Immediate post-procedural functional assessment of percutaneous coronary intervention: current evidence and future directions

Abstract

Percutaneous coronary intervention (PCI) guided by coronary physiology provides symptomatic benefit and improves patient outcomes. Nevertheless, over one-fourth of patients still experience recurrent angina or major adverse cardiac events following the index procedure. Coronary angiography, the current workhorse for evaluating PCI efficacy, has limited ability to identify suboptimal PCI results. Accumulating evidence supports the usefulness of immediate post-procedural functional assessment. This review discusses the incidence and possible mechanisms behind a suboptimal physiology immediately after PCI. Furthermore, we summarize the current evidence base supporting the usefulness of immediate post-PCI functional assessment for evaluating PCI effectiveness, guiding PCI optimization, and predicting clinical outcomes. Multiple observational studies and post hoc analyses of datasets from randomized trials demonstrated that higher post-PCI functional results are associated with better clinical outcomes as well as a reduced rate of residual angina and repeat revascularization. As such, post-PCI functional assessment is anticipated to impact patient management, secondary prevention, and resource utilization. Pre-PCI physiological guidance has been shown to improve clinical outcomes and reduce health care costs. Whether similar benefits can be achieved using post-PCI physiological assessment requires evaluation in randomized clinical outcome trials.

Research on the Method of Predicting Fractional Flow Reserve Based on Multiple Independent Risk Factors

“…Many studies showed that the prediction accuracy of FFR using DS was low (≤35%) (Park et al, 2012;Cho et al, 2014;Curzen et al, 2014). Angiography-derived FFR was invasive detection and ignored individual risk factors of patients to predict FFR (Kogame et al, 2020;Suzuki et al, 2020;Ding et al, 2021). With the development of predictive FFR technology, some studies, including case reports, have shown that other risk factors besides DS can also have a significant impact on the prediction of FFR.…”

Fractional Flow Reserve: Patient Selection and Perspectives

“… 30 , 31 , 33 Additionally, improved coronary flow after PCI might show other stenoses in the same coronary artery to be functionally significant as well, especially more distal lesions. 31 …”

“…The cause for suboptimal and impaired post-PCI FFR-values is often located outside the stent. 31 It might be that patients at higher risk for future MACE or target vessel failure are also more likely to have suboptimal post-PCI FFR-values, regardless of any existing causal relationship. Although theoretically likely, it is currently unknown whether additional treatments based on suboptimal or impaired post-PCI FFR lead to better long-term outcomes.…”

“…Although theoretically likely, it is currently unknown whether additional treatments based on suboptimal or impaired post-PCI FFR lead to better long-term outcomes. 31 More randomized controlled trials with long follow-up duration are needed to assess this. Therefore, current evidence does not support FFR-measurements post-PCI.…”

“…30 Optimal post-PCI FFR-values, generally meaning FFR ≥0.90, are associated with better outcomes, such as a lower rate of MACE and angina recurrence. 30,31 With angiographically satisfactory PCI-results, assessment of post-PCI FFR shows suboptimal FFR-values in 30-65% of the patients, and impaired FFR-values (FFR ≤0.80) in up to 20% of the patients. [30][31][32][33] Post-PCI FFR-values are influenced by various factors, such as diffuse CAD without focal lesions, the presence of residual lesions unsuitable for PCI, an initial narrow or short stent trajectory, stent malposition or suboptimal expansion, edge dissection and plaque protrusion.…”