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Meta-Analysis
. 2024 May 21;13(10):e034401.
doi: 10.1161/JAHA.124.034401. Epub 2024 May 18.

Differential Effect of Aortic Valve Replacement for Severe Aortic Stenosis on Hyperemic and Resting Epicardial Coronary Pressure Indices

Lennert Minten  1   2 , Johan Bennett  1   3 , Hisao Otsuki  2 , Kuniaki Takahashi  2 , William F Fearon  2 , Christophe Dubois  1   3
Affiliations
Meta-Analysis

Differential Effect of Aortic Valve Replacement for Severe Aortic Stenosis on Hyperemic and Resting Epicardial Coronary Pressure Indices

Lennert Minten et al. J Am Heart Assoc. .

Abstract

Background: Coronary pressure indices to assess coronary artery disease are currently underused in patients with aortic stenosis due to many potential physiological effects that might hinder their interpretation. Studies with varying sample sizes have provided us with conflicting results on the effect of transcatheter aortic valve replacement (TAVR) on these indices. The aim of this meta-analysis was to study immediate and long-term effects of TAVR on fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs).

Methods and results: Lesion-specific coronary pressure data were extracted from 6 studies, resulting in 147 lesions for immediate change in FFR analysis and 105 for NHPR analysis. To investigate the long-term changes, 93 lesions for FFR analysis and 68 for NHPR analysis were found. Lesion data were pooled and compared with paired t tests. Immediately after TAVR, FFR decreased significantly (-0.0130±0.0406 SD, P: 0.0002) while NHPR remained stable (0.0003±0.0675, P: 0.9675). Long-term after TAVR, FFR decreased significantly (-0.0230±0.0747, P: 0.0038) while NHPR increased nonsignificantly (0.0166±0.0699, P: 0.0543). When only borderline NHPR lesions were considered, this increase became significant (0.0249±0.0441, P: 0.0015). Sensitivity analysis confirmed our results in borderline lesions.

Conclusions: TAVR resulted in small significant, but opposite, changes in FFR and NHPR. Using the standard cut-offs in patients with severe aortic stenosis, FFR might underestimate the physiological significance of a coronary lesion while NHPRs might overestimate its significance. The described changes only play a clinically relevant role in borderline lesions. Therefore, even in patients with aortic stenosis, an overtly positive or negative physiological assessment can be trusted.

Keywords: RFR; aortic stenosis; aortic valve replacement; coronary artery disease; fractional flow reserve; iFR; nonhyperemic pressure ratios.

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Figures

Figure 1
Figure 1. Short‐term effects in FFR and iFR/RFR.
(A) Immediate change in FFR. (B) Immediate change in iFR/RFR. FFR indicates fractional flow reserve; iFR, instantaneous wave‐free ratio; and RFR, resting flow ratio.
Figure 2
Figure 2. Long‐term effects in FFR and iFR/RFR.
(A) Long‐term change in FFR, (B) long‐term change in iFR/RFR. AVR indicates aortic valve replacement; FFR, fractional flow reserve; iFR, instantaneous wave‐free ratio; and RFR, resting flow ratio.
Figure 3
Figure 3. Forest‐plots of the immediate and long‐term effects of AVR on both hyperemic and resting indices.
(A) Forest plots of immediate change in FFR, (B) Forest‐plots of immediate change in iFR/RFR, (C) Forest plots of long‐term change in FFR, (D) Forest plots of long‐term change in iFR/RFR. df indicates degrees of freedom; FFR, fractional flow reserve; iFR, instantaneous wave‐free ratio; RFR, resting flow ratio; and Q, Cochran's Q test.
Figure 4
Figure 4. Scatterplot and Bland–Altman on long‐term effects FFR and iFR.
(A) Scatterplot of FFR before and after TAVR with the line of equality. (B) Bland–Altman plot of change in FFR. (C) Scatterplot of iFR/RFR before and after TAVR with the line of equality. (D) Bland–Altman plot of change in iFR/RFR. FFR indicates fractional flow reserve; iFR, instantaneous wave‐free ratio; RFR, resting flow ratio; and TAVR, transcatheter aortic valve replacement.
Figure 5
Figure 5. Differential change in FFR and iFR/RFR.
Mean and standard error of the mean are shown in the graph. AVR indicates aortic valve replacement; FFR, fractional flow reserve; iFR, instantaneous wave‐free ratio; pre, before AVR; post, after AVR; and RFR, resting flow ratio.
Figure 6
Figure 6. Correlation between pre‐transcatheter aortic valve replacement FFR and delta FFR.
(A) Scatterplot showing the relation between pre‐AVR FFR and immediate Delta FFR. (B) Scatterplot showing the relation between pre‐AVR FFR and long‐term Delta FFR. The green lines represent the linear regression line and the dotted line shows the 95% confidence interval (CI) of the best‐fit line. Delta: change in the index after AVR. AVR indicates aortic valve replacement; FFR, fractional flow reserve; pre, before AVR; post, after AVR; and RFR, resting flow ratio.
Figure 7
Figure 7. Long‐ and short‐term effects on borderline lesions of FFR and iFR.
(A) Immediate changes in FFR. (B) Immediate changes in iFR/RFR. (C) Long‐term changes in FFR. (D) Long‐term changes in iFR/RFR. FFR indicates fractional flow reserve; iFR, instantaneous wave‐free ratio; and RFR, resting flow ratio.
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