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TCT-375 Deferred Versus Performed Revascularization in Coronary Stenoses With Gray Zone Fractional Flow Reserve: Data From IRIS FFR Registry
B154
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 70, NO. 18, SUPPL B, 2017
CONCLUSION A comprehensive assessment of the coronary circulation, based on separate calculation of epicardial- and microcirculatory conductance, is feasible and provides a clear, coherent depiction of coronary haemodynamics in ischaemic heart disease. As part of this novel approach, calculation of zero flow pressure (an index of extravascular compression) can also be performed. The findings should foster the development of simple, reliable methods for its calculation in the clinical arena. CATEGORIES IMAGING: FFR and Physiologic Lesion Assessment TCT-375 Deferred Versus Performed Revascularization in Coronary Stenoses With Gray Zone Fractional Flow Reserve: Data From IRIS FFR Registry Do-yoon Kang,1 Jung-Min Ahn,1 Cheol Hyun Lee,2 Osung Kwon,1 Ungjeong Do,3 Kyusup Lee,4 Pil Hyung Lee,1 Duk-Woo Park,1 Soo-Jin Kang,1 Seung-Whan Lee,1 Young-Hak Kim,1 Cheol Whan Lee,1 Seong-Wook Park,1 Seung-Jung Park1 1 Asan Medical Center, Seoul, Korea, Republic of; 2Asan medical center, seoul, Korea, Republic of; 3Asan medical center, Seoul, Korea, Republic of; 4AMC, Seoul, Korea, Republic of
CONCLUSION HSR is a better diagnostic index to identify myocardial ischemia as defined by moderately/reduced CFC as compared to pressure-only indices. CATEGORIES IMAGING: FFR and Physiologic Lesion Assessment TCT-374 Novel method to assess both the epicardial and microvascular domain using vascular conductance obtained from intracoronary pressure and flow velocity Nina van der Hoeven,1 Guus de Waard,1 Alicia Quirós,2 Alfonso de Hoyos,2 Sukhjinder Nijjer,3 Tim van de Hoef,4 Ricardo Petraco,5 Roel Driessen,6 Hernan Mejia-Renteria,7 Martijn Meuwissen,8 Paul Knaapen,9 Jan Piek,10 Justin Davies,3 Niels van Royen,11 Javier Escaned12 1 VU University Medical Centre, Amsterdam, Netherlands; 2Hospital Clínico San Carlos and Universidad Complutense de Madrid, Madrid, Spain; 3Imperial College London, London, United Kingdom; 4Academic Medical Center - University of Amsterdam, Amsterdam, Netherlands; 5 Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; 6Baylor Heart and Vascular Hospital, Dallas, Texas, Amsterdam, Netherlands; 7Hospital Universitario Clinico San Carlos, Madrid, Spain; 8Breda Amphia Ziekenhuis, Breda, Netherlands; 9 VU University Medical Center, Amsterdam, Netherlands; 10Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; 11 Radboud University, Nijmegen, Netherlands; 12Hospital Clínico San Carlos, Madrid, Spain
BACKGROUND The optimal cutoff of fractional flow reserve (FFR) for revascularization is in debate. We evaluated the prognosis of deferred and performed revascularization in coronary stenoses with gray zone FFR (0.75-0.80). METHODS From prospective IRIS-FFR registry, 1334 native coronary stenoses in 1334 patients with gray zone FFR were evaluated. Revascularization was deferred in 683 patients and performed in 651 patients. Primary outcome was a composite of death, myocardial infarction, and target vessel revascularization. RESULTS During a median follow-up of 2.9 years, primary outcome occurred in 55 patients (8.1%) in deferred group and 55 patients (8.4%) in performed group (adjusted hazard ratio [aHR] 1.05, 95% confidence interval [CI] 0.67-1.66; P¼0.79). Overall mortality was not different between two groups (aHR 0.82; 95% CI 0.34-2.00; P¼0.66). Performed group showed significant higher risk of myocardial infarction (aHR 0.27; 95% CI 0.09-0.80; P¼0.02), mainly due to higher risk of periprocedural myocardial infarction. Spontaneous myocardial infarction was not different between groups (aHR 1.85; 95% CI 0.35-9.75, P¼0.47). Target vessel revascularization was significantly higher in deferred group (aHR 2.17; 95% CI 1.17-4.02; P¼0.01). The trend was consistent after propensity score matching and inverse probability-oftreatment weighting.
