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Interventional Cardiology
treating physiologically significant stenoses. The goal should be FFR can be used to further optimise stent deployment. The FFR Post
‘functionally complete revascularisation’ rather than angiographically Stent Registry found that the FFR post-stenting was a strong
complete revascularisation.
7
independent predictor of six-month MACEs.
9
With a post-stent FFR of
>0.95, the event rate was 4.9%; with an FFR of 0.90–0.95, the event
rate was 6.2%; with an FFR of <0.90, the event rate was 20.3%; and
The next step in optimising the efficacy
with an FFR <0.80, the event rate was 29.5%. The detection of a
persistent pressure gradient across the stented segment may
and safety of percutaneous coronary
highlight under- or mal-deployment of the stent or the presence of
intervention is to move towards a more
persisting significant plaque without the stented segment, indicating
the need for further optimisation.
focused and functional approach, only
treating physiologically significant stenoses.
Finally, we should consider whether functional revascularisation
would improve outcomes after CABG. We know that bypass grafts on
non-functionally significant lesions are more likely to be occluded at
The COURAGE nuclear substudy re-emphasised the lesson from one year than bypass grafts on functionally significantly lesions (21.4
previous myocardial perfusion studies that reducing myocardial versus 8.9%).
10
Despite this, there was no difference in angina class or
ischaemia optimises prognosis.
5
In addition, the PCI of Functionally repeat revascularisation between patients with patent or occluded
Non-significant Stenosis (DEFER) study clearly demonstrated that grafts. This observation was also reported recently in the SYNTAX Le
stenting non-ischaemic stenoses (with a lesion event rate of Man LM angiographic follow-up substudy. Sixteen per cent of bypass
approximately 1% per year) has no benefit over medical therapy, grafts for LM disease were occluded or >50% stenosed at 15 months,
while stenting ischaemia-related stenoses (with a lesion event rate but there was no difference in the 9% MACCE rate between those
of approximately 5% per year) improves symptoms and outcome.
4
with and without graft problems. This reflects the fact that placing a
With an estimated stent thrombosis risk of approximately 3% per graft on a vessel with no functionally significant stenosis has minimal
year in SYNTAX, this clearly illustrates why stenting non-ischaemic potential for an adverse outcome if that graft subsequently occludes.
stenoses provides no benefit and very likely causes harm. The native vessel almost always remains open and, of course, the
Therefore, the current widely used approach of performing PCI on patient did not need the graft in the first place. Placing a stent in a
all angiographically significant stenoses results in offsetting the vessel with no functionally significant stenosis is an entirely different
benefits of appropriate stenting of ischaemic lesions with the matter. If that stent occludes, the patient will almost certainly sustain
unnecessary stent related risk of treating non-ischaemic lesions. an MI having had no potential for benefit from the index procedure
anyway. This is perhaps one of the strongest arguments for FFR
The higher MACCE rate with PCI in SYNTAX was largely driven by guidance during multivessel PCI.
repeat revascularisation. Total stent length is a predictor of repeat
revascularisation and one-third of patients in SYNTAX received Conclusion
more than 100mm of stent. This highlights the need for a more We believe that aiming for functional as opposed to anatomical
focused approach to stenting.
6
In this context, an additional benefit revascularisation will result in added benefit from PCI in CSA, and
of pressure wire guidance is that it offers the option of performing that the significant improvement in PCI outcomes seen with FFR
an FFR pullback in diffusely diseased vessels to identify local guidance will result in FFR-guided PCI achieving non-inferiority
segments with significant pressure gradients, which can be treated to CABG. ■
by focal stent implantation, thus avoiding the need for extensive
stenting. In some cases, a functional approach to revascularisation
Margaret B McEntegart is a Registrar in Interventional Cardiology at the West of
may lead to no PCI being performed or to a decrease in the number
Scotland Regional Heart and Lung Centre in Glasgow. She plans to undertake an
of lesions treated, while in other cases it will lead to performing PCI Interventional Fellowship at Columbia University/New York Presbytarian Hospital in
on angiographically under-estimated stenoses. As demonstrated in
New York in 2010.
FAME, FFR-guided PCI led to a reduction in the mean number of Keith G Oldroyd is Clinical Director of Cardiology at the new West of Scotland
stents and stent length per patient.
7
Both of these parameters were
Regional Heart and Lung Centre based in the Golden Jubilee National Hospital in
Glasgow. He was an investigator in both the SYNTAX and FAME trials. Dr Oldroyd
predictors of repeat revascularisation in SYNTAX, so this more
trained in cardiology in Stoke-on-Trent and Glasgow and in interventional cardiology
focused use of stents should lead to enhanced efficacy and safety in Toronto.
after PCI.
1. Boden WE, O’Rourke RA, Teo KK, et al., Optimal Medical significant Stenosis: 5-Year Follow-Up of the DEFER Study, for Guiding Percutaneous Coronary Intervention, N Engl J
Therapy with or without PCI for Stable Coronary Disease, J Am Coll Cardiol, 2007;49:2105–11. Med, 2009;360:213–24.
N Engl J Med, 2007;356:1503–16. 5. Shaw LJ, Berman DS, Maron DJ, et al., Optimal Medical 8. De Bruyne B, Oral presentation, Coronary Physiology in
2. Serruys PW, Morice MC, Kappetein AP, et al., Percutaneous Therapy With or Without Percutaneous Coronary the Catheterization Laboratory, Sophia Antipolis, April
Coronary Intervention versus Coronary-Artery Bypass Intervention to Reduce Ischemic Burden: Results From the 2009.
Grafting for Severe Coronary Artery Disease, N Engl J Med, Clinical Outcomes Utilizing Revascularization and 9. Pijls NH, Klauss V, Siebert U, et al., Fractional Flow Reserve
2009;360:961–72 and supplementary appendix. Aggressive Drug Evaluation (COURAGE) Trial Nuclear (FFR) Post-Stent Registry Investigators. Coronary pressure
3. Lima RS, Watson DD, Goode AR, et al., Incremental value Substudy, Circulation, 2008;117:1283–91. measurement after stenting predicts adverse events at
of combined perfusion and function over perfusion alone 6. Singh M, Gersh BJ, McClelland RL, et al., Predictive Factors follow-up: a multicenter registry, Circulation, 2002;105:
by gated SPECT myocardial perfusion imaging for for Ischemic Target Vessel Revascularization in the 2950–54.
detection of severe three-vessel coronary artery disease, Prevention of Restenosis With Tranilast and its Outcomes 10. Botman CJ, Schonberger J, Koolen S, et al., Does stenosis
J Am Coll Cardiol, 2003;42:64–70. (PRESTO) Trial, J Am Coll Cardiol, 2005;45:198–203. severity of native vessels influence bypass graft patency?
4. Pijls NHJ, van Schaardenburgh P, Manoharan G, et al., 7. Tonino PA, De Bruyne B, Pijls NH, et al., FAME Study A prospective fractional flow reserve-guided study, Ann
Percutaneous Coronary Intervention of Functionally Non- Investigators. Fractional Flow Reserve Versus Angiography Thorac Surg, 2007;83:2093–7.
66 EUROPEAN CARDIOLOGY
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