Fractional Flow Reserve or Intravascular Ultrasonography to Guide PCI

Koo, Bon‐Kwon; Hu, Xinyang; Kang, Jeehoon; Zhang, Jinlong; Jiang, Jun; Hahn, Joo Yong; Nam, Chang‐Wook; Doh, Joon‐Hyung; Lee, Bong Ki; Kim, Weon; Huang, Jinyu; Jiang, Fan; Zhang, Hao; Chen, Peng; Tang, Lijiang; Jiang, Wenbing; Chen, Xiaomin; He, Wenming; Ahn, Sung Gyun; Yoon, Myeong‐Ho; Kim, Ung; Lee, Joo Myung; Hwang, Doyeon; Ki, You-Jeong; Shin, Eun‐Seok; Kim, Hyo–Soo; Tahk, Seung‐Jea; Wang, Jianan

doi:10.1056/nejmoa2201546

Cited by 76 publications

(72 citation statements)

References 36 publications

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“…The definition of complete revascularization and evaluating system for non-culprit lesions varies widely among studies, based on angiographic percentage of diameter stenosis (%DS) on visual estimation or quantitative coronary angiography, non-invasive stress tests, and invasive physiological testing such as fractional flow reserve (FFR) [ 10 ]. Furthermore, intracoronary imaging guidance may be an alternative to coronary physiological testing [ 22 ]. In the major RCTs listed in Table 1 , non-culprit lesions were defined by %DS on angiography (cut-off values of 50% or 70%) with or without FFR values.…”

Section: Introductionmentioning

confidence: 99%

Complete revascularization in acute myocardial infarction: a clinical review

Saito

Kobayashi

2023

Cardiovasc Interv and Ther

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In patients with ST segment elevation and non-ST elevation myocardial infarction (MI), multivessel (MV) coronary artery disease is found in approximately 50%, leading to worse clinical outcomes. Recent data have suggested that complete revascularization with MV percutaneous coronary intervention is associated with a reduced risk of major adverse cardiovascular events as compared to culprit vessel-only revascularization. However, the optimal timing of MV intervention, appropriate non-culprit lesion assessment, and the best revascularization strategy in specific subsets such as cardiogenic shock remain to be established. This review article summarizes current evidence on revascularization strategies in patients with acute MI and MV disease.

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Section: Introductionmentioning

confidence: 99%

Complete revascularization in acute myocardial infarction: a clinical review

Saito

Kobayashi

2023

Cardiovasc Interv and Ther

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“…After more than 20 years of studies showing the benefit of fractional flow reserve (FFR) for lesion assessment and directing decisions for percutaneous coronary intervention (PCI) or medical therapy in stable ischemic heart disease, the last few years have produced several negative studies on physiologically directed interventions. Recently the FLAVOR study 1 found no clinical outcome difference between FFR‐guided PCI compared to IVUS guided PCI. Before accepting the results of any study, particularly those that might be practice changing, interventionalists should delve into the results more closely to see why these are contrarians in the face of many positive studies.…”

Section: Is Ffr Dead?mentioning

confidence: 99%

“…Dr. David Cox from North Carolina asked me and a large group of interventional cardiologists, [Recently, the FLAVOR study 1 reported that IVUS‐guided PCI has the same outcome as FFR‐guided PCI.] For years, many argued from both the podium and privately that “FFR trumps IVUS for assessing non‐Left Main lesions.” Does FLAVOR change that opinion?…”

Section: Is Ffr Dead?mentioning

confidence: 99%

“…Mort Kern, Long Beach, CA: David, the FLAVOR study by Koo et al 1 asked, “Is FFR better than IVUS for guiding PCI?” and randomized 1682 patients. Stents were implanted in 44% of the FFR group and in 65% of the IVUS group.…”

Section: Is Ffr Dead?mentioning

confidence: 99%

“…Here's what some said.William Fearon, Stanford University, Palo Alto CA: I agree with you and David. In FLAVOR,1 and others like it, IVUS resulted in more stenting because some FFR negative lesions were deemed significant by IVUS. Because every stent has an inherent risk associated with it, both acute and longer term, and because this risk is generally higher than the risk of medical therapy alone in most FFR negative lesions, eventually, with enough patients and long enough follow up, the excess unnecessary stenting will lead to an increased event rate.…”

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Is FFR dead? A conversation in cardiology

Kern¹,

Cox²,

Fearon

et al. 2022

Cathet Cardio Intervent

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Physiology- or Imaging-Guided Strategies for Intermediate Coronary Stenosis

Yang,

Kang,

Hwang

et al. 2024

JAMA Netw Open

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ImportanceTreatment strategies for intermediate coronary lesions guided by fractional flow reserve (FFR) and intravascular ultrasonography (IVUS) have shown comparable outcomes. Identifying low-risk deferred vessels to ensure the safe deferral of percutaneous coronary intervention (PCI) and high-risk revascularized vessels that necessitate thorough follow-up can help determine optimal treatment strategies.ObjectivesTo investigate outcomes according to treatment types and FFR and IVUS parameters after FFR- or IVUS-guided treatment.Design, Setting, and ParticipantsThis cohort study included patients with intermediate coronary stenosis from the Fractional Flow Reserve and Intravascular Ultrasound-Guided Intervention Strategy for Clinical Outcomes in Patients With Intermediate Stenosis (FLAVOUR) trial, an investigator-initiated, prospective, open-label, multicenter randomized clinical trial that assigned patients into an IVUS-guided strategy (which recommended PCI for minimum lumen area [MLA] ≤3 mm2 or 3 mm2 to 4 mm2 with plaque burden [PB] ≥70%) or an FFR-guided strategy (which recommended PCI for FFR ≤0.80). Data were analyzed from November to December 2022.ExposuresFFR or IVUS parameters within the deferred and revascularized vessels.Main Outcomes and MeasuresThe primary outcome was target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, and revascularization at 2 years.ResultsA total of 1619 patients (mean [SD] age, 65.1 [9.6] years; 1137 [70.2%] male) with 1753 vessels were included in analysis. In 950 vessels for which revascularization was deferred, incidence of TVF was comparable between IVUS and FFR groups (3.8% vs 4.1%; P = .72). Vessels with FFR greater than 0.92 in the FFR group and MLA greater than 4.5 mm2 or PB of 58% or less in the IVUS group were identified as low-risk deferred vessels, with a decreased risk of TVF (hazard ratio [HR], 0.25 [95% CI, 0.09-0.71]; P = .009). In 803 revascularized vessels, the incidence of TVF was comparable between IVUS and FFR groups (3.6% vs 3.7%; P = .95), which was similar in the revascularized vessels undergoing PCI optimization (4.2% vs 2.5%; P = .31). Vessels with post-PCI FFR of 0.80 or less in the FFR group or minimum stent area of 6.0 mm2 or less or with PB at stent edge greater than 58% in the IVUS group had an increased risk for TVF (HR, 7.20 [95% CI, 3.20-16.21]; P &lt; .001).Conclusions and RelevanceIn this cohort study of patients with intermediate coronary stenosis, FFR- and IVUS-guided strategies showed comparable outcomes in both deferred and revascularized vessels. Binary FFR and IVUS parameters could further define low-risk deferred vessels and high-risk revascularized vessels.

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Fractional Flow Reserve or Intravascular Ultrasonography to Guide PCI

Cited by 76 publications

References 36 publications

Complete revascularization in acute myocardial infarction: a clinical review

Complete revascularization in acute myocardial infarction: a clinical review

Is FFR dead? A conversation in cardiology

Physiology- or Imaging-Guided Strategies for Intermediate Coronary Stenosis

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