Response by Puymirat and Danchin to Letter Regarding Article, "Compared Outcomes of ST-Elevation Myocardial Infarction Patients With Multivessel Disease Treated With Primary Percutaneous Coronary Intervention and Preserved Fractional Flow Reserve of Nonculprit Lesions Treated Conservatively and of Those With Low Fractional Flow Reserve Managed Invasively: Insights From the FLOWER MI Trial".

Abstract

HomeCirculation: Cardiovascular InterventionsVol. 15, No. 1Response by Puymirat and Danchin to Letter Regarding Article, “Compared Outcomes of ST-Elevation Myocardial Infarction Patients With Multivessel Disease Treated With Primary Percutaneous Coronary Intervention and Preserved Fractional Flow Reserve of Nonculprit Lesions Treated Conservatively and of Those With Low Fractional Flow Reserve Managed Invasively: Insights From the FLOWER MI Trial” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBResponse by Puymirat and Danchin to Letter Regarding Article, “Compared Outcomes of ST-Elevation Myocardial Infarction Patients With Multivessel Disease Treated With Primary Percutaneous Coronary Intervention and Preserved Fractional Flow Reserve of Nonculprit Lesions Treated Conservatively and of Those With Low Fractional Flow Reserve Managed Invasively: Insights From the FLOWER MI Trial” Etienne Puymirat, MD, PhD and Nicolas Danchin, MD Etienne PuymiratEtienne Puymirat https://orcid.org/0000-0002-0533-9682 Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Department of Cardiology, Paris, France. Université de Paris, Paris, France. Search for more papers by this author and Nicolas DanchinNicolas Danchin https://orcid.org/0000-0001-9263-5051 Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Department of Cardiology, Paris, France. Université de Paris, Paris, France. Search for more papers by this author Originally published18 Jan 2022https://doi.org/10.1161/CIRCINTERVENTIONS.121.011614Circulation: Cardiovascular Interventions. 2022;15:e011614In Response:Le Ruz and Manigold raise important points. There are 3 (not necessarily mutually exclusive) potential explanations for the increased risk in patients in whom percutaneous coronary intervention of a nonculprit lesion was deferred on the basis of a normal (ie, >0.80) fractional flow reserve (FFR) value.1,2The first one is that, because of the reasons mentioned by Le Ruz and Manigold, the specific situation of acute myocardial infarction at its early stage may engender faulty results mostly linked to generalized impaired micro-circulation. The second hypothesis is that the threshold for FFR values is not ideal for acute myocardial infarction patients. The third hypothesis is that lesions with a normal FFR actually did not cause myocardial ischemia, but that the postinfarction setting caused a generalized fragility/inflammatory state, rendering these lesions more prone to rupture in the first weeks or months following the acute event.Unfortunately, we could not reliably assess troponin values because of diverging standards in the participating centers; there was no difference in left ventricular ejection fraction between patients who underwent percutaneous coronary intervention and those who did not, however, which strongly suggests that there was little difference in infarct extent likely to explain faulty measurements in one group rather than the other.The second potential explanation would imply that patients with events would have had lower FFR values, compared with those with events. As suggested, we analyzed FFR values separately in the patients with and those without events in the deferred group. Again, FFR values were not lower in patients with events (N=15, mean value 0.88±0.09, median value 0.90 [0.87–0.93]), compared with those without events (N=175, mean value 0.88±0.05, median value 0.88 [0.85–0.90], P=0.12). The second potential explanation therefore seems quite unlikely, and these findings probably also weaken the first potential explanation.This leaves the third explanation (specific fragility of plaques causing no ischemia) as the most likely reason for the lack of benefit of FFR measurement at the acute stage of myocardial infarction.Article InformationDisclosuresNone.