Physiology-guided Percutaneous Coronary Intervention Research Articles

Comparison between Imaging and Physiology in Guiding Coronary Revascularization: A Meta-Analysis.

Background: Percutaneous coronary intervention (PCI) is a widely used revascularization strategy for coronary artery disease. The choice between imaging-guided and physiology-guided PCI has been a subject of debate. This meta-analysis aims to systematically compare outcomes between imaging and physiology-guided PCI and management of intermediate coronary lesions (ICLs). Methods: A comprehensive literature search was conducted across major databases for studies published up to December 2023 following PRISMA guidelines. Seven eligible studies comparing imaging-guided and physiology-guided PCI were selected for the final analysis. Relevant outcome measures included major adverse cardiovascular events (MACE), target vessel revascularization (TVR), target vessel failure (TVF), and target lesion revascularization (TLR). Subgroup analysis was performed for ICLs. Results: A total of 5701 patients were included in the meta-analysis. After a mean follow-up of 2.1 years, imaging-guided PCI was associated with lower rates of TVR compared to physiology-guided PCI (OR 0.70, 95% CI 0.52-0.95, p = 0.02); concerning MACE, TVF, and TLR, no differences were found. When the analysis was restricted to studies considering ICLs management, there were no differences between the two techniques. Meta regression analysis did not show any impact of acute coronary syndromes (ACS) presentation on MACE and TVR. Conclusions: The findings suggest that imaging-guided PCI may reduce the need for future revascularization of the target vessel compared to the functional-guided approach, and this result was not influenced by ACS presentation. These results may have important implications for clinical practice, guiding interventional cardiologists in selecting the most appropriate guidance strategy.

A randomised multicentre study of angiography- versus physiologyguided percutaneous coronary intervention in patients with coronary artery disease undergoing TAVI: design and rationale of the FAITAVI trial

A randomised multicentre study of angiography- versus physiologyguided percutaneous coronary intervention in patients with coronary artery disease undergoing TAVI: design and rationale of the FAITAVI trial

Routine functional testing in high-risk patients after imaging- or physiology-guided percutaneous coronary intervention

Abstract Background Imaging-guided or physiology-guided percutaneous coronary intervention (PCI) improved clinical outcomes in complex coronary artery disease. However, it is not known to what extent routine functional testing after imaging or physiology-guided PCI affect clinical outcomes among high-risk patients. Objectives To assess clinical impact of routine functional test or standard care alone after intravascular ultrasound (IVUS) or fractional flow reserve(FFR) guided PCI. Methods Of the 1706 randomized patients with high-risk anatomical or clinical features enrolled in the POST-PCI (Pragmatic Trial Comparing Symptom-Oriented versus Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention) trial, 1269 patients underwent IVUS-guided PCI and 609 patients underwent FFR-guided PCI. The primary outcome was a composite of death from any cause, myocardial infarction, or hospitalization for unstable angina at 2 years. Results The rate of the 2-year primary outcomes was similar between strategies of routine functional-testing or standard-care in IVUS use group (5.3% vs. 6.6%, respectively; HR, 0.79; 95% CI, 0.50–1.24; P=0.30) and in IVUS non-use group (5.7% vs. 3.8%, respectively; HR,1.52; 95% CI, 0.63–3.68; P=0.21); there was no significant interaction between IVUS use and follow up strategies (p for interaction=0.21). The rate of the 2-year outcomes was not significantly different with functional-testing or standard-care in FFR use group (2.6% vs. 3.9%, respectively; HR, 0.65; 95% CI, 0.26–1.58, P=0.34) and in FFR non-use group (7.0% vs. 7.1%, respectively; HR, 0.99; 95% CI, 0.63–1.55, P=0.97) without significant interaction (p for interaction=0.59). Conclusions In patients with high-risk PCI, IVUS and FFR use did not affect clinical outcome of routine surveillance stress testing and standard-care alone during follow-up.TableFigure

