iFR uncovers profound but mostly reversible ischemia in CTOs and helps to optimize PCI results.
coronary
occlusion
physiology
Journal
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
ISSN: 1522-726X
Titre abrégé: Catheter Cardiovasc Interv
Pays: United States
ID NLM: 100884139
Informations de publication
Date de publication:
03 2021
03 2021
Historique:
revised:
19
05
2020
received:
13
01
2020
accepted:
26
05
2020
pubmed:
18
6
2020
medline:
25
9
2021
entrez:
18
6
2020
Statut:
ppublish
Résumé
The study aimed to demonstrate through instant wave-free ratio (iFR) measurements that myocardium distal to a chronic total occlusion (CTO) is ischemic, that ischemia is reversible by PCI, and that iFR assessment after PCI can be used to optimize PCI results. The greatest benefit of revascularization is found in patients with low fractional flow reserve. In patients with CTOs, iFR measurement may be more appropriate to evaluate ischemia as it does not require maximal microvascular vasodilation, which may be hampered by microvascular dysfunction. The iFR was measured in 81 CTO patients, both pre- and post-PCI in 63 patients, and only post-PCI in the following 18 patients. A pressure wire pullback was performed post-PCI if iFR ≤0.89. The first 63 patients all had significant ischemia distal to the CTO with a median iFR of 0.33 [0.22; 0.44], improving significantly post-PCI to a median iFR of 0.93 [0.89;0.96] (p < .001). In the complete cohort, the median iFR post-PCI was 0.93 [0.86;0.96] but still ≤0.89 in 23 patients (30%). 12 of these patients had further PCI optimization because of a residual focal pressure gradient on pullback, after which only two had a final iFR ≤0.89. In CTO patients with an indication for PCI, iFR consistently demonstrated profound myocardial ischemia. Successful PCI immediately relieved ischemia in 70% of patients. In the remaining 30% of cases, a manual iFR pullback proved helpful in guiding further optimization of the PCI result.
Sections du résumé
OBJECTIVES
The study aimed to demonstrate through instant wave-free ratio (iFR) measurements that myocardium distal to a chronic total occlusion (CTO) is ischemic, that ischemia is reversible by PCI, and that iFR assessment after PCI can be used to optimize PCI results.
BACKGROUND
The greatest benefit of revascularization is found in patients with low fractional flow reserve. In patients with CTOs, iFR measurement may be more appropriate to evaluate ischemia as it does not require maximal microvascular vasodilation, which may be hampered by microvascular dysfunction.
METHODS
The iFR was measured in 81 CTO patients, both pre- and post-PCI in 63 patients, and only post-PCI in the following 18 patients. A pressure wire pullback was performed post-PCI if iFR ≤0.89.
RESULTS
The first 63 patients all had significant ischemia distal to the CTO with a median iFR of 0.33 [0.22; 0.44], improving significantly post-PCI to a median iFR of 0.93 [0.89;0.96] (p < .001). In the complete cohort, the median iFR post-PCI was 0.93 [0.86;0.96] but still ≤0.89 in 23 patients (30%). 12 of these patients had further PCI optimization because of a residual focal pressure gradient on pullback, after which only two had a final iFR ≤0.89.
CONCLUSIONS
In CTO patients with an indication for PCI, iFR consistently demonstrated profound myocardial ischemia. Successful PCI immediately relieved ischemia in 70% of patients. In the remaining 30% of cases, a manual iFR pullback proved helpful in guiding further optimization of the PCI result.
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
646-655Commentaires et corrections
Type : CommentIn
Informations de copyright
© 2020 Wiley Periodicals LLC.
Références
Brilakis ES, Mashayekhi K, Tsuchikane E, et al. Guiding principles for chronic total occlusion percutaneous coronary intervention. Circulation. 2019;140:420-433.
Neumann F-J, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2019;40:87-165.
Götberg M, Christiansen EH, Gudmundsdottir IJ, et al. Instantaneous wave-free ratio versus fractional flow reserve to guide PCI. N Engl J Med. 2017;376:1813-1823.
Davies JE, Sen S, Dehbi H-M, et al. Use of the instantaneous wave-free ratio or fractional flow reserve in PCI. N Engl J Med. 2017;376:1814-1834.
Cohen M, Sherman W, Rentrop KP, Gorlin R. Determinants of collateral filling observed during sudden controlled coronary artery occlusion in human subjects. J Am Coll Cardiol. 1989;13:297-303.
Werner GS, Ferrari M, Heinke S, et al. Angiographic assessment of collateral connections in comparison with invasively determined collateral function in chronic coronary occlusions. Circulation. 2003;107:1972-1977.
Morino Y, Abe M, Morimoto T, et al. Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes. JACC Cardiovasc Interv. 2011;4:213-221.
Al-Lamee R, Howard JP, Shun-Shin MJ, et al. Fractional flow reserve and instantaneous wave-free ratio as predictors of the placebo-controlled response to percutaneous coronary intervention in stable single-vessel coronary artery disease. Circulation. 2018;138:1780-1792.
Johnson NP, Tóth GG, Lai D, et al. Prognostic value of fractional flow reserve: linking physiologic severity to clinical outcomes. J Am Coll Cardiol. 2014;64:1641-1654.
