Results showed that of the 77 patients, obtaining the CTA-SS was feasible in 86 percent and the noninvasive FSS was feasible in 80 percent. While the anatomic SYNTAX score was shown to be overestimated by CTA compared with conventional angiography, the calculation of the FSS yielded similar results between the noninvasive and invasive imaging modalities.

The authors also found that the noninvasive FSS reclassified 30 percent of patients from the high and intermediate SYNTAX score tertiles to the low risk tertile, whereas the invasive functional SYNTAX score reclassified 23 percent of patients from the high and intermediate SYNTAX score tertiles to the low risk tertile.

Furthermore, the diagnostic accuracy of FFRCT to detect functionally significant stenosis — based on an instantaneous-wave free ratio of 0.89 or less — revealed an area under the receiver-operating characteristics curve of 0.85 with a sensitivity of 95 percent, specificity of 61 percent, positive predictive value of 81 percent and negative predictive value of 87 percent.

In an accompanying editorial comment, Bjarne L. Nørgaard, MD, PhD, et al., note that this study may present a new era in the management of CAD and “the days of having patients going to the catheterization laboratory with nothing more than symptoms and a positive stress test result may be coming to an end.” They add, “This study may be signaling a shifting paradigm with CAD diagnosed and thoroughly characterized non-invasively, revascularization planning made in a collaborative fashion integrating the heart team, and a wealth of non-invasive data that will hopefully lead to more effective and cost-efficient revascularization strategies.”

Collet C, Miyazaki Y, Ryan N, et al. J Am Coll Cardiol 2018;May 22:[Epub ahead of print].

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Results showed that the primary endpoint of reactive hyperemia index did not differ after ticagrelor vs. prasugrel (1.970 vs. 2.007; p=0.557) or vs. clopidogrel (1.970 vs. 2.072; p=0.685). No differences were seen between the drugs for systemic adenosine plasma levels or vascular biomarkers at any time points. Additionally, P2Y12 platelet reactivity units were lower after ticagrelor vs. clopidogrel at all time points and after a maintenance dose vs. prasugrel. Flow-mediated dilatation did not differ after the maintenance dose of ticagrelor vs. clopidogrel and prasugrel.

The authors explain that further research is needed to assess the effect of ticagrelor on tissue adenosine plasma levels in humans compared with other oral P2Y12 inhibitors and its relationship with clinical outcomes.

In an accompanying editorial comment, Jay S. Giri, MD, MPH, and Ashwin Nathan, MD, note that “it is imperative to ascertain whether these medications are accessible for individual patients.” They add, “although studies will attempt to identify nuanced differences among different antiplatelet agents to maximize benefits to patients, the best antiplatelet agent in the current era is likely the one the patient can afford to obtain.”

Ariotti S, Ortega-