BACKGROUND Invasive assessment of the coronary circulation has been largely based on the use of pressure ratios (epicardial-) and resistance (micro-vessels). Simultaneous assessment of epicardial(CEPI) and microvascular conductance (CMICRO), might provide a more coherent (same units for both compartments) and intuitive (expressing deliverability of blood) approach. METHODS Validation of this new approach was performed in a total of 403 both obstructive and non-obstructive coronary vessels interrogated with intracoronary Doppler and pressure in 261 patients with stable angina pectoris. Hyperaemic mid-late diastolic pressure and flow velocity (PV) relationships were calculated from PV loops using an automated algorithm. The slope of the linear PV relationship was first calculated from both aortic and intracoronary pressures and, subsequently, used to derive separately CEPI , CMICRO and zero-flow pressure (Pfz). RESULTS Median CEPI and CMICRO were 4.56 (IQR 2.18 – 8.64) and 1.28 (IQR 0.95-1.73) cm/s/mmHg respectively. Concordance in stenosis severity classification of two validated indices of stenosis severity (FFR and hyperemic stenosis resistance) was used as a robust reference standard to validate CEPI. ROC curves demonstrated an excellent ability of CEPI to characterize significant epicardial stenoses indicating a cutoff of 1.69 (AUC 0.93) with a sensitivity of 93% and a specificity of 82%. Validation of CMICRO (previously reported in endomyocardial biopsies) was not feasible in this population given the lack of a reference standard. Mean Pzf was 29.8914.16 mmHg.
CONCLUSION For coronary stenoses with gray zone FFR, revascularization was not associated with better clinical outcomes. Higher risk of periprocedural myocardial infarction in performed group was offset by higher risk of target vessel revascularization in deferred group. CATEGORIES IMAGING: FFR and Physiologic Lesion Assessment
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 70, NO. 18, SUPPL B, 2017
CONCLUSION A comprehensive assessment of the coronary circulation, based on separate calculation of epicardial- and microcirculatory conductance, is feasible and provides a clear, coherent depiction of coronary haemodynamics in ischaemic heart disease. As part of this novel approach, calculation of zero flow pressure (an index of extravascular compression) can also be performed. The findings should foster the development of simple, reliable methods for its calculation in the clinical arena. CATEGORIES IMAGING: FFR and Physiologic Lesion Assessment TCT-375 Deferred Versus Performed Revascularization in Coronary Stenoses With Gray Zone Fractional Flow Reserve: Data From IRIS FFR Registry Do-yoon Kang,1 Jung-Min Ahn,1 Cheol Hyun Lee,2 Osung Kwon,1 Ungjeong Do,3 Kyusup Lee,4 Pil Hyung Lee,1 Duk-Woo Park,1 Soo-Jin Kang,1 Seung-Whan Lee,1 Young-Hak Kim,1 Cheol Whan Lee,1 Seong-Wook Park,1 Seung-Jung Park1 1 Asan Medical Center, Seoul, Korea, Republic of; 2Asan medical center, seoul, Korea, Republic of; 3Asan medical center, Seoul, Korea, Republic of; 4AMC, Seoul, Korea, Republic of
CONCLUSION HSR is a better diagnostic index to identify myocardial ischemia as defined by moderately/reduced CFC as compared to pressure-only indices. CATEGORIES IMAGING: FFR and Physiologic Lesion Assessment TCT-374 Novel method to assess both the epicardial and microvascular domain using vascular conductance obtained from intracoronary pressure and flow velocity Nina van der Hoeven,1 Guus de Waard,1 Alicia Quirós,2 Alfonso de Hoyos,2 Sukhjinder Nijjer,3 Tim van de Hoef,4 Ricardo Petraco,5 Roel Driessen,6 Hernan Mejia-Renteria,7 Martijn Meuwissen,8 Paul Knaapen,9 Jan Piek,10 Justin Davies,3 Niels van Royen,11 Javier Escaned12 1 VU University Medical Centre, Amsterdam, Netherlands; 2Hospital Clínico San Carlos and Universidad Complutense de Madrid, Madrid, Spain; 3Imperial College London, London, United Kingdom; 4Academic Medical Center - University of Amsterdam, Amsterdam, Netherlands; 5 Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; 6Baylor Heart and Vascular Hospital, Dallas, Texas, Amsterdam, Netherlands; 7Hospital Universitario Clinico San Carlos, Madrid, Spain; 8Breda Amphia Ziekenhuis, Breda, Netherlands; 9 VU University Medical Center, Amsterdam, Netherlands; 10Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; 11 Radboud University, Nijmegen, Netherlands; 12Hospital Clínico San Carlos, Madrid, Spain
