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Published on: June 28, 2019
The prognostic value of residual coronary stenoses after functionally complete revascularisation
1Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, 3168 VIC, Australia.
Insights
Fractional flow reserve (FFR) is the gold standard for assessing coronary artery blockages. Functional assessment, not just visual estimation, guides optimal treatment for better patient outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Fractional flow reserve (FFR) is the gold standard for assessing coronary artery stenosis severity.
- FFR-guided percutaneous coronary intervention (PCI) shows superiority over angiography-guided PCI.
- High FFR costs limit its routine use, making visual stenosis estimation the primary decision-making tool.
Discussion:
- A significant "visual-functional mismatch" exists between diameter stenosis and FFR in 57% of non-left main stenosis cases.
- Angiography may overestimate lesion significance, potentially leading to unnecessary interventions.
- Complete revascularization improves outcomes in multivessel disease, but functional significance is key.
Key Insights:
- Functional revascularization guided by FFR is crucial for optimal patient outcomes.
- Residual angiographic lesions lacking functional significance do not indicate residual ischemia or predict worse outcomes.
- Prioritizing functional completeness over angiographic completeness ensures effective treatment.
Outlook:
- Further research into cost-effective FFR integration is needed.
- Developing advanced imaging techniques to better predict FFR could improve clinical decision-making.
- Emphasizing functional assessment will refine revascularization strategies and enhance long-term results.
Abstract:
Fractional flow reserve (FFR) has become the gold standard for functional assessment of coronary artery stenosis. Studies have confirmed the superiority of FFR guided percutaneous coronary intervention (PCI) compared to angiography guided PCI. Due to the high cost of FFR, it is not economically viable for FFR to be incorporated into every routine invasive coronary angiography. As a result, visual estimation of diameter stenosis on invasive coronary angiography still remains the cornerstone for decision making regarding revascularisation treatment for patients. This is despite recent studies questioning the "visual functional mismatch" between diameter stenosis and FFR in 57% of patients with non-left main stenosis. In patients with multivessel disease, complete revascularisation leads to improved long term outcomes. However, some lesions classified as significant by angiography may not be functionally significant. Kobayashi and colleagues demonstrated that after functionally complete revascularization with FFR guidance, residual angiographic lesions that are not functionally significant do not reflect residual ischemia or predict a worse outcome, supporting functionally complete, rather than angiographically complete, revascularization.
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