Fractional Flow Reserve Versus Angiography-Guided Revascularisation in Patients With Severe Aortic Stenosis: A Systematic Review.

BACKGROUND

Aortic stenosis (AS) and coronary artery disease usually coexist in older adults. Although fractional flow reserve (FFR) is the gold standard for demonstrating functionally significant coronary artery stenoses, its efficacy in patients with severe AS awaiting transcatheter aortic valve implantation is unclear. This systematic review assesses the clinical outcomes between FFR- and angiography-guided coronary revascularisation in patients with severe AS.

METHOD: This review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Ovid MEDLINE, Web of Science, and Cochrane databases were searched until 12 March 2024. Eligible studies included randomised controlled trials or observational studies including patients with severe AS with concurrent coronary disease comparing FFR- with angiography-guided percutaneous coronary intervention. Primary outcomes were all-cause mortality and myocardial infarction. Secondary outcomes were composite major adverse cardiovascular events.

RESULTS

Five retrospective cohort studies were identified, including 1,927 patients. The average follow-up was 34.7 months. FFR-guided cohorts exhibited higher incidence rates for all-cause mortality (17.4% vs 15.6%), myocardial infarction (4.4% vs 3.3%), and major adverse cardiovascular events (21.8% vs 18.5%) than the angiography-guided cohorts. A total of 32.8% the angiography-guided cohort and 33.1% from the FFR-guided cohort underwent percutaneous coronary intervention. Due to insufficient power and inconsistency of the available data (including heterogenous patient selection criteria, differences in procedural protocols, anatomical distribution of stented lesions, non-uniform reporting of measured outcomes), a meta-analysis for the primary and secondary outcomes was not conducted. The methodological quality of the included studies was found to be of fair quality according to the Newcastle-Ottawa checklist.

CONCLUSIONS

Despite the recognised usefulness of FFR in the assessment of coronary artery disease, its clinical efficacy in patients with severe AS undergoing transcatheter aortic valve implantation remains uncertain amidst inconclusive observational data. Large-scale randomised controlled trials are required.