Doyeon Hwang, MD1; Bon-Kwon Koo, MD, PhD1; Jinlong Zhang, MD, PhD2; Jiesuck Park, MD1; Seokhun Yang, MD1; Minsang Kim, MD1; Jun Pil Yun, MD1; Joo Myung Lee, MD, MPH, PhD3; Chang-Wook Nam, MD, PhD4; Eun-Seok Shin, MD, PhD5; Joon-Hyung Doh, MD, PhD6; Shao-Liang Chen, MD, PhD7; Tsunekazu Kakuta, MD, PhD8; Gabor G. Toth, MD, PhD9; Zsolt Piroth, MD, PhD10; Nils P. Johnson, MD11; Nico H. J. Pijls, MD, PhD12; Abdul Hakeem, MD13,14; Barry F. Uretsky, MD15,16; Yohei Hokama, MD17; Nobuhiro Tanaka, MD, PhD17; Hong-Seok Lim, MD, PhD18; Tsuyoshi Ito, MD19; Akiko Matsuo, MD20; Lorenzo Azzalini, MD, PhD, MSc21; Massoud A. Leesar, MD22; Tara Neleman, BSc23; Nicolas M. van Mieghem, MD, PhD23; Roberto Diletti, MD, PhD23; Joost Daemen, MD, PhD23; Damien Collison, MB, BCh24; Carlos Collet, MD, PhD25; Bernard De Bruyne, MD, PhD25,26
1Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
2Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
3Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
4Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
5Division of Cardiology, Ulsan Hospital, Ulsan, Korea
6Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
7Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
8Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
9University Heart Centre Graz, Medical University Graz, Austria
10Gottsegen Hungarian Institute of Cardiology, Budapest, Hungary
11Weatherhead PET Center For Preventing and Reversing Atherosclerosis, Division of Cardiology, Department of Medicine, University of Texas Medical School and Memorial Hermann Hospital, Houston
12Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
13Division of Cardiovascular Diseases & Hypertension, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
14National Institute of Cardiovascular Diseases, Karachi, Pakistan
15Central Arkansas VA Health System, Little Rock, Arkansas
16University of Arkansas for Medical Sciences, Little Rock
17Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
18Department of Cardiology, Ajou University School of Medicine, Suwon, Korea
19Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
20Department of Cardiology, Kyoto Second Red Cross Hospital, Kyoto, Japan
21Division of Cardiology, Department of Medicine, University of Washington, Seattle
22Division of Cardiovascular Diseases, University of Alabama, Birmingham
23Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
24West of Scotland Regional Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
25Cardiovascular Center Aalst, Aalst, Belgium
26Department of Cardiology, University of Lausanne, Switzerland
Corresponding Author: Bon-Kwon Koo, MD, PhD
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.