Coronary Physiology Guidance vs Conventional Angiography for Optimization of Percutaneous Coronary Intervention: The AQVA-II Trial

BackgroundThe debate surrounding the efficacy of coronary physiological guidance compared with conventional angiography in achieving optimal post–percutaneous coronary intervention (PCI) fractional flow reserve (FFR) values persists. ObjectivesThe primary aim of this study was to demonstrate the superiority of physiology-guided PCI, using either angiography or microcatheter-derived FFR, over conventional angiography-based PCI in complex high-risk indicated procedures (CHIPs). The secondary aim was to establish the noninferiority of angiography-derived FFR guidance compared with microcatheter-derived FFR guidance. MethodsPatients with obstructive coronary lesions and meeting CHIP criteria were randomized 2:1 to receive undergo physiology- or angiography-based PCI. Those assigned to the former were randomly allocated to angiography- or microcatheter-derived FFR guidance. CHIP criteria were long lesion (>28 mm), tandem lesions, severe calcifications, severe tortuosity, true bifurcation, in-stent restenosis, and left main stem disease. The primary outcome was invasive post-PCI FFR value. The optimal post-PCI FFR value was defined as >0.86. ResultsA total of 305 patients (331 study vessels) were enrolled in the study (101 undergoing conventional angiography-based PCI and 204 physiology-based PCI). Optimal post-PCI FFR values were more frequent in the physiology-based PCI group compared with the conventional angiography-based PCI group (77% vs 54%; absolute difference 23%, relative difference 30%; P < 0.0001). The occurrence of the primary outcome did not differ between the 2 physiology-based PCI subgroups, demonstrating the noninferiority of angiography- vs microcatheter-derived FFR (P < 0.01). ConclusionsIn CHIP patients, procedural planning and guidance on the basis of physiology (through either angiography- or microcatheter-derived FFR) are superior to conventional angiography for achieving optimal post-PCI FFR values. (Physiology Optimized Versus Angio-Guided PCI [AQVA-II]; NCT05658952)

Applied coronary physiology for planning and guidance of percutaneous coronary interventions. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the European Society of Cardiology.

The clinical value of fractional flow reserve and non-hyperaemic pressure ratios are well established in determining an indication for percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD). In addition, over the last 5 years we have witnessed a shift towards the use of physiology to enhance procedural planning, assess post-PCI functional results, and guide PCI optimisation. In this regard, clinical studies have reported compelling data supporting the use of longitudinal vessel analysis, obtained with pressure guidewire pullbacks, to better understand how obstructive CAD contributes to myocardial ischaemia, to establish the likelihood of functionally successful PCI, to identify the presence and location of residual flow-limiting stenoses and to predict long-term outcomes. The introduction of new functional coronary angiography tools, which merge angiographic information with fluid dynamic equations to deliver information equivalent to intracoronary pressure measurements, are now available and potentially also applicable to these endeavours. Furthermore, the ability of longitudinal vessel analysis to predict the functional results of stenting has played an integral role in the evolving field of simulated PCI. Nevertheless, it is important to have an awareness of the value and challenges of physiology-guided PCI in specific clinical and anatomical contexts. The main aim of this European Association of Percutaneous Cardiovascular Interventions clinical consensus statement is to offer up-to-date evidence and expert opinion on the use of applied coronary physiology for procedural PCI planning, disease pattern recognition and post-PCI optimisation.

