Prognostic Implications of Prestent Pullback Pressure Gradient and Poststent Quantitative Flow Ratio in Patients Undergoing Percutaneous Coronary Intervention

Abstract

Background Coronary diffuse disease associates with poor outcomes, but little is known about its role after percutaneous coronary intervention (PCI). We aimed to investigate the prognostic implication of pre‐PCI focal or diffuse disease patterns combined with post‐PCI quantitative flow ratio (QFR). Methods and Results Pre‐PCI QFR derived pullback pressure gradient (PPG) (QFR‐PPG) was measured to assess physiological disease patterns for 1685 included vessels; the vessels were classified according to dichotomous pre‐PCI QFR‐PPG and post‐PCI QFR. Vessel‐oriented composite outcome, a composite of vessel‐related ischemia‐driven revascularization, vessel‐related myocardial infarction, or cardiac death at 2 years was compared among these groups. Vessels with low pre‐PCI PPG (3.9% versus 2.0%, hazard ratio [HR], 1.93; 95% CI, 1.08–3.44; P =0.02) or low post‐PCI QFR (9.8% versus 2.7%, HR, 3.78; 95% CI, 1.61–8.87; P =0.001) demonstrated higher vessel‐oriented composite outcome risk after stent implantation. Of note, despite high post‐PCI QFR achieved, vessels with low pre‐PCI QFR‐PPG presented higher risk of vessel‐oriented composite outcome than those with high pre‐PCI QFR‐PPG (3.7% versus 1.8%, HR, 2.03; 95% CI, 1.09–3.76; P =0.03) and pre‐PCI QFR‐PPG demonstrated direct prognostic effect not mediated by post‐PCI QFR. Integration of groups classified by pre‐PCI QFR‐PPG and post‐PCI QFR showed significantly higher discriminant and reclassification abilities than clinical factors (C‐index 0.77 versus 0.72, P =0.03; integrated discrimination improvement 0.93%, P =0.04; net reclassification index 0.33, P =0.02). Conclusions Prognostic value of pre‐PCI focal or diffuse disease patterns assessed by QFR‐PPG index was retained even after successful PCI, which is mostly explained by its direct effect that was not mediated by post‐PCI QFR. Integration of both pre‐PCI and post‐PCI physiological information can provide better risk stratification in vessels with stent implantation. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT05104580.

Pre‐stenting angiography‐FFR based physiological map provides virtual intervention and predicts physiological and clinical outcomes

“…Angio‐FFR permits not only the measurement at the distal part of the vessel, but also the virtual pullback of the entire vessel. Feasibility of angio‐FFR based pullback quantification in assessing physiological distribution and local severity of coronary atherosclerosis has been confirmed in previous studies 11,12,19 . In the present analysis, with the angio‐FFR from another vendor, pullback pressure gradient was also quantified successfully in all included vessels.…”

“…Feasibility of angio-FFR based pullback quantification in assessing physiological distribution and local severity of coronary atherosclerosis has been confirmed in previous studies. 11,12,19 In the present analysis, with the angio-FFR from another vendor, pullback pressure gradient was also quantified successfully in all included vessels. In the prospective iFR GRADIENT Registry, 20 the authors revealed that iFR pullback predicted the physiological outcome of PCI with a high degree of accuracy.…”

Prognostic Value of Post-PCI Angiography-Derived Fractional Flow Reserve: A Systematic Review and Meta-Analysis of Cohort Studies

“…This difference could be attributed firstly to the inclusion of neutral FFR studies in the meta-analysis by Griffioen et al [ 38 ]. Secondly, in contrast to Griffioen et al we included two large QFR studies that reported significantly higher risks of adverse cardiovascular events in patients with lower post-PCI QFR values [ 18 , 19 ]. Accordingly, a recent meta-analysis of post-PCI invasive FFR studies reported similar results, supporting the prognostic value of post-PCI physiology [ 39 , 40 ].…”

“…The immediate post-stenting measurement of the FFR could aid in optimizing revascularization results and potentially improve outcomes as it is well established that suboptimal PCI is an independent predictor of major cardiac adverse events [ 13 , 14 , 15 ]. Recent studies demonstrated the role of the post-PCI angiography-derived FFR as a predictor of a vessel- or patient-oriented outcomes in patients with stable CAD, acute coronary syndromes, or in-stent restenosis [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ]. The primary objective of this meta-analysis was to evaluate whether the post-PCI angiography-derived FFR predicts coronary adverse events in CAD patients undergoing PCI.…”

Practical Application of Coronary Physiologic Assessment

“…The point-by-point functional distribution provided by the virtual computational pressure pullback along the vessel length can inform the functional pattern of coronary artery disease either qualitatively (eg, step-ups, progressive decline, or mixed) or quantitatively and further guide and optimize PCI ( Supplemental Figure 2 ). 145 , 146 , 147 …”