BACKGROUND The optimal cutoff of fractional flow reserve (FFR) for revascularization is in debate. We evaluated the prognosis of deferred and performed revascularization in coronary stenoses with gray zone FFR (0.75-0.80). METHODS From prospective IRIS-FFR registry, 1334 native coronary stenoses in 1334 patients with gray zone FFR were evaluated. Revascularization was deferred in 683 patients and performed in 651 patients. Primary outcome was a composite of death, myocardial infarction, and target vessel revascularization. RESULTS During a median follow-up of 2.9 years, primary outcome occurred in 55 patients (8.1%) in deferred group and 55 patients (8.4%) in performed group (adjusted hazard ratio [aHR] 1.05, 95% confidence interval [CI] 0.67-1.66; P¼0.79). Overall mortality was not different between two groups (aHR 0.82; 95% CI 0.34-2.00; P¼0.66). Performed group showed significant higher risk of myocardial infarction (aHR 0.27; 95% CI 0.09-0.80; P¼0.02), mainly due to higher risk of periprocedural myocardial infarction. Spontaneous myocardial infarction was not different between groups (aHR 1.85; 95% CI 0.35-9.75, P¼0.47). Target vessel revascularization was significantly higher in deferred group (aHR 2.17; 95% CI 1.17-4.02; P¼0.01). The trend was consistent after propensity score matching and inverse probability-oftreatment weighting.
BACKGROUND Invasive assessment of the coronary circulation has been largely based on the use of pressure ratios (epicardial-) and resistance (micro-vessels). Simultaneous assessment of epicardial(CEPI) and microvascular conductance (CMICRO), might provide a more coherent (same units for both compartments) and intuitive (expressing deliverability of blood) approach. METHODS Validation of this new approach was performed in a total of 403 both obstructive and non-obstructive coronary vessels interrogated with intracoronary Doppler and pressure in 261 patients with stable angina pectoris. Hyperaemic mid-late diastolic pressure and flow velocity (PV) relationships were calculated from PV loops using an automated algorithm. The slope of the linear PV relationship was first calculated from both aortic and intracoronary pressures and, subsequently, used to derive separately CEPI , CMICRO and zero-flow pressure (Pfz). RESULTS Median CEPI and CMICRO were 4.56 (IQR 2.18 – 8.64) and 1.28 (IQR 0.95-1.73) cm/s/mmHg respectively. Concordance in stenosis severity classification of two validated indices of stenosis severity (FFR and hyperemic stenosis resistance) was used as a robust reference standard to validate CEPI. ROC curves demonstrated an excellent ability of CEPI to characterize significant epicardial stenoses indicating a cutoff of 1.69 (AUC 0.93) with a sensitivity of 93% and a specificity of 82%. Validation of CMICRO (previously reported in endomyocardial biopsies) was not feasible in this population given the lack of a reference standard. Mean Pzf was 29.8914.16 mmHg.
CONCLUSION For coronary stenoses with gray zone FFR, revascularization was not associated with better clinical outcomes. Higher risk of periprocedural myocardial infarction in performed group was offset by higher risk of target vessel revascularization in deferred group. CATEGORIES IMAGING: FFR and Physiologic Lesion Assessment