Intracoronary physiology-guided percutaneous coronary intervention in patients with diabetes

ObjectiveThe risk of vessel-oriented cardiac adverse events (VOCE) in patients with diabetes mellitus (DM) undergoing intracoronary physiology-guided coronary revascularization is poorly defined. The purpose of this work is to evaluate the risk of VOCE in patients with and without DM in whom percutaneous coronary intervention (PCI) was performed or deferred based on pressure-wire functional assessment.MethodsThis is a retrospective analysis of a multicenter registry of patients evaluated with fractional flow reserve (FFR) and/or non-hyperaemic pressure ratio (NHPR). Primary endpoint was a composite of VOCE including cardiac death, vessel-related myocardial infarction (MI), and ischemia-driven target vessel revascularization (TVR).ResultsA large cohort of 2828 patients with 3353 coronary lesions was analysed to assess the risk of VOCE at long-term follow-up (23 [14–36] months). Non-insulin-dependent-DM (NIDDM) was not associated with the primary endpoint in the overall cohort (adjusted Hazard Ratio [aHR] 1.18, 95% CI 0.87–1.59, P = 0.276) or in patients with coronary lesions treated with PCI (aHR = 1.30, 95% CI 0.78–2.16, P = 0.314). Conversely, insulin-dependent diabetes mellitus (IDDM) demonstrated an increased risk of VOCE in the overall cohort (aHR 1.76, 95% CI 1.07–2.91, P = 0.027), but not in coronary lesions undergoing PCI (aHR 1.26, 95% CI 0.50–3.16, P = 0.621). Importantly, in coronary lesions deferred after functional assessment IDDM (aHR 2.77, 95% CI 1.11–6.93, P = 0.029) but not NIDDM (aHR = 0.94, 95% CI 0.61–1.44, P = 0.776) was significantly associated with the risk of VOCE. IDDM caused a significant effect modification of FFR-based risk stratification (P for interaction < 0.001).ConclusionOverall, DM was not associated with an increased risk of VOCE in patients undergoing physiology-guided coronary revascularization. However, IDDM represents a phenotype at high risk of VOCE.Graphical abstract

Physiology-guided PCI versus CABG for left main coronary artery disease: insights from the DEFINE-LM registry

There have been no studies comparing clinical outcomes of physiology-guided revascularization in patients with unprotected left main coronary disease (ULMD) between percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG). The aim of this study was to assess the long-term clinical outcomes between PCI and CABG of patients with physiologically significant ULMD. From an international multicenter registry of ULMD patients interrogated with instantaneous wave-free ratio (iFR), we analyzed data from 151 patients (85 PCI vs. 66 CABG) who underwent revascularization according to the cutoff value of iFR ≤ 0.89. Propensity score matching was employed to adjust for baseline clinical characteristics. The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, and ischemia-driven target lesion revascularization. The secondary endpoints were the individual components of the primary endpoint. Mean age was 66.6 (± 9.2) years, 79.2% male. Mean SYNTAX score was 22.6 (± 8.4) and median iFR was 0.83 (IQR 0.74–0.87). After performing propensity score matching analysis, 48 patients treated with CABG were matched to those who underwent PCI. At a median follow-up period of 2.8 years, the primary endpoint occurred in 8.3% in PCI group and 20.8% in CABG group, respectively (HR 3.80; 95% CI 1.04–13.9; p = 0.043). There was no difference in each component of the primary event (p > 0.05 for all). Within the present study, iFR-guided PCI was associated with lower cardiovascular events rate in patients with ULMD and intermediate SYNTAX score, as compared to CABG.Graphical abstractState-of-the-art PCI vs. CABG for ULMD. Study design and primary endpoint in patients with physiologically significant ULMD. MACE was defined as the composite of all-cause death, non-fatal myocardial infarction, and target lesion revascularization. The blue line denotes the PCI arm, and the red line denotes the CABG arm. PCI was associated with significantly lower risk of MACE than CABG. CABG: coronary artery bypass grafting; iFR: instantaneous wave-free ratio; MACE: major adverse cardiovascular events; PCI: percutaneous coronary intervention; ULMD: unprotected left main coronary artery disease.

