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Revascularization Deferral of Left Main Stenosis Based on iFR
Quick Takes
- Observational data from this small study suggest that iFR can be used to guide treatment for intermediate stenosis of left main (LM) disease.
- Outcomes at 30 months were similar in patients who received revascularization compared to those who were deferred based on iFR cut-off.
- Randomized data are needed to ascertain the role of iFR in managing intermediate LM disease.
Study Questions:
What are the long-term clinical outcomes of patients with left main (LM) disease who were treated based on instantaneous wave-free ratio (iFR) assessment?
Methods:
This multicenter observational study included 314 patients in whom LM stenosis was deferred (n = 163 [51.9%]) or revascularized (n = 151 [48.1%]) according to the iFR cutoff <0.89. The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, and ischemia-driven target lesion revascularization. The secondary endpoints were each individual component of the primary endpoint and also cardiac death.
Results:
At a median follow-up period of 30 months, the primary endpoint occurred in 15 patients (9.2%) in the deferred group and 22 patients (14.6%) in the revascularized group (hazard ratio, 1.45; 95% confidence interval, 0.75-2.81; p = 0.26), indicating no evidence of a significant difference between the two groups. For the secondary endpoints, findings in the iFR-based deferral and revascularization groups were as follows: all-cause death, 3.7% versus 4.6%; cardiac death, 1.2% versus 2.0%; nonfatal myocardial infarction, 2.5% versus 5.3%; and target lesion revascularization, 4.3% versus 5.3% (p > 0.05 for all).
Conclusions:
Deferral of revascularization of LM stenosis on the basis of iFR appears to be safe, with similar long-term outcomes to those in patients in whom LM revascularization was performed according to iFR values.
Perspective:
This observational analysis from the DEFINE-LM registry, which includes patients with stable angina and angiographically intermediate unprotected LM disease who underwent treatment based on iFR assessment, shows that clinical outcomes at approximately 30 months were similar in patients who underwent revascularization compared to those who were managed medically due to nonsignificant iFR. This was a small, mostly male cohort with predominant distal LM disease. Approximately 25% (100 patients out of 446) of patients screened were excluded regardless of the iFR, confounding the results. Randomized analyses are needed to confirm the role of iFR in management of intermediate LM disease.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD, Interventions and Imaging, Angiography, Nuclear Imaging, Chronic Angina
Keywords: Angina, Stable, Cardiology Interventions, Constriction, Pathologic, Coronary Angiography, Death, Sudden, Cardiac, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization
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