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. 2023 Aug 21;19(6):464-481.
doi: 10.4244/EIJ-D-23-00194.

Applied coronary physiology for planning and guidance of percutaneous coronary interventions. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the European Society of Cardiology

Javier Escaned  1 , Colin Berry  2 , Bernard De Bruyne  3   4 , Asad Shabbir  1 , Carlos Collet  3 , Joo Myung Lee  5 , Yolande Appelman  6 , Emanuele Barbato  3   7 , Simone Biscaglia  8 , Piotr P Buszman  9   10 , Gianluca Campo  8 , Alaide Chieffo  11 , Róisín Colleran  12   13 , Damien Collison  14 , Justin Davies  15 , Daniele Giacoppo  12   16   17 , Niels R. Holm  18 , Allen Jeremias  19 , Valeria Paradies  20 , Zsolt Piróth  21 , Luís Raposo  22 , Ariel Roguin  23   24 , Tanja Rudolph  25 , Giovanna Sarno  26 , Sayan Sen  15 , Gabor G Toth  27 , Eric Van Belle  28   29 , Frederick M Zimmermann  30 , Dariusz Dudek  31   32 , Giulio Stefanini  33   34 , Giuseppe Tarantini  34   35
Affiliations

Applied coronary physiology for planning and guidance of percutaneous coronary interventions. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the European Society of Cardiology

Javier Escaned et al. EuroIntervention. .

Abstract

The clinical value of fractional flow reserve and non-hyperaemic pressure ratios are well established in determining an indication for percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD). In addition, over the last 5 years we have witnessed a shift towards the use of physiology to enhance procedural planning, assess post-PCI functional results, and guide PCI optimisation. In this regard, clinical studies have reported compelling data supporting the use of longitudinal vessel analysis, obtained with pressure guidewire pullbacks, to better understand how obstructive CAD contributes to myocardial ischaemia, to establish the likelihood of functionally successful PCI, to identify the presence and location of residual flow-limiting stenoses and to predict long-term outcomes. The introduction of new functional coronary angiography tools, which merge angiographic information with fluid dynamic equations to deliver information equivalent to intracoronary pressure measurements, are now available and potentially also applicable to these endeavours. Furthermore, the ability of longitudinal vessel analysis to predict the functional results of stenting has played an integral role in the evolving field of simulated PCI. Nevertheless, it is important to have an awareness of the value and challenges of physiology-guided PCI in specific clinical and anatomical contexts. The main aim of this European Association of Percutaneous Cardiovascular Interventions clinical consensus statement is to offer up-to-date evidence and expert opinion on the use of applied coronary physiology for procedural PCI planning, disease pattern recognition and post-PCI optimisation.

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Conflict of interest statement