Real-world comparison of intracoronary imaging and fractional flow reserve measurements on outcomes of semi-urgent and elective percutaneous coronary intervention in a multi-ethnic asian population

Abstract Funding Acknowledgements Type of funding sources: None. Background Intracoronary imaging and fractional flow reserve measurements (FFR) are helpful in optimisation of percutaneous coronary intervention (PCI) for patients with stable coronary artery disease, but their comparative efficacy is not well described. Furthermore, few studies involve Asian patients in a real-world context. Purpose This study aims to compare the use of intracoronary imaging and fractional flow reserve measurements on the outcomes of semi-urgent and elective PCI in a multi-ethnic Asian population. Methods This was a retrospective database study of patients who underwent semi-urgent and elective PCI from 1st Jan 2014 to 31st Dec 2015 at a tertiary academic centre. The patients were split into 2 groups – imaging-guided (IG) consisting of intravascular ultrasound guided PCI or optical coherence tomography guided PCI and physiology-guided (PG) which included FFR-guided PCI. Patients who underwent both IG PCI and PG PCI were excluded. Incidence rates of major adverse cardiovascular events (MACE) (Subsequent myocardial infarction, congestive cardiac failure, all-cause mortality) and major adverse cardiovascular and cerebrovascular events (MACCE) (Subsequent myocardial infarction, congestive cardiac failure, stroke or transient ischemic attack and all-cause mortality) were compared between the two groups. One-to-one propensity score matching (PSM) was performed to control for potential bias. Results Of 1,732 patients studied, the median age was 61.0 years (IQR 53.0 to 68.0) and 336 were female (19.4%). There were 266 patients (15.4%) in IG and 186 (10.7%) in PG. The patients were followed up for 33 ±37 months. A total of 133 pairs were matched. In the unmatched cohort, there was no statistical difference between the IG and PG group in the incidence of MACE (24.2% vs 15.5%, p= 0.099) and MACCE (26.6% vs 17.7%, p= 0.112). Baseline and procedural characteristics were balanced between the IG and PG groups. In the matched cohort, the incidence rates of MACE (11.3% vs 7.5%, p= 0.383) and MACCE (15.8% vs 12.8%, p=0.596) did not differ significantly between the two groups. Conclusion In a real-world multi-ethnic Asian registry of semi-urgent and elective PCI patients, there was no difference in outcomes whether patients underwent the use of intracoronary imaging or fractional flow reserve measurements during PCI.

How to Apply Physiology-Guided Percutaneous Coronary Intervention Optimization?: Theory and Practice

How to Apply Physiology-Guided Percutaneous Coronary Intervention Optimization?: Theory and Practice

Revascularization strategies versus optimal medical therapy in chronic coronary syndrome: A network meta-analysis

BackgroundThe impact of myocardial revascularization on outcomes and prognosis in patients with chronic coronary syndrome (CCS) without left main (LM) disease or reduced left ventricle ejection fraction (LVEF) may be influenced by the revascularization strategy adopted. MethodsWe performed a network meta-analysis including 18 randomized controlled trials comparing different revascularization strategies, including angiography-guided percutaneous coronary intervention (PCI), physiology-guided PCI and coronary artery bypass graft (CABG), in patients with CCS without LM disease or reduced LVEF. ResultsCompared with medical therapy, all revascularization strategies were associated with a reduction of the primary endpoint, as defined in each trial, the extent of which was modest with angiography-guided PCI (IRR 0.86, 95% CI 0.75–0.99) and greater with physiology-guided PCI (IRR 0.60, 95% CI 0.47–0.77) and CABG (IRR 0.58, 95% CI 0.48–0.70). Moreover, angiography-guided PCI was associated with an increase of the primary endpoint compared to physiology-guided PCI (IRR 1.43, 95% CI 1.14–1.79) and CABG (IRR 1.49, 95% CI 1.27–1.74). CABG was the only strategy associated with reduced myocardial infarction (IRR 0.68, 95% CI 0.52–0.90), cardiovascular death (IRR 0.76, 95% CI 0.64–0.89), and all-cause death (IRR 0.87, 95% CI 0.77–0.99), but increased stroke (IRR 1.69, 95% CI 1.04–2.76). ConclusionsIn CCS patients without LM disease or reduced LVEF, physiology-guided PCI and CABG are associated with better outcomes than angiography-guided PCI. Compared with medical therapy, CABG is the only revascularization strategy associated with a reduction of myocardial infarction and death rates, at the cost of higher risk of stroke.Study registration: This study is registered in PROSPERO (CRD42022313612).

