Prospective Evaluation of the Strategy of Functionally Optimized Coronary Intervention

Figures

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  Figure 1. Patient example of the functionally optimized coronary intervention strategy. A, Angiogram before percutaneous coronary intervention (PCI). Fractional flow reserve (FFR) in the distal vessel was 0.72. On pullback, FFR distal to lesion (*) was 0.78, with step up to 0.87 across the lesion, then gradually to 0.94 in the proximal left anterior descending artery (LAD). B, Post‐PCI angiogram. FFR in the distal vessel after stent deployment across the lesion, denoted by (*). FFR in the distal vessel was 0.71. On pullback, FFR distal to stent was 0.78, proximal to stent was 0.82 (TSG 0.04) with step‐up across a less apparent lesion (#) to 0.92, then gradually to 0.98 in proximal LAD. C, Angiogram after stenting, less apparent lesion denoted by (#) and dilatation with noncompliant balloon of first stent (*). FFR after these interventions in the distal vessel was 0.73. On pullback, FFR distal to distal stent was 0.84, proximal to proximal stent 0.90 (TSG: 0.06), and then gradually rose to 0.97 in the proximal LAD. D, Intravascular ultrasound showed the distal stent was adequately expanded (90% of the target minimal luminal area [MLA]) but the proximal stent was underexpanded (74% of target…

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  Figure 2. Outcomes of the 250 vessels attempted using the functional optimized coronary intervention strategy. Of these, 230 had successful pre‐ and post–fractional flow reserve (FFR) and intervention using the FFR wire alone (92.5% success). PCI indicates percutaneous coronary intervention.

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  Figure 3. Distribution of lesion severity for 250 lesions.

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  Figure 4. Relationship of resting pressure gradient across the lesion (Pd/Pa) (A) and fractional flow reserve (FFR) (B) to severity of lesion, as assessed by percentage diameter stenosis. PCI indicates percutaneous coronary intervention; Pd/Pa, ratio of resting pressure distal to an obstruction to arterial pressure.

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  Figure 5. In the entire cohort, fractional flow reserve (FFR) significantly improved from 0.64±0.15 to 0.83±0.09 (P<0.0001). PCI indicates percutaneous coronary intervention.

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  Figure 6. Fractional flow reserve (FFR) distribution after angiographic optimization. More than a third (36.5%) of vessels showed FFR in the ischemic range (≤0.80), and only 21.3% had FFR ≥0.90.

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  Figure 7. Forest plot of factors related to postintervention ischemia. FFR indicates fractional flow reserve; LAD, left anterior descending artery; MI, myocardial infarction; PCI, percutaneous coronary intervention.

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  Figure 8. Vessels that underwent further intervention because of ischemic fractional flow reserve (FFR) after angiographic optimization showed an increase in FFR from 0.71±0.07 to 0.81±0.06 (P<0.0001). PCI indicates percutaneous coronary intervention.

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  Figure 9. Patients with lowest final fractional flow reserve (FFR) had the smallest change in FFR from before to after intervention (0.12; interquartile range: 0.04–0.30), and the highest final FFR showed the greatest increment (0.23; interquartile range: 0.13–0.37).

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  Figure 10. Incidence of ischemia (fractional flow reserve [FFR] ≤0.80) after percutaneous coronary intervention relative to pressure transducer location on pullback. With the pressure transducer in the distal vessel, a third of angiographically optimized vessels showed an ischemic FFR. The frequency dropped to <10% immediately distal to the stent site and <1% proximal to the stent. This finding emphasizes that relative stent underexpansion plays a substantial role in producing ischemia after angiographic optimization.

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  Figure 11. Forest plot of factors related to increased trans‐stent fractional flow reserve gradient (>0.04). LAD indicates left anterior descending artery.