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Meta-Analysis
. 2022 Sep 1;5(9):e2232842.
doi: 10.1001/jamanetworkopen.2022.32842.

Prognostic Implications of Fractional Flow Reserve After Coronary Stenting: A Systematic Review and Meta-analysis

Doyeon Hwang  1 , Bon-Kwon Koo  1 , Jinlong Zhang  2 , Jiesuck Park  1 , Seokhun Yang  1 , Minsang Kim  1 , Jun Pil Yun  1 , Joo Myung Lee  3 , Chang-Wook Nam  4 , Eun-Seok Shin  5 , Joon-Hyung Doh  6 , Shao-Liang Chen  7 , Tsunekazu Kakuta  8 , Gabor G Toth  9 , Zsolt Piroth  10 , Nils P Johnson  11 , Nico H J Pijls  12 , Abdul Hakeem  13   14 , Barry F Uretsky  15   16 , Yohei Hokama  17 , Nobuhiro Tanaka  17 , Hong-Seok Lim  18 , Tsuyoshi Ito  19 , Akiko Matsuo  20 , Lorenzo Azzalini  21 , Massoud A Leesar  22 , Tara Neleman  23 , Nicolas M van Mieghem  23 , Roberto Diletti  23 , Joost Daemen  23 , Damien Collison  24 , Carlos Collet  25 , Bernard De Bruyne  25   26
Affiliations
Meta-Analysis

Prognostic Implications of Fractional Flow Reserve After Coronary Stenting: A Systematic Review and Meta-analysis

Doyeon Hwang et al. JAMA Netw Open. .

Abstract

Importance: Fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) is generally considered to reflect residual disease. Yet the clinical relevance of post-PCI FFR after drug-eluting stent (DES) implantation remains unclear.

Objective: To evaluate the clinical relevance of post-PCI FFR measurement after DES implantation.

Data sources: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant published articles from inception to June 18, 2022.

Study selection: Published articles that reported post-PCI FFR after DES implantation and its association with clinical outcomes were included.

Data extraction and synthesis: Patient-level data were collected from the corresponding authors of 17 cohorts using a standardized spreadsheet. Meta-estimates for primary and secondary outcomes were analyzed per patient and using mixed-effects Cox proportional hazard regression with registry identifiers included as a random effect. All processes followed the Preferred Reporting Items for Systematic Review and Meta-analysis of Individual Participant Data.

Main outcomes and measures: The primary outcome was target vessel failure (TVF) at 2 years, a composite of cardiac death, target vessel myocardial infarction (TVMI), and target vessel revascularization (TVR). The secondary outcome was a composite of cardiac death or TVMI at 2 years.

Results: Of 2268 articles identified, 29 studies met selection criteria. Of these, 28 articles from 17 cohorts provided data, including a total of 5277 patients with 5869 vessels who underwent FFR measurement after DES implantation. Mean (SD) age was 64.4 (10.1) years and 4141 patients (78.5%) were men. Median (IQR) post-PCI FFR was 0.89 (0.84-0.94) and 690 vessels (11.8%) had a post-PCI FFR of 0.80 or below. The cumulative incidence of TVF was 340 patients (7.2%), with cardiac death or TVMI occurring in 111 patients (2.4%) at 2 years. Lower post-PCI FFR significantly increased the risk of TVF (adjusted hazard ratio [HR] per 0.01 FFR decrease, 1.04; 95% CI, 1.02-1.05; P < .001). The risk of cardiac death or MI also increased inversely with post-PCI FFR (adjusted HR, 1.03; 95% CI, 1.00-1.07, P = .049). These associations were consistent regardless of age, sex, the presence of hypertension or diabetes, and clinical diagnosis.

Conclusions and relevance: Reduced FFR after DES implantation was common and associated with the risks of TVF and of cardiac death or TVMI. These results indicate the prognostic value of post-PCI physiologic assessment after DES implantation.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Koo reported receiving grants from Abbott Vascular and Philips Volcano during the conduct of the study. Dr Johnson reported receiving grants from Philips Volcano, St Jude Medical, Abiomed, and CoreAalst during the conduct of the study; he reported receiving licensing fees from Boston Scientific Institutional and the University of Texas outside the submitted work; in addition, Dr Johnson reported multiple patents pending with University of Texas; he reported receiving honoraria for talks hosted by academic institutions and industry outside the submitted work, which he donates to his institution. Dr Pijls reported receiving an institutional research grant from Abbott; he reported holding minor equity in Philips, Heartflow, GE, and ASML and has patents pending in the field of aortic valve physiology and the coronary microcirculation. Dr Tanaka reported receiving personal fees from Abbott Vascular Japan and personal fees from Daiichi-Sankyo Co Ltd during the conduct of the study. Dr Azzalini reported receiving personal fees from Abiomed, GE Healthcare, Abbott Vascular, Teleflex, Philips, Asahi Intecc, and Cardiovascular Systems, Inc outside the submitted work. Dr Neleman reported receiving grants from Acist Medical outside the submitted work. Dr van Mieghem reported receiving grants from Abbott, Boston Scientific, Biotronik, Medtronic, Daiichi Sankyo, Abiomed, and PulseCath BV outside the submitted work. Dr Daemen reported receiving grants from Astra Zeneca, Abbott Vascular, Boston Scientific, ACIST Medical, Medtronic, Microport, Pie Medical, and ReCor Medical and consultancy or speaker fees from Abiomed, ACIST Medical, Boston Scientific, PulseCath, Pie Medical, Siemens Health Care, and Medtronic outside the submitted work. Dr Collison reported receiving personal fees from Abbott outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Distribution of Post-PCI FFR
FFR indicates fractional flow reserve; PCI, percutaneous coronary intervention.
Figure 2.
Figure 2.. Event Rates According to Post-PCI FFR
FFR indicates fractional flow reserve; PCI, percutaneous coronary intervention; TVF, target vessel failure; TVMI, target vessel myocardial infarction.
Figure 3.
Figure 3.. Association Between Post-PCI FFR and Clinical Events
The estimated risk of clinical events was calculated from multivariable-adjusted, mixed-effects Cox proportional hazards regression, accounting for age, sex, hypertension, diabetes mellitus, hypercholesterolemia, and clinical diagnosis. Blue dotted lines represent optimal cutoff values for TVF (0.86) and cardiac death or TVMI (0.80) at 2 years. FFR indicates fractional flow reserve; PCI, percutaneous coronary intervention; TVF, target vessel failure; TVMI, target vessel myocardial infarction.
Figure 4.
Figure 4.. Clinical Events According to Post-PCI FFR Cutoff
FFR indicates fractional flow reserve; HR, hazard ratio; PCI, percutaneous coronary intervention; TVF, target vessel failure; TVMI, target vessel myocardial infarction.
See this image and copyright information in PMC

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