Revascularization strategies versus optimal medical therapy in chronic coronary syndrome: a systematic review and network meta-analysis

Abstract Background Whether revascularization reduces ischemic events and improves prognosis in patients with chronic coronary artery syndrome (CCS) without left main (LM) disease or reduced left ventricle ejection fraction (LVEF) remains a topic of debate. Nevertheless, the impact of revascularization on outcomes in patients with CCS may be influenced by the revascularization strategy adopted. Purpose We aimed at evaluating the comparative effects of different revascularization strategies in patients with CCS. Methods A total of 18 randomized controlled trials including angiography-guided percutaneous coronary intervention (PCI), physiology-guided PCI and coronary artery bypass graft (CABG), were included. Effect estimates included direct comparisons for all treatments and direct and indirect evidence were in agreement for all included outcomes, fulfilling the consistency assumption. Incidence rate ratios (IRR) and associated 95% confidence intervals (CIs) were used to adjust outcomes according to follow-up durations. Medical therapy was used as reference strategy. Results Compared with medical therapy, at a mean follow-up of 5.1 years, all revascularization strategies were associated with a reduction of the primary endpoint, as defined in each trial, the extent of which was modest with angiography-guided PCI (IRR 0.86, 95% CI 0.75–0.99) and greater with physiology-guided PCI (IRR 0.60, 95% CI 0.47–0.77) and CABG (IRR 0.58, 95% CI 0.48–0.70). Moreover, angiography-guided PCI was associated with increased primary endpoint compared to physiology-guided PCI (IRR 1.43, 95% CI 1.14–1.79) and CABG (IRR 1.49, 95% CI 1.27–1.74). CABG was the only strategy associated with reduced myocardial infarction (IRR 0.68, 95% CI 0.52–0.90), cardiovascular death (IRR 0.76, 95% CI 0.64–0.89), and all-cause death (IRR 0.87, 95% CI 0.77–0.99), but increased stroke (IRR 1.69, 95% CI 1.04–2.76). Results were consistent at secondary analysis exploring the impact on outcomes of baseline characteristics, such as 3-vessel disease, diabetes mellitus, year of publication or stents used. Conclusions In CCS patients without LM disease or reduced LVEF, physiology-guided PCI and CABG were associated with better outcomes than angiography-guided PCI. Compared with medical therapy, CABG was the only revascularization strategy associated with a reduction of myocardial infarction and death rates, at the cost of higher risk of stroke. Funding Acknowledgement Type of funding sources: None.

The Effect of Coronary Lesion Complexity and Preprocedural Revascularization on5-Year Outcomes After TAVR.

Aortic stenosis and coronary artery disease (CAD) frequently coincide. However, the management of coexisting CAD in patients undergoing transcatheter aortic valve replacement (TAVR) remains controversial. This study sought to determine whether the presence of CAD, its complexity, and angiography-guided percutaneous coronary intervention (PCI) are associated with outcomes after TAVR. All patients undergoing TAVR at a tertiary referral center between 2008 and 2020 were included in a prospective observational study. Baseline SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score (SS) and, whenever applicable, a residual SS after PCI were calculated. A multivariate analysis was performed to determine the effect of CAD, stratified according to complexity, and PCI on 5-year outcomes. In 604 patients, the presence of CAD and its complexity were significantly associated with worse 5-year survival (SS 0: 67.9% vs SS 1-22: 56.1% vs SS >22: 53.0%; log-rank P=0.027) and increased cardiovascular mortality (SS 0: 15.1% vs SS 1-22: 24.0% vs SS >22: 27.8%; log-rank P=0.024) after TAVR. Having noncomplex CAD (SS 1-22) was an independent predictor for increased all-cause mortality (HR: 1.43; P=0.046), while complex CAD (SS >22) increased cardiovascular mortality significantly (HR: 1.84; P=0.041). Angiography-guided PCI or completeness of revascularization was not associated with different outcomes. The presence of CAD and its anatomical complexity in patients undergoing TAVR are associated with significantly worse 5-year outcomes. However, angiography-guided PCI did not improve outcomes, highlighting the need for further research into physiology-guided PCI.

