Evaluation of Instantaneous Wave-Free Ratio and Fractional Flow Reserve in Severe Aortic Valve Stenosis

Abstract

BACKGROUND: The optimal functional evaluation of coronary artery stenosis in patients with severe aortic stenosis (AS) has not been established. The objective of the study was to evaluate the instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) in patients with and without severe AS. METHODS: We retrospectively investigated 395 lesions in 293 patients with severe AS and 2257 lesions in 1882 patients without severe AS between 2010 and 2022 from a subgroup of the Interventional Cardiology Research In-Cooperation Society FFR Registry. All patients had FFR values, and iFR was analyzed post hoc using dedicated software only in lesions with adequate resting pressure curves (311 lesions in patients with severe AS and 2257 lesions in patients with nonsevere AS). RESULTS: The incidence of iFR ≤0.89 was 66.6% and 31.8% ( P <0.001), while the incidence of FFR ≤0.80 was 45.3% and 43.9% ( P =0.60) in the severe AS group and the nonsevere AS group, respectively. In the severe AS group, most lesions (95.2%) with iFR >0.89 had FFR >0.80, while 36.2% of lesions with iFR ≤0.89 had FFR >0.80. During a median follow-up of 2 years, FFR ≤0.80 was significantly associated with deferred lesion failure (adjusted hazard ratio, 2.71 [95% CI, 1.08–6.80]; P =0.034), while iFR ≤0.89 showed no prognostic value (adjusted hazard ratio, 1.31 [95% CI, 0.47–3.60]; P =0.60) in the severe AS group. Lesions with iFR ≤0.89 and FFR >0.80, in particular, were not associated with a higher rate of deferred lesion failure at 3 years compared with lesions with iFR >0.89 (15.4% versus 17.0%; P =0.58). CONCLUSIONS: This study suggested that FFR appears to be less affected by the presence of severe AS and is more associated with prognosis. iFR may overestimate the functional severity of coronary artery disease without prognostic significance, yet it can be useful for excluding significant stenosis in patients with severe AS.

Compunction: The Present Tense of Physiology to Guide Coronary Revascularization in Severe Aortic Stenosis

“…5 In several studies, however, FFR values in nonrevascularized lesions did not change after TAVR in patients with severe AS. 6 Uncertainty remains as to whether hyperemic (FFR) or nonhyperemic (eg, iFR) physiological indices should be viewed as interchangeable for use in clinical decision-making when considering deferring revascularization for patients with severe AS and moderate severity CAD.…”

“…In this context, in this issue of Circulation: Cardiovascular Interventions, Jo et al 6 report on the predictive value of iFR and FFR in patients with severe AS (n=293) utilizing data from the Interventional Cardiology Research In-Cooperation Society Fractional Flow Reserve Registry. The Interventional Cardiology Research In-Cooperation Society Fractional Flow Reserve Registry includes real-world data from 30 centers collected prospectively between 2009 and 2015 in the Republic of Korea.…”