Much research has been done on the usefulness of functional testing such as fractional Flow reserve (FFR) after percutaneous coronary intervention (PCI), resulting in the correlation of pathological FFR values with major adverse events at 6 months, as shown by Pijls, et al.
The impact of post PCI FFR on prognosis has not been studied in contemporary cohorts, with the latest generation stents and in complex scenarios, such as multivessel disease, that can be treated both with PCI and coronary artery bypass graft (CABG).
The FAME 3 study compared FFR guided multivessel PCI against CABG (excluding left main patients). This study did not reach non-inferiority for the composite of death, MI, stroke, or repeat revascularization. Despite these results, a subanalysis was conducted to assess the prognostic value of post PCI FFR in these patients.
Primary end point was target vessel failure (TVF) defined as the composite of cardiac death, target vessel MI and repeat revascularization at one year.
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Of the 1,500 FAME 3 patients, 757 were randomized to the FFR branch, and 61% of these pateints received post PCI FFR. As per protocol, there were no changes in therapy after the new measurement. 48% of measurements were from the anterior descending, 24.2% the circumflex and 27.6% the right coronary. Mean FFR value was 0.89 (RIC 0.85), and 9.1% of FFR cases was lower than 0.80.
Multiple regression analysis showed predictors of post PCI FFR were male sex, anterior descending localization, minimal stent diameter and total stent length. Pathological post PCI FFR value were a predictor of target vessel failure (TVF) (HR=0.67, CI 95% 0.48-0.93, for 0.1 unit increase, p=0.165). A ROC curve analysis was done, which determined 0.88 as the best cutoff value to define TVF events.
Upon multivariable analysis, the independent factors of primary end point were kidney disease (HR 5.71, CI 95% 1.91-17.1, P=0.002) and continuously altered FFR values (HR 0.67, CI 0.49-0.91; P=0.03).
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There was another analysis of patients receiving intravascular imaging (11.1% in the FFR branch FFR), which showed no higher rates of cardiac mortality, MI or repeat revascularization compared against patients not getting IVUS/OCT (log-rank P=0.21).
Conclusions
This FAME 3 subanalysis showed altered FFR values after PCI in patients with multivessel disease were a predictor of cardiovascular events, mainly due to target vessel failure at one year, while the use of intravascular imaging did not reduce the studied outcomes.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Reference: Piroth, Zsolt et al. “Prognostic Value of Measuring Fractional Flow Reserve After Percutaneous Coronary Intervention in Patients With Complex Coronary Artery Disease: Insights From the FAME 3 Trial.” Circulation. Cardiovascular interventions vol. 15,11 (2022): 884-891. doi:10.1161/CIRCINTERVENTIONS.122.012542.
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