87 year old male with known aortic stenosis and moderate pulmonary hypertension presented on March 19, 2018 with NSTEMI (TnI of 2.0) and acute diastolic heart failure. A Cardiac Cath on March 20, 2018 revealed 3 V CAD: 80% calcified proximal LAD/Diagonal bifurcation (Medina 1,1,1), 90% thrombotic distal LCx, 70% proximal RCA with normal LV function and SYNTAX Score of 24. Patient improved rapidly on medical therapy and a follow-up echo revealed severe AS with PG/MG/AVA/PV: 110/82/0.3/5.2. Patient is now planned for iFR guided multi-vessel PCI of LAD/D1 bifurcation, distal circumflex and BAV as prelude to planned TAVR procedure after one month.
Moderator: Sameer Mehta, MD
Q In what situations with simultaneous severe AS and CAD, will you proceed with PCI first?
A. If both AS and CAD are significant enough, then our practice is to do BAV first and then do PCI even it involves LM. This approach will allow pts to tolerate PCI better after aortic valve intervention. Also if appropriate for TAVR, then TAVR is scheduled after 30-days letting stent to endothelize partially before the TAVR procedure.
Q Any special considerations in such situations that will also require Impella? Precautions?
A. Few of these combined AS and CAD cases have complex coronary lesions and low EF (<30%). In these cases usual recommendation will be to do BAV first, then insert Impella and then proceed with complex PCI which will be safer with Impella assist (concept of Protected PCI).
Q Are you actively moving from FFR to iFR?
A. We are waiting some more iFR data to accumulate from US centers before making the switch from FFR. Currently we use FFR in 80% and iFR in 20% (iFR in pts with AS, asthma, bradycardia, and cases with multiple lesions in single vessel).
Q What changes are required for iFR to gain greater adoption?
A. I think longer than 1 year F/U data and trials done in USA comparing iFR with FFR, will change the practice in favor of iFR as the preferred physiological testing.
Q Should we expect guidelines to recommend both FFR and iFR?
A. YES actually recent updated AUC guidelines of March 2017, have placed both iFR and FFR in the same category but iFR is still not the part of ACC-NCDR data element. Now we were told that as of last month, iFR (in addition to FFR) has also been incorporated in the NCDR data element reporting.
Q In which situations with complex CAD, do you feel iFR to be particularly advantageous?
A. Patients with multiple lesions in a single vessel is ideal for iFR interrogation as iFR can accurately point out to the lesions which are hemodynamically significant on one pullback.
Q How do FFR and iFR compare in cost?
A. In the RCT, iFR guided strategy was about $500 cheaper than FFR guided due to the cost of IV adenosine and IV pump & tubing. The cost of the iFR and FFR wires are the same; about $700 each.
Q And reimbursement?
A. Reimbursement is similar for both FFR and iFR procedures for the physician. The procedural hospital reimbursement is separately added for the Ambulatory PCI but is the part of DRG of PCI once done as In-patient.
Q The recent publication from Bhat et al notwithstanding, what is your perspective on top ranked hospitals versus mezzanine centers and PCI outcomes?
A. Recent report stating no significant differences in PCI outcomes of Top 50 ranked Heart hospitals versus non-ranked hospitals has a major flaw of different patient populations in these two groups (obviously more complex and sicker pts in the top ranked hospitals). Hence the final conclusions need to be taken cautiously; that there is no difference between 2 hospital groups. It was really surprising to see higher inappropriate PCI by the AUC criteria in the Top ranked hospital and it may just pertain to the acuity and complexity of the cases at the Top ranked hospitals.
Q Also, between academic and non-academic centers?
A. The report did not stratify pts according to academic or non-academic centers and report only included Top ranked and not ranked hospitals who are doing >400 PCIs per year.
What are the pitfalls in using FFR/iFR in patients with concomitant severe aortic stenosis?