J. Escaned reports speaker or advisory board member fees from Abbott, Boston Scientific, Medis, and Philips. C. Berry is employed by the University of Glasgow, which holds consultancy and research agreements for his work with Abbott Vascular, AstraZeneca, Boehringer Ingelheim, Causeway Therapeutics, Coroventis, Genentech, GSK, HeartFlow, Menarini, Neovasc, Novartis, Siemens Healthcare, and Valo Health. B. De Bruyne reports receiving consultancy fees from Boston Scientific and Abbott Vascular; research grants from Coroventis Research, Pie Medical Imaging, CathWorks, Boston Scientific, Siemens, HeartFlow, and Abbott Vascular; and owning equity in Siemens, GE HealthCare, Philips, HeartFlow, Edwards Lifesciences, Bayer, Sanofi, and Celyad. C. Collet reports receiving research grants from Biosensor, Coroventis Research, Medis Medical Imaging, Pie Medical Imaging, CathWorks, Boston Scientific, Siemens, HeartFlow, and Abbott Vascular; and consultancy fees from HeartFlow, OpSens, Abbott Vascular, and Philips/Volcano. J.M. Lee received institutional research grants from Abbott Vascular, Boston Scientific, Terumo Corporation, Philips/Volcano, Medis Medical Imaging, and Zoll Medical. Y Appelman received speaker fees from Abbott Vascular. Si. Biscaglia received unrestricted research grants and speaker's fees from SMT, Medis, Abbott, and Insight Lifetech. P.P. Buszman is employed by the American Heart of Poland, which holds research agreements with Meril Life, and received speakers’ honoraria from Novartis. G. Campo received institutional research grants from Medis, GE HealthCare, Siemens Healthcare, Abbott Vascular, Sahajanand Medical Technologies, and Insight Lifetech. D. Collison has received consultancy and speaker fees from Abbott. A. Jeremias reports consultancy fees from Philips/Volcano, Abbott Vascular, Boston Scientific, and ACIST Medical Systems. Z. Piróth has received speakers’ fees from Abbott, Boston Scientific, and Opsens. L. Raposo has received honoraria and research grants from Philips/Volcano, St. Jude Medical (now Abbott Vascular) and HeartFlow, as well as consultancy fees from Boston Scientific. T. Rudolph received speaker honoraria from Abbott Vascular, Philips, Neovasc, AstraZeneca, Bayer, Pfizer, Philips/Volcano, Zoll Medical, and RainMed. G. Sarno has received a research grant from Boston Scientific (to the institution); and personal fees from Abbott Vascular, Boston Scientific, and Pfizer/BMS. D. Dudek reports participation in company-sponsored speaker’s bureaus for Abbott, Boston Scientific, Bracco, Philips, and Siemens Healthcare; and unrestricted grants from Abbott, Boston Scientific, Bracco, Philips, and Siemens Healthcare. The other authors have no conflicts of interest to declare.

Figures

Central illustration
Central illustration. Applications of physiology in planning and guiding PCI procedures.
iFR: instantaneous wave-free ratio; PCI: percutaneous coronary intervention; PPG: pullback pressure gradient; QFR: quantitative flow ratio
Figure 1
Figure 1. Patterns of flow-limiting disease identified in longitudinal vessel analysis before and after PCI.
PCI: percutaneous coronary intervention; QFR: quantitative flow ratio
Figure 2
Figure 2. Approaches for simulating functional PCI results based on longitudinal vessel analysis.
3D-QCA: three-dimensional quantitative coronary angiography; CFD: computational fluid dynamics; CTCA: computed tomography coronary angiography; FFR: fractional flow reserve; FFRCT: computed tomography-derived FFR; iFR: instantaneous wave-free ratio; LAD: left anterior descending artery; NHPR: non-hyperaemic pressure ratio; PCI: percutaneous coronary intervention; QFR: quantitative flow ratio; RCA: right coronary artery
Figure 3
Figure 3. Simulation of functional PCI results using coregistration of physiology and the coronary angiogram.
A) Angiography of the left circumflex artery interrogated with longitudinal physiological assessment. B) The presence of flow-limiting disease in the vessel is demonstrated by a distal iFR of 0.57. Longitudinal vessel analysis revealed a focal disease phenotype. iFR coregistration with angiography allows accurate localisation of flow-limiting disease in the coronary anatomy. The PCI simulation suggests adequate functional results of the intervention, with a predicted post-PCI iFR of 0.94. C) Final co-registered angiographic-physiology result shown, with final iFR of 0.90. iFR: instantaneous wave-free ratio; PCI: percutaneous coronary intervention
Figure 4
Figure 4. Mechanisms of suboptimal post-PCI physiological results.
PCI: percutaneous coronary intervention; QFR: quantitative flow ratio
Figure 5
Figure 5. Proposed algorithm for pre-PCI physiology assessment and planning of PCI based on physiological interrogation.
CABG: coronary artery bypass graft; FCA: functional coronary angiography; FFR: fractional flow reserve; NHPR: non-hyperaemic pressure ratio; PCI: percutaneous coronary intervention
Figure 6
Figure 6. Proposed algorithm for postprocedural assessment and optimisation of functional PCI results based on physiological interrogation.
PCI: percutaneous coronary intervention
See this image and copyright information in PMC

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