Impact of coronary plaque morphology on the precision of computational fractional flow reserve derived from optical coherence tomography imaging.

Computational fractional flow reserve (FFR) was recently developed to expand the use of physiology-guided percutaneous coronary intervention (PCI). Nevertheless, current methods do not account for plaque composition. It remains unknown whether the numerical precision of computational FFR is impacted by the plaque composition in the interrogated vessels. This study is an observational, retrospective, cross-sectional study. Patients who underwent both optical coherence tomography (OCT) and FFR prior to intervention between August 2011 and October 2018 at Wakayama Medical University Hospital were included. All frames from OCT pullbacks were analyzed using a deep learning algorithm to obtain coronary plaque morphology including thin-cap fibroatheroma (TCFA), lipidic plaque volume (LPV), fibrous plaque volume (FPV), and calcific plaque volume (CPV). The interrogated vessels were stratified into three subgroups: the overestimation group with the numerical difference between the optical flow ratio (OFR) and FFR >0.05, the reference group with the difference ≥-0.05 and ≤0.05, and the underestimation group with the difference <-0.05. In total 230 vessels with intermediate coronary artery stenosis from 193 patients were analyzed. The mean FFR was 0.82±0.10. Among them, 21, 179, and 30 vessels were in the overestimation, the reference, and the underestimation group, respectively. TCFA was higher in the underestimation group (60%) compared with reference (36.3%) and overestimation group (19%). Besides, it was not associated with numerical difference between OFR and FFR (NDOF) after multilevel linear regression. LPV was associated with NDOF as OFR underestimated FFR with -0.028 [95% confidence interval (CI): -0.047, -0.009] for every 100 mm3 increase in LPV. High lipid burden underestimates FFR when OFR is used to assess the hemodynamic importance of intermediate coronary artery stenosis. TCFA, FPV, and CPV were not independent predictors of NDOF.

Long‐term prognostic value of dynamic function assessment of intermediate coronary lesion with computational physiology

This study sought to investigate the dynamic functional changes of coronary intermediate lesions using quantitative flow ratio (QFR) and its implication on long-term clinical outcomes.Physiology-guided percutaneous coronary intervention in patients with angiographic intermediate lesions has been associated with favorable outcomes.This study consecutively enrolled 1130 patients with deferred intermediate lesions at baseline angiography and subsequently received second-time angiography between 9 months and 2 years later from two centers in China. The functional changes of intermediate lesions at angiographic follow-up (ΔQFR) were defined as (baseline QFR-follow-up QFR)/years. The primary outcome was vessel-oriented composite endpoint (VOCE), defined as the composite of vessel-related cardiac death, vessel-related myocardial infarction (MI), and ischemia-driven target vessel revascularization (ID-TVR) at angiographic follow-up for up to 5 years.Retrospective QFR assessment was available in 820 patients (996 intermediate lesions). QFR ≤ 0.80 at second-time angiography was associated with significantly higher 5-year VOCE (41.9% vs. 13.4%, p < 0.0001). In 777 intermediate lesions with baseline QFR > 0.80, mean ΔQFR was 0.03 ± 0.07 (median: 0.006; Q1: 0; and Q3: 0.04). The optimal cutoff of ΔQFR for predicting the primary outcome was 0.03 (area under the curve [AUC]: 0.68). The cumulative event rate of VOCE in patients with ΔQFR ≥ 0.03 was significantly higher than in those with ΔQFR < 0.03 (33.8% vs. 12.2%, p < 0.0001), driven by higher vessel-related MI and ID-TVR.The ΔQFR was a useful tool for evaluating the dynamic functional change of deferred intermediate lesions, as it demonstrates good prognostic value for long-term target vessel-related adverse events.

