Post-stenting fractional flow reserve vs coronary angiography for optimization of percutaneous coronary intervention (TARGET-FFR)

Abstract

Aims A fractional flow reserve (FFR) value ≥0.90 after percutaneous coronary intervention (PCI) is associated with a reduced risk of adverse cardiovascular events. TARGET-FFR is an investigator-initiated, single-centre, randomized controlled trial to determine the feasibility and efficacy of a post-PCI FFR-guided optimization strategy vs. standard coronary angiography in achieving final post-PCI FFR values ≥0.90. Methods and results After angiographically guided PCI, patients were randomized 1:1 to receive a physiology-guided incremental optimization strategy (PIOS) or a blinded coronary physiology assessment (control group). The primary outcome was the proportion of patients with a final post-PCI FFR ≥0.90. Final FFR ≤0.80 was a prioritized secondary outcome. A total of 260 patients were randomized (131 to PIOS, 129 to control) and 68.1% of patients had an initial post-PCI FFR <0.90. In the PIOS group, 30.5% underwent further intervention (stent post-dilation and/or additional stenting). There was no significant difference in the primary endpoint of the proportion of patients with final post-PCI FFR ≥0.90 between groups (PIOS minus control 10%, 95% confidence interval −1.84 to 21.91, P = 0.099). The proportion of patients with a final FFR ≤0.80 was significantly reduced when compared with the angiography-guided control group (−11.2%, 95% confidence interval −21.87 to −0.35], P = 0.045). Conclusion Over two-thirds of patients had a physiologically suboptimal result after angiography-guided PCI. An FFR-guided optimization strategy did not significantly increase the proportion of patients with a final FFR ≥0.90, but did reduce the proportion of patients with a final FFR ≤0.80.

Anatomical Assessment vs. Pullback REsting full-cycle rAtio (RFR) Measurement for Evaluation of Focal and Diffuse CoronarY Disease: Rationale and Design of the “READY Register”

“…Another group used the hyperemic pullback to detect native focal lesions within the 20 mm segment or the intra-stent gradient by the definition of an FFR increase of ≥0.05 on the pullback curve. However, in that study among patients undergoing successful PCI, a physiology-guided incremental optimization strategy failed to improve the proportion of patients with an optimal result of FFR ≥ 0.9 ( 19 ).…”

Fractional Flow Reserve: Patient Selection and Perspectives

“… 30–33 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. 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 …”

“… 30–33 Limited evidence is available, whereas the only randomized controlled trial showed no significant difference in outcomes between physiology-guided and FFR-guided assessment of PCI-results. 33 …”

Development, validation, and reproducibility of the pullback pressure gradient (PPG) derived from manual fractional flow reserve pullbacks

“…For the adoption of the PPG, a mandatory requirement is an acceptable test/retest reliability. While the usefulness of an intracoronary pullback maneuver is increasingly recognized, there is no data on the accuracy and reproducibility of PPG derived from manual FFR pullbacks 5 …”

“…While the usefulness of an intracoronary pullback maneuver is increasingly recognized, there is no data on the accuracy and reproducibility of PPG derived from manual FFR pullbacks. 5 The objectives of the current study are (1) to validate the PPG calculation derived from manual FFR pullbacks with motorized FFR pullbacks as a reference, and (2) to assess the intra-and interoperator reproducibility of the PPG derived from manual FFR pullbacks.…”