Physiological Insight Into the Discordance Between Non-Hyperemic Pressure Ratio-Guided and Fractional Flow Reserve-Guided Revascularization

IF 1.9 3区医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS

Catheterization and Cardiovascular Interventions Pub Date : 2025-03-31 DOI:10.1002/ccd.31517

Masahiro Hada, Masahiro Hoshino, Eisuke Usui, Yoshihisa Kanaji, Tatsuhiro Nagamine, Kai Nogami, Hiroki Ueno, Mirei Setoguchi, Kodai Sayama, Takahiro Watanabe, Hikaru Shimosato, Takashi Mineo, Yoshihiro Hanyu, Toru Misawa, Masao Yamaguchi, Tomoyo Sugiyama, Tadashi Murai, Taishi Yonetsu, Tetsuo Sasano, Tsunekazu Kakuta

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Abstract

Background

Five-year outcomes from the two major trials indicated higher mortality with instantaneous wave-free ratio (iFR)-guided revascularization compared to fractional flow reserve (FFR)-guidance, despite similar outcomes in deferred patients. This discrepancy likely comes from discordant revascularization decisions.

To precisely assess the characteristic differences, including microvascular function, between resting full-cycle ratio (RFR)-guided and FFR-guided strategies, we performed virtual randomization, specially targeting discordant lesions, to simulate RFR-guided and FFR-guided groups. Microvascular resistance reserve (MRR) was utilized to assess microvascular function independently of epicardial stenosis.

Methods and Results

We retrospectively analyzed 837 intermediate lesions in 620 patients, from our institutional physiological database, with a median follow-up of 6.9 years. Using thresholds of FFR ≤ 0.80 and RFR ≤ 0.89, lesions were categorized into concordant-high (n = 280), high-RFR/low-FFR (n = 105), low-RFR/high-FFR (n = 93), and concordant-low (n = 359) groups. Discordant and concordant lesions were virtually randomized into RFR- and FFR-guided groups. Patients were followed for 6.9 (4.6–9.1) years. Age, sex, percentage diameter stenosis, and MRR differed significantly between the RFR/FFR discordant groups. After randomization, no significant characteristic-based differences were observed between both concordant and discordant virtual RFR/FFR-guided groups. Compared with the patients with FFR-guided would-be-revascularized lesions, those with RFR-guided would-be-revascularized lesions with discordant RFR/FFR results had significantly lower MRR, higher age, and tended to be female. MRR significantly predicted all-cause death in the total and would-be-revascularized cohorts, but not in deferred patients.

Conclusions

In discordant lesions of virtually randomized RFR- and FFR-guided strategies, RFR-guided would-be-revascularized lesions were associated with impaired microvascular function (low MRR) compared with FFR-guided would-be-revascularized lesions, which may underlie the reported increased mortality in iFR-guided revascularized patients.

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非充血压力比引导和分数血流储备引导的血运重建之间不一致的生理学见解。

背景：两项主要试验的5年结果表明，瞬时无波比（iFR）引导下的血运重建术与分数血流储备（FFR）指导下的血运重建术相比死亡率更高，尽管延迟患者的结果相似。这种差异可能来自于不一致的血运重建决定。为了准确评估静息全周期比（RFR）引导和ffr引导策略之间的特征差异，包括微血管功能，我们进行了虚拟随机化，特别针对不一致的病变，模拟RFR引导和ffr引导组。微血管阻力储备（MRR）用于评估独立于心外膜狭窄的微血管功能。方法和结果：我们回顾性分析了620例患者的837个中间病变，这些患者来自我们的机构生理数据库，中位随访时间为6.9年。以FFR≤0.80和RFR≤0.89为阈值，将病变分为高一致性组（n = 280）、高RFR/低FFR组（n = 105）、低RFR/高FFR组（n = 93）和低一致性组（n = 359）。不一致和一致病变实际上随机分为RFR和ffr引导组。随访时间为6.9（4.6-9.1）年。年龄、性别、管径狭窄百分比和MRR在RFR/FFR不一致组之间存在显著差异。随机化后，在虚拟RFR/ ffr引导组和不协调组之间没有观察到显著的基于特征的差异。与FFR引导下的血管重建病变患者相比，RFR/FFR结果不一致的RFR引导下的血管重建病变患者的MRR明显较低，年龄较大，且倾向于女性。MRR显著预测全因死亡在完全和可能重建血管的队列中，但在延迟患者中没有。结论：在几乎随机化的RFR和ffr引导策略的不一致病变中，与ffr引导的血管重建病变相比，RFR引导的血管重建病变与微血管功能受损（低MRR）相关，这可能是ifr引导的血管重建患者死亡率增加的原因。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Catheterization and Cardiovascular Interventions 医学-心血管系统

CiteScore

5.40

自引率

8.70%

发文量

419

审稿时长

2 months

期刊介绍： Catheterization and Cardiovascular Interventions is an international journal covering the broad field of cardiovascular diseases. Subject material includes basic and clinical information that is derived from or related to invasive and interventional coronary or peripheral vascular techniques. The journal focuses on material that will be of immediate practical value to physicians providing patient care in the clinical laboratory setting. To accomplish this, the journal publishes Preliminary Reports and Work In Progress articles that complement the traditional Original Studies, Case Reports, and Comprehensive Reviews. Perspective and insight concerning controversial subjects and evolving technologies are provided regularly through Editorial Commentaries furnished by members of the Editorial Board and other experts. Articles are subject to double-blind peer review and complete editorial evaluation prior to any decision regarding acceptability.