Physiologic Assessment of Coronary Stenosis: Current Status and Future Directions

Percutaneous coronary intervention (PCI) is a commonly used treatment option in coronary artery disease (CAD). Reduced major adverse cardiovascular events (MACE) in those randomized to PCI compared to optimal medical therapy have been demonstrated only if it is performed for physiologically significant coronary lesions. Despite data demonstrating improved outcomes primarily in stable CAD and then acute settings, physiology-guided PCI remains underutilized. This review summarizes the evidence and commonly used methods for physiologic assessment of coronary stenosis. Fractional flow reserve (FFR) is the gold standard for the analysis of lesion severity. Its use is limited by the need for adenosine, which adds time, complexity, and potential adverse effects. Non-hyperemic instantaneous wave-free ratio-guided revascularization and quantitative flow reserve ratio assessment both have shown safety and effectiveness with improved patient outcomes. Coronary physiological assessment solves the ambiguity of coronary angiography. Detecting physiologically significant stenoses is crucial to decide which lesion needs to be treated. Technological advances have led to the development of new assessment indices in addition to FFR.

Fractional flow reserve, quantitative flow ratio, and instantaneous wave-free ratio: a comparison of the procedure-related dose of ionising radiation.

IntroductionThe development of interventional cardiology increases the number of invasive procedures which are inevitably associated with increased exposure to ionizing radiation and associated risks. A percutaneous coronary intervention (PCI) substantiated by evaluation of the coronary artery lesion’s functional significance is recommended by both European and American cardiologists. Nevertheless, the prevalence of physiology-guided PCIs does not exceed 10% all over the globe.AimTo identify the physiology evaluation method which is associated with the lowest exposure to ionising radiation.Material and methodsAnonymised data of 421 patients with stable angina pectoris for whom elective coronary artery angiography followed by physiological assessment of intermediate coronary artery stenosis was performed were prospectively included in this study. Only diagnostic-procedure-related data of dose of ionizing radiation were analysed. Physiological assessment of coronary artery lesions was performed by fractional flow reserve (FFR), quantitative flow ratio (QFR), or instantaneous wave-free ratio (iFR).ResultsCompared to FFR as a reference, fluoroscopy time (FT) was almost half in QFR and almost double in iFR, p < 0.001. QFR was associated with more than 3 times shorter FT compared to iFR. The dose area product was 663.87 ±260.51 cGy/cm2 (p = 0.03) lower in QFR compared to iFR.ConclusionsQFR is associated with significantly reduced exposure to ionising radiation compared to both FFR and iFR. Therefore, wider QFR application in clinical practice could eliminate any additional exposure to ionising radiation and increase the prevalence of physiology-guided coronary artery revascularization.

Physiological Assessment of Coronary Lesions in 2020.

Physiological assessment of coronary artery disease (CAD) is an essential component of the interventional cardiology toolbox. However, despite long-term data demonstrating improved outcomes, physiology-guided percutaneous coronary intervention (PCI) remains underutilized in current practice. This review outlines the indications and technical aspects involved in evaluating coronary stenosis physiology, focusing on the latest developments in the field. Beyond fractional flow reserve (FFR), non-hyperemic pressure ratios (NHPR) that assess coronary physiology at rest without hyperemia now abound. Additional advances in other alternative FFR approaches, including non-invasive coronary CT (FFRCT), invasive angiography (FFRangio), and optical coherence tomography (FFROCT), are being realized. Artificial intelligence algorithms and robust tools that enable detailed pre-procedure "virtual" intervention are also emerging. The benefits of coronary physiological assessment to determine lesion functional significance are well established. In addition to stable CAD, coronary physiology can be especially helpful in clinical scenarios such as left main and multivessel CAD, serial lesions, non-infarct-related arteries in acute coronary syndromes, and residual ischemia post-PCI. Today, coronary physiological assessment remains an indispensable tool in the catheterization laboratory, with an exciting technological future that will further refine clinical practice and improve patient care.