Werner GS, Surber R, Ferrari M, Fritzenwanger M, Figulla HR. The functional reserve of collaterals supplying long-term chronic total coronary occlusions in patients without prior myocardial infarction. Eur Heart J. 2006;27:2406-2412.
Sachdeva R, Agrawal M, Flynn SE, Werner GS, Uretsky BF. The myocardium supplied by a chronic total occlusion is a persistently ischemic zone. Catheter Cardiovasc Interv. 2014;83:9-16.
Götberg M, Cook CM, Sen S, Nijjer S, Escaned J, Davies JE. The evolving future of instantaneous wave-free ratio and fractional flow reserve. J Am Coll Cardiol. 2017;70:1379-1402.
Echavarria-Pinto M, Escaned J, Macias E, et al. Disturbed coronary hemodynamics in vessels with intermediate stenoses evaluated with fractional flow reserve: a combined analysis of epicardial and microcirculatory involvement in ischemic heart disease. Circulation. 2013;128:2557-2566.
Werner GS, Ferrari M, Richartz BM, Gastmann O, Figulla HR. Microvascular dysfunction in chronic total coronary occlusions. Circulation. 2001;104:1129-1134.
Werner GS, Emig U, Bahrmann P, Ferrari M, Figulla HR. Recovery of impaired microvascular function in collateral dependent myocardium after recanalisation of a chronic total coronary occlusion. Heart. 2004;90:1303-1309.
Ladwiniec A, Cunnington MS, Rossington J, Thackray S, Alamgir F, Hoye A. Microvascular dysfunction in the immediate aftermath of chronic total coronary occlusion recanalization. Catheter Cardiovasc Interv. 2016;87:1071-1079.
Keulards DCJ, Zimmermann FM, Pijls NHJ, Teeuwen K. Recovery of absolute coronary flow and resistance one week after percutaneous coronary intervention of a chronic totally occluded coronary artery using the novel RayFlow infusion catheter. EuroIntervention. 2018;14:e588-e589.
Stoller M, Seiler C. Pathophysiology of coronary collaterals. Curr Cardiol Rev. 2014;10:38-56.
Sen S, Escaned J, Malik IS, et al. Development and validation of a new adenosine-independent index of stenosis severity from coronary wave-intensity analysis: results of the ADVISE (ADenosine vasodilator independent stenosis evaluation) study. J Am Coll Cardiol. 2012;59:1392-1402.
Obedinskiy AA, Kretov EI, Boukhris M, et al. The IMPACTOR-CTO trial. JACC Cardiovasc Interv. 2018;11:1309-1311.
Werner GS, Martin-Yuste V, Hildick-Smith D, et al. Louvard Y; EUROCTO trial investigators. A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions. Eur Heart J. 2018;39:2484-2493.
Werner GS, Emig U, Mutschke O, Schwarz G, Bahrmann P, Figulla HR. Regression of collateral function after recanalization of chronic Total coronary occlusions: a serial assessment by intracoronary pressure and Doppler recordings. Circulation. 2003;108:2877-2882.
Karamasis GV, Kalogeropoulos AS, Mohdnazri SR, et al. Serial fractional flow reserve measurements post coronary chronic total occlusion percutaneous coronary intervention. Circ Cardiovasc Interv. 2018;11:e006941.
Okuya Y, Saito Y, Takahashi T, Kishi K, Hiasa Y. Novel predictors of late lumen enlargement in distal reference segments after successful recanalization of coronary chronic total occlusion. Catheter Cardiovasc Interv. 2019;94:546-552.
Allahwala UK, Brilakis ES, Byrne J, et al. Applicability and interpretation of coronary physiology in the setting of a chronic Total occlusion. Circ Cardiovasc Interv. 2019;12:e007813.
Tremmel JA, Fearon WF. Is post-percutaneous coronary intervention fractional flow reserve of value in chronic total occlusions? Circ Cardiovasc Interv. 2018;11:e007360.
Hakeem A, Uretsky BF. Role of postintervention fractional flow reserve to improve procedural and clinical outcomes. Circulation. 2019;139:694-706.
Petraco R, van de Hoef TP, Nijjer S, et al. Baseline instantaneous wave-free ratio as a pressure-only estimation of underlying coronary flow reserve: results of the JUSTIFY-CFR study (joined coronary pressure and flow analysis to determine diagnostic characteristics of basal and hyperemic indices of functional lesion severity-coronary flow reserve). Circ Cardiovasc Interv. 2014;7:492-502.
van de Hoef TP, Meuwissen M, Escaned J, et al. Fractional flow reserve as a surrogate for inducible myocardial ischaemia. Nat Rev Cardiol. 2013;10:439-452.
Werner GS, Bahrmann P, Mutschke O, et al. Determinants of target vessel failure in chronic total coronary occlusions after stent implantation. J Am Coll Cardiol. 2003;42:219-225.
Kim HL, Koo BK, Nam CW, et al. Clinical and physiological outcomes of fractional flow reserve-guided percutaneous coronary intervention in patients with serial stenoses within one coronary artery. JACC Cardiovasc Interv. 2012;5:1013-1018.