Fractional Flow Reserve to Guide Revascularization in Patients With Coronary Artery Disease Undergoing TAVR.

Summary

In NOTION-3, patients with FFR ≤0.80 randomized to conservative therapy before TAVR had significantly higher 3-year rates of cardiovascular death, MI, or urgent revascularization compared with PCI or deferral of FFR >0.80 lesions. Lesion-level revascularization occurred far more often when FFR ≤0.80 segments were left untreated. These results support using an FFR threshold of 0.80 to guide revascularization in the TAVR pathway.

Key Findings

• At 36 months, the composite of CV death, MI, or urgent revascularization was 21.6% (FFR ≤0.80 conservative) vs 11.5% (FFR ≤0.80 PCI) vs 10.5% (FFR >0.80 deferred).
• Lesion-level revascularization: 12.6% in untreated FFR ≤0.80 segments vs 1.3% after PCI and 0.9% in deferred FFR >0.80 segments.
• Supports an FFR threshold of 0.80 to guide pre-TAVR revascularization decisions.

Clinical Implications

In TAVR candidates with ≥50% CAD, consider PCI for lesions with FFR ≤0.80 and defer revascularization for FFR >0.80. This reduces MI and urgent revascularization risk and may streamline procedural planning.

Limitations

• Registry design for the FFR >0.80 deferred cohort may introduce selection bias
• FFR measurements in severe AS physiology may be affected by altered hemodynamics

Future Directions

Prospective trials to test full physiology-guided revascularization strategies in TAVR workups, including cost-effectiveness, valve timing, and long-term outcomes.