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Fractional Flow Reserve to Guide Revascularization in Patients With Coronary Artery Disease Undergoing TAVR
Troels Højsgaard Jørgensen1, Thomas Engstrøm1, Reza Jabbari1
1Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
Insights
Conservative management of coronary lesions with fractional flow reserve (FFR) ≤0.80 before transcatheter aortic valve replacement (TAVR) increased cardiovascular risk. Percutaneous coronary intervention (PCI) or deferral of FFR >0.80 lesions yielded similar outcomes.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- The prognostic significance of fractional flow reserve (FFR) in patients undergoing transcatheter aortic valve replacement (TAVR) remains incompletely understood.
- Assessing coronary stenosis severity before TAVR is crucial for optimal patient management.
Purpose of the Study:
- To investigate the cardiovascular risks associated with significant (FFR ≤0.80) and nonsignificant (FFR >0.80) coronary stenosis before TAVR.
- To compare outcomes between conservative management, percutaneous coronary intervention (PCI), and deferral strategies based on FFR values.
Main Methods:
- The study analyzed data from the NOTION-3 trial, including patients with severe aortic stenosis scheduled for TAVR and significant coronary stenosis.
- Patients with FFR ≤0.80 were randomized to conservative therapy or PCI, while those with FFR >0.80 were managed conservatively (deferral group).
- Primary outcomes included cardiovascular death, myocardial infarction, and/or urgent revascularization assessed up to 36 months.
Main Results:
- The conservative management group (FFR ≤0.80) exhibited a significantly higher cumulative incidence of adverse cardiovascular events (21.6%) compared to the PCI group (11.5%) and deferral group (10.5%).
- Higher rates of myocardial infarction and urgent revascularization primarily drove the excess risk in the conservative FFR ≤0.80 group.
- Revascularization rates were substantially higher in conservatively treated FFR ≤0.80 lesions (12.6%) versus PCI-treated (1.3%) or deferred (0.9%) lesions.
Conclusions:
- Conservative management of coronary lesions with FFR ≤0.80 is associated with increased cardiovascular risk in TAVR patients.
- PCI for FFR ≤0.80 lesions and deferral for FFR >0.80 lesions demonstrated comparable and favorable outcomes.
- An FFR threshold of 0.80 is supported for guiding coronary revascularization decisions in the TAVR population.
Background:
The prognostic value of fractional flow reserve (FFR) in assessing coronary stenosis before transcatheter aortic valve replacement (TAVR) is unclear.
Objectives:
The aim of this study was to evaluate cardiovascular risks associated with significant and nonsignificant FFR values of coronary stenosis prior to TAVR.
Methods:
Patients were enrolled from the NOTION-3 (Nordic Aortic Valve Intervention-3) randomized trial and registry, including those with severe aortic stenosis scheduled for TAVR and ≥50% coronary stenosis. Patients with FFR ≤0.80 or stenosis ≥90% were randomized to conservative therapy (FFR ≤0.80 conservative group) or percutaneous coronary intervention (PCI; FFR ≤0.80 PCI group). Those with FFR >0.80 were included in the registry (FFR >0.80 defer group). Outcomes were cardiovascular death, myocardial infarction, and/or urgent revascularization through 36 months.
Results:
Of 587 patients, 232 were in the FFR ≤0.80 conservative group, 220 in the FFR ≤0.80 PCI group, and 135 in the FFR >0.80 defer group. The cumulative incidence rates of cardiovascular death, myocardial infarction, or urgent revascularization were 21.6%, 11.5%, and 10.5%, respectively (P = 0.003). Excess risk in the FFR ≤0.80 conservative group was due mainly to higher myocardial infarction and urgent revascularization rates compared with the other groups. At a coronary lesion level, revascularization occurred in 12.6% of conservatively treated FFR ≤0.80 segments vs 1.3% of PCI-treated FFR ≤0.80 segments and 0.9% of deferred FFR >0.80 segments (P < 0.0001).
Conclusions:
Conservative management of FFR ≤0.80 lesions was linked to higher cardiovascular risk compared with either PCI of FFR ≤0.80 lesions or deferral of FFR >0.80 lesions, which had similar outcomes. These findings support an FFR threshold of 0.80 to guide coronary revascularization in patients undergoing TAVR. (Revascularization in Patients Undergoing Transcatheter Aortic Valve Implantation [NOTION-3]; NCT03058627).
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