Srikanth Kasula

Clinical and prognostic value of poststenting fractional flow reserve in acute coronary syndromes

Objectives Fractional flow reserve (FFR) has been suggested to have value in acute coronary syndromes (ACSs). The clinical and prognostic value of ischaemia reduction assessed by post-percutaneous coronary intervention (PCI) FFR has not been studied in this population. Methods Consecutive stable ischaemic heart disease (SIHD) (N=390) and patients with ACS (N=189) who had pre-PCI FFR and post-PCI FFR were followed for 2.4±1.5 years. Primary endpoint was major adverse cardiac events (MACE) (composite of myocardial infarction, target vessel revascularisation and death). Results In patients with ACS, PCI led to significant improvement in FFR from 0.62±0.15 to post-PCI FFR 0.88±0.08 (p<0.0001). Post-PCI FFR identified 29 patients (15%) who had persistently low FFR<0.80 (0.75±0.06) despite angiographically optimal results prompting subsequent interventions improving repeat FFR (0.85±0.06; p<0.0001). The difference in MACE events between patients with ACS and patients with SIHD varied according to the post-PCI FFR value (interaction p=0.044). Receiver operator curve analysis identified a final FFR cut-off of ≤0.91 as having the best predictive accuracy for MACE in the ACS study population (30% vs 19%; p=0.03). Patients with ACS achieving final FFR of >0.91 had similar outcomes compared with patients who had SIHD (19% vs 16%; p=0.51). However, in patients with final FFR of ≤0.91 there was increased MACE versus patients with SIHD (30% vs 16%; p<0.01). Conclusions Post-PCI FFR is valuable in assessing the functional outcome of PCI in patients with ACS. Use of post-PCI FFR in patients with ACS allows for functional optimisation of PCI results and is predictive of long-term outcomes in patients with ACS.

A Change of Heart: Reopening of a Foramen Ovale

Platypnea-orthodeoxia is a rare syndrome characterized by dyspnea and hypoxemia that is exacerbated by assuming an upright position. The most common cause is intracardiac shunting through an atrial septal defect or patent foramen ovale (PFO). We present a 63-year-old man with dyspnea after right pneumonectomy for lung cancer, who was found to have a large PFO with right-to-left shunt in the presence of normal right-sided pressures. Percutaneous closure of the PFO led to resolution of symptoms.

A novel stent inflation protocol improves long‐term outcomes compared with rapid inflation/deflation deployment method

High‐pressure inflation for coronary stent deployment is universally performed. However, the duration of inflation is variable and does not take into account differences in lesion compliance. We developed a standardized “pressure optimization protocol” (POP) using inflation pressure stability rather than an arbitrary inflation time or angiographic balloon appearance for stent deployment. Whether this approach improves long‐term outcomes is unknown.

Clinical and angiographic predictors of persistently ischemic fractional flow reserve after percutaneous revascularization

Aims Despite optimal angiographic results after percutaneous coronary intervention (PCI), some lesions may continue to produce ischemia under maximal hyperemia. We evaluated the factors associated with persistently ischemic fractional flow reserve (FFR) after angiographically successful PCI. Methods and results A total of 574 consecutive patients with 664 lesions undergoing PCI who had FFR pre‐ and post‐PCI were analyzed. Percutaneous coronary intervention led to effective ischemia reduction from pre‐FFR (0.65 ± 0.14) to post‐FFR (0.87 ± 0.08; &Dgr;FFR 0.22 ± 0.16, P < .001). There were 63 (9.5%) lesions with a persistently ischemic FFR of ≤0.80 despite optimal angiographic PCI results. Multivariate analysis revealed the presence of diffuse disease (odds ratio [OR] 3.54, 95% CI 1.80‐6.94, P < .01), left anterior descending artery PCI (OR 8.35, 95% CI 3.82‐18.27, P < .01), use of intravenous adenosine for inducing hyperemia (OR 3.95, 95% CI 2.0‐7.84, P < .01), and pre‐PCI FFR (OR 0.03, 95% CI 0.004‐0.23, P < .01) as independent predictors of persistently ischemic FFR (≤0.80) after PCI. The predictive accuracy of this model was robust, with an area under the curve of 0.85 (95% CI 0.82‐0.88). Conclusion Multiple factors are associated with persistently ischemic FFR after angiographically optimal PCI. It is recommended that in lesions with the above‐identified factors, FFR should be remeasured after PCI, and if abnormal, further measures should be undertaken for functional optimization.

PREDICTIVE ACCURACY OF RESTING GRADIENT (PD/PA) FOR IDENTIFYING ISCHEMIC CORONARY LESIONS

Adenosine is used to induce maximal hyperemia during fractional flow reserve (FFR) measurement. Adenosine administration can be time consuming, with added cost and sometimes may have undesirable side effects. We evaluated the predictive accuracy of resting trans-lesional gradient (distal coronary

DEGREE OF ISCHEMIA REDUCTION DURING PERCUTANEOUS CORONARY INTERVENTION IS A STRONG PREDICTOR OF LONG TERM ADVERSE EVENTS: MAKING THE CASE FOR ROUTINE POST PERCUTANEOUS CORONARY INTERVENTION FRACTIONAL FLOW RESERVE ASSESSMENT

Post percutaneous coronary interventions (PCI) fractional flow reserve (FFR) has been shown to be a predictor of adverse events. We analyzed the utility of post intervention FFR (P-FFR) after physiological optimization in predicting long term adverse outcomes. Consecutive patients undergoing PCI

DOES POST PCI FFR CARRY THE SAME PROGNOSTIC WEIGHT AS NON-ISCHEMIC FFR IN DEFERRED LESIONS?

Background: Deferring PCI based on a non-ischemic FFR has been well established. Growing evidence suggests an increasingly important role of post-PCI FFR in outcome prediction. Whether the FFR value post-PCI contains the same prognostic weight as FFR in deferred lesions is not known. Methods: Major

CLINICAL DECISION MAKING FOR THE HEMODYNAMIC GRAY ZONE (FFR 0.75-0.80) AND IMPACT ON LONG TERM OUTCOMES

A fractional flow reserve (FFR) value between 0.75 and 0.80 is considered the “gray zone” and outcomes data are limited in this group. We sought to evaluate the impact of revascularization vs. medical therapy alone (deferral) on long term outcomes for patients in the gray zone. Consecutive

CLINICAL AND PROGNOSTIC VALUE OF POST STENTING FFR FOR ASSESSMENT OF ISCHEMIA REDUCTION IN PATIENTS WITH ACUTE CORONARY SYNDROMES

results: Of 176 patients with ACS (age 63+/-10 years, 47% diabetics), 65 patients had NSTEMI and 111 unstable angina. PCI lead to angiographic lesion reduction from 76+13% to 1.2+6% with significant ischemia reduction from baseline FFR 0.63+-0.15 to PSFFR 0.90+0.6 (p<0.0001). PS-FFR identified 23 patients (13%) who had persistent ischemia (<0.80) despite angiographically optimal results. The low FFR prompted a subsequent intervention including post dilation or placement of another stent improving FFR on repeat measurement (0.73 +0.06 to 0.85+ 0.05; P<0.0001). The clinical utility of PS-FFR was similar for patients with NSTEMI and unstable angina. ROC analysis identified a cutoff of 0.86 for PS-FFR for MACE prediction in ACS population at a mean follow up of 2.7(+ 1.4) years

VALUE OF ROUTINE POST PCI FFR IN THE IDENTIFICATION AND MANAGEMENT OF ANGIOGRAPHICALLY OPTIMIZED STENTED LESIONS

Fractional flow reserve after stenting (FFR-S) is a predictor of adverse events. We evaluated the value of a routine FFR-S strategy for the identification and management of persistently ischemic lesions (despite angiographic optimization) after stenting. Clinical, angiographic and FFR