Objectives: The aim of this study was to investigate the clinical outcomes of patients deferred from coronary revascularization on the basis of instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) measurements in stable angina pectoris (SAP) and acute coronary syndromes (ACS). Background: Assessment of coronary stenosis severity with pressure guidewires is recommended to determine the need for myocardial revascularization. Methods: The safety of deferral of coronary revascularization in the pooled per-protocol population (n = 4,486) of the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) and iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trials was investigated. Patients were stratified according to revascularization decision making on the basis of iFR or FFR and to clinical presentation (SAP or ACS). The primary endpoint was major adverse cardiac events (MACE), defined as the composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization at 1 year. Results: Coronary revascularization was deferred in 2,130 patients. Deferral was performed in 1,117 patients (50%) in the iFR group and 1,013 patients (45%) in the FFR group (p < 0.01). At 1 year, the MACE rate in the deferred population was similar between the iFR and FFR groups (4.12% vs. 4.05%; fully adjusted hazard ratio: 1.13; 95% confidence interval: 0.72 to 1.79; p = 0.60). A clinical presentation with ACS was associated with a higher MACE rate compared with SAP in deferred patients (5.91% vs. 3.64% in ACS and SAP, respectively; fully adjusted hazard ratio: 0.61 in favor of SAP; 95% confidence interval: 0.38 to 0.99; p = 0.04). Conclusions: Overall, deferral of revascularization is equally safe with both iFR and FFR, with a low MACE rate of about 4%. Lesions were more frequently deferred when iFR was used to assess physiological significance. In deferred patients presenting with ACS, the event rate was significantly increased compared with SAP at 1 year.

/pdf/safety-of-the-deferral-of-coronary-revascularization-on-the-15a9ahzq6t.pdf

Safety of the Deferral of Coronary Revascularization on the Basis of Instantaneous Wave-Free Ratio and Fractional Flow Reserve Measurements in Stable Coronary Artery Disease and Acute Coronary Syndromes.

Fractional flow reserve (FFR) is increasingly used to guide myocardial revascularisation. However, supporting evidence regarding its use originates from studies that have enrolled mainly patients with stable angina, while patients with acute coronary syndromes (ACS) have not been included. Notably, multifactorial microvascular dysfunction and an increased sympathetic tone in patients with ACS may lead to blunted response to adenosine and false-negative results of FFR due to submaximal hyperaemia. This may raise the possibility of deferring treatment of stenosis that instead would have needed dilatation, thus leaving a residual risk of preventable cardiac events. In this literature review, we aim at summarising laboratory and clinical investigations concerning the use of FFR in culprit and non-culprit lesions in ACS. Furthermore, we will report recent data on instantaneous wave-free ratio, an adenosine-free index of functional stenosis severity, in stable coronary artery disease and in patients with ACS.

https://openheart.bmj.com/content/openhrt/4/2/e000431.full.pdf

Evaluation of intermediate coronary stenoses in acute coronary syndromes using pressure guidewire.

Objective:To define the in-hospital and 6-month post-discharge resource use, following Transcatheter Aortic Valve Implantation (TAVI) and conventional Aortic Valve Replacement (AVR) surgery within a single UK hospital.Methods:A local service evaluation of patients undergoing TAVI or AVR between January 2011 and May 2012 captured data until 6-months post-procedure, collected from hospital records and via a General Practitioner questionnaire. The main end-points were mortality, time in ITU/HDU, hospital length of stay (LoS), discharge destination, re-admission, and post-discharge primary/secondary care resource use. Sub-group analyses were performed for AVR patients aged ≥80 (AVR ≥ 80) and with EuroSCORE of ≥10 (AVR ES ≥ 10) to allow more direct comparison with ‘TAVI type’ patients.Results:Results are given as means (standard deviation) for TAVI (n = 51), AVR (n = 188), AVR ≥ 80 (n = 48), and AVR ES ≥ 10 (n = 47), respectively, unless otherwise stated. Age in years was 83.0 (8.1), 71.2 (13.1), 84.1 ...

Comparing post-operative resource consumption following transcatheter aortic valve implantation (TAVI) and conventional aortic valve replacement in the UK

As transcatheter aortic valve implantation (TAVI) becomes a standardised procedure with reproducible and excellent periprocedural, early and medium-term outcomes, it is opportune to question whether the time has come to simplify the TAVI procedure. In some centres, a minimalist approach to TAVI is already the standard of care. In this perspective, we share our experience and opinions on how and when we can simplify the TAVI procedure.

Is it time to simplify the TAVI procedure? "Make it simple but not too simple".

Functional disorders in non-culprit coronary arteries and their implications in patients with acute myocardial infarction.

Stability of Non Culprit Vessel Fractional Flow Reserve in Patients With St-Segment Elevation Myocardial Infarction

A Multidisciplinary, Multimodality But Minimalist (3M) Approach to Transfemoral Transcatheter Aortic Valve Replacement Facilitates Safe Next Day Discharge in High Risk Patients

https://www.onlinecjc.ca/article/S0828-282X(14)00657-6/pdf

A multidisciplinary, multimodality, but minimalist (3m) approach to transfemoral transcatheter aortic valve replacement facilitates safe next day discharge home in high risk patients: 1 year follow up

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Stability of Non Culprit Vessel Fractional Flow Reserve in Patients With St-Segment Elevation Myocardial Infarction

A Multidisciplinary, Multimodality But Minimalist (3M) Approach to Transfemoral Transcatheter Aortic Valve Replacement Facilitates Safe Next Day Discharge in High Risk Patients

A multidisciplinary, multimodality, but minimalist (3m) approach to transfemoral transcatheter aortic valve replacement facilitates safe next day discharge home in high risk patients: 1 year follow up