR randomized clinical trial (NCT03259815). The study protocol directed that optimisation be attempted for patients in the PIOS arm when post-PCI FFR was <0.90. Overall, 114 patients (n = 61 PIOS and 53 controls) with both pre-PCI fractional flow reserve (FFR) pullbacks and post-PCI FFR were included. A PPG ≥ 0.74 defined focal CAD. The PPG correlated significantly with post-PCI FFR (r = 0.43; 95% CI 0.26 to 0.57; p-value < 0.001) and normalised delta FFR (r = 0.49; 95% CI 0.34 to 0.62; p-value < 0.001). PIOS was more frequently applied to vessels with diffuse CAD (6% focal vs. 42% diffuse; p-value = 0.006). In patients randomized to PIOS, those with focal disease achieved higher post-PCI FFR than patients with diffuse CAD (0.93 ± 0.05 vs. 0.83 ± 0.07, p < 0.001). There was a significant interaction between CAD patterns and the randomisation arm for post-PCI FFR (p-value for interaction = 0.004). Physiology-guided stent optimisation was applied more frequently to vessels with diffuse disease; however, patients with focal CAD at baseline achieved higher post-PCI FFR.

SUBMITTER: Ohashi H

PROVIDER: S-EPMC10417445 | biostudies-literature | 2023 Aug

REPOSITORIES: biostudies-literature

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Fractional Flow Reserve-Guided Stent Optimisation in Focal and Diffuse Coronary Artery Disease.

Ohashi Hirofumi H Collison Damien D Mizukami Takuya T Didagelos Matthaios M Sakai Koshiro K Aetesam-Ur-Rahman Muhammad M Munhoz Daniel D McCartney Peter P Ford Thomas J TJ Lindsay Mitchell M Shaukat Aadil A Rocchiccioli Paul P Brogan Richard R Watkins Stuart S McEntegart Margaret M Good Richard R Robertson Keith K O'Boyle Patrick P Davie Andrew A Khan Adnan A Hood Stuart S Eteiba Hany H Amano Tetsuya T Sonck Jeroen J Berry Colin C De Bruyne Bernard B Oldroyd Keith G KG Collet Carlos C

Diagnostics (Basel, Switzerland) 20230807 15

Assessing coronary physiology after stent implantation facilitates the optimisation of percutaneous coronary intervention (PCI). Coronary artery disease (CAD) patterns can be characterised by the pullback pressure gradient (PPG) index. The impact of focal vs. diffuse disease on physiology-guided incremental optimisation strategy (PIOS) is unknown. This is a sub-study of the TARGET-FFR randomized clinical trial (NCT03259815). The study protocol directed that optimisation be attempted for patients ...[more]

PMID: 37568975

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Project description:Amongst patients with suspected obstructive coronary artery disease (CAD), less than a third of patients have obstructive disease on invasive coronary angiography (ICA) and fewer still have flow-limiting obstructive disease as determined by invasive fractional flow reserve (FFR). FFR is a powerful tool in guiding revascularization of flow-limiting lesions which in turn improves clinical outcome in those with haemodynamically significant obstructive disease. However FFR is infrequently performed due to the cost, time and patient discomfort the procedure entails. Further advances in non-invasive imaging has allowed FFR to be derived non-invasively by applying computational fluid dynamic (CFD) modeling to the coronary computed tomography angiography (CCTA) dataset without the need to induce hyperemia or modify the standard CCTA acquisition protocol. FFR derived from CCTA has been shown to have excellent correlation with invasive FFR and remains diagnostically robust in presence of reduced signal-to-noise ratio (SNR), coronary calcification and motion artifact. More recently, new data have emerged evaluating the clinical impact of fractional flow reserve computed tomography (FFRCT) on the assessment and management of patients with stable chest pain. One such study is the Prospective LongitudinAl trial of FFRCT: Outcome and Resource IMpacts (PLATFORM) study which showed an improved patient selection for ICA using CCTA-FFRCT approach by increasing the likelihood of identifying obstructive CAD at ICA amongst those intended for invasive testing. CCTA-FFRCT may therefore serve as efficacious gatekeeper to ICA that enriches the ICA population. The utility of FFRCT has also helped deepened our understanding of CAD. Through CFD modeling, it is now recognized that there are mechanistic forces of wall shear stress (WSS) and axial plaque force acting on coronary plaques. This has created further interest in exploring the possible interplay between these mechanistic forces on the development of coronary plaque and vulnerability of these plaques to rupture.

Project description:BackgroundCoronary computed tomography angiography-derived fractional flow reserve (FFRCT) is a per-vessel index reflecting cumulative hemodynamic burden while coronary events occur in focal lesions.ObjectivesThe authors sought to evaluate the additive prognostic value of the local gradient of FFRCT (FFRCT gradient) in addition to FFRCT to predict future coronary events.MethodsThe current study included 245 patients (634 vessels) who underwent coronary computed tomography angiography within 6 to 36 months before the index angiography, of which 209 vessels had future coronary events and 425 vessels did not. Future coronary events were defined as a composite of vessel-specific myocardial infarction or urgent revascularization during a mean interval of 1.5 years. Pre-existing disease patterns were classified according to FFRCT of ≤0.80 and FFRCT gradient of ≥0.025/mm.ResultsBoth FFRCT (per 0.01 decrease; adjusted HR: 1.040; 95% CI: 1.029-1.051; P < 0.001) and FFRCT gradient (per 0.01 increase; adjusted HR: 1.144; 95% CI: 1.101-1.190; P < 0.001) were significantly associated with the risk of future coronary events. Lesions with FFRCT gradient of ≥0.025/mm showed significantly higher risk of future coronary events than those with FFRCT gradient of <0.025/mm in both the FFRCT >0.80 (49.2% vs 30.1%; HR: 2.069; 95% CI: 1.265-3.385; P = 0.004) and FFRCT ≤0.80 groups (60.9% vs 38.3%; HR: 1.988; 95% CI: 1.317-2.999; P =0 .001). Adding FFRCT gradient into the model with FFRCT alone showed significantly increased predictability of future coronary events (global chi-square: 45.8 vs 39.9; P = 0.015).ConclusionsPatients with high FFRCT gradient showed increased risk of future coronary events irrespective of FFRCT. Integrating both FFRCT and FFRCT gradient showed incremental predictability of future coronary events compared with FFRCT alone. (Prediction and Validation of Clinical Course of Coronary Artery Disease With CT-Derived Non-Invasive Hemodynamic Phenotyping and Plaque Characterization [DESTINY Study]; NCT04794868).

Dataset Information

Fractional Flow Reserve-Guided Stent Optimisation in Focal and Diffuse Coronary Artery Disease.

Publications

Fractional Flow Reserve-Guided Stent Optimisation in Focal and Diffuse Coronary Artery Disease.

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