Consensus document for invasive coronary physiologic assessment in Asia-Pacific countries

Currently, invasive physiologic assessment such as fractional flow reserve is widely used worldwide with different adoption rates around the globe. Patient characteristics and physician preferences often differ in the Asia-Pacific (APAC) region with respect to treatment strategy, techniques, lesion complexity, access to coronary physiology and imaging devices, as well as patient management. Thus, there is a need to construct a consensus document on recommendations for use of physiology-guided percutaneous coronary intervention (PCI) in APAC populations. This document serves as an overview of recommendations describing the best practices for APAC populations to achieve more consistent and optimal clinical outcomes. A comprehensive multiple-choice questionnaire was provided to 20 interven- tional cardiologists from 10 countries in the APAC region. Clinical evidence, tips and techniques, and clinical situations for the use of physiology-guided PCI in APAC were reviewed and used to propose key recommendations. There are suggestions to continue to develop evidence for lesion and patient types that will benefit from physiology, develop directions for future research in health economics and local data, develop appropriate use criteria in different countries, and emphasize the importance of education of all stakeholders. A consensus recommendation to enhance the penetration of invasive physiology-based therapy was to adopt the 5E approach: Evidence, Education, Expand hardware, Economics and Expert consensus. This consensus document and recommendations support interventional fellows and cardiologists, hospital administrators, patients, and medical device companies to build confidence and encourage wider implementation of invasive coronary physiology-guided therapy in the APAC region.

Percutaneous coronary intervention in patients with multi-vessel coronary artery disease: a focus on physiology.

Multi-vessel coronary artery disease (MVD) frequently features ambiguous or intermediate lesions that may be both serial and complex, suggesting that multiple regions require revascularization. Percutaneous coronary intervention (PCI) is associated with various challenges such as appropriate identification of lesions that should be treated, the choice of an optimum revascularization method, and limitations of long-term outcomes. Optimal patient selection and careful targeting of lesions are key when planning treatment. Physiology-guided decision-making (based on the fractional flow reserve) can overcome the current limitations of PCI used to treat MVD regardless of clinical presentation or disease subtype, as confirmed in recent clinical trials. Here, we review the use of physiology-guided PCI for patients with MVD, and their early and late outcomes.

Imaging- and physiology-guided percutaneous coronary intervention without contrast administration in advanced renal failure: a feasibility, safety, and outcome study

The feasibility, safety, and clinical utility of percutaneous coronary intervention (PCI) without radio-contrast medium in patients with advanced chronic kidney disease (CKD) are unknown. In this series, we investigated a specific strategy for 'zero contrast' PCI with the aims of preserving renal function and preventing the need for renal replacement therapy (RRT) in patients with advanced CKD. A total of 31 patients with advanced CKD [creatinine = 4.2 mg/dL, inter-quartile range (IQR) 3.1-4.8, estimated glomerular filtration rate = 16 ± 8 mL/min/1.73 m2] who had clinical indication for PCI based on a prior minimal contrast coronary angiogram were included. Zero contrast PCI was performed at least 1 week after diagnostic angiography using real-time intravascular ultrasound (IVUS) guidance, with pre- and post-PCI measurements of fractional flow reserve and coronary flow reserve to confirm physiological improvement. This approach resulted in successful PCI, no major adverse cardiovascular events and preservation of renal function without the need for RRT within a follow-up time of 79 days (IQR 33-207) in all patients. In patients with advanced CKD who require revascularization, PCI may safely be performed without contrast using IVUS and physiological guidance with high procedural success and without complications.