Physiological Versus Angiographic Guidance for Myocardial Revascularization in Patients Undergoing Transcatheter Aortic Valve Implantation

• Published in: Journal of the American Heart Association 2019-11, Vol.8 (22), p.e012618
• Main Authors: Lunardi, Mattia, Scarsini, Roberto, Venturi, Gabriele, Pesarini, Gabriele, Pighi, Michele, Gratta, Andrea, Gottin, Leonardo, Barbierato, Marco, Caprioglio, Francesco, Piccoli, Anna, Ferrero, Valeria, Ribichini, Flavio
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; aortic valve stenosis; Aortic Valve Stenosis - complications; Aortic Valve Stenosis - surgery; Clinical Decision-Making; Coronary Angiography; coronary artery disease; Coronary Artery Disease - complications; Coronary Artery Disease - diagnostic imaging; Coronary Artery Disease - physiopathology; Coronary Artery Disease - surgery; Dual Anti-Platelet Therapy; Female; fractional flow reserve; Fractional Flow Reserve, Myocardial; Heart Diseases - mortality; Humans; Kaplan-Meier Estimate; Male; Myocardial Infarction - epidemiology; Myocardial Revascularization - statistics & numerical data; Original Research; Percutaneous Coronary Intervention; Postoperative Complications; Progression-Free Survival; Proportional Hazards Models; Severity of Illness Index; Stroke - epidemiology; transcatheter aortic valve implantation; Transcatheter Aortic Valve Replacement
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.119.012618

Background Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation is uncertain. Fractional flow reserve (FFR) has never been clinically validated in aortic stenosis. The study aim was to analyze the clinical outcome of FFR-guided revascularization in patients undergoing transcatheter aortic valve implantation. Methods and Results Patients with severe aortic stenosis and coronary artery disease at coronary angiography were included in this retrospective analysis and divided in 2 groups: angiography guided (122/216; 56.5%) versus FFR-guided revascularization (94/216; 43.5%). Patients were clinically followed up and evaluated for the occurrence of major adverse cardiac and cerebrovascular events at 2-year follow-up. Most lesions in the FFR group resulted negative according to the conventional 0.80 cutoff value (111/142; 78.2%) and were deferred. The FFR-guided group showed a better major adverse cardiac and cerebrovascular event-free survival compared with the angio-guided group (92.6% versus 82.0%; hazard ratio, 0.4; 95% CI, 0.2-1.0; =0.035). Patients with deferred lesions based on FFR presented better outcome compared with patients who underwent angio-guided percutaneous coronary intervention (91.4% versus 68.1%; hazard ratio, 0.3; 95% CI, 0.1-0.6; =0.001). Conclusions FFR guidance was associated with favorable outcome in this observational study in patients undergoing transcatheter aortic valve implantation. Randomized trials are needed to investigate the long-term effects of FFR-guided revascularization against angiographic guidance alone in patients with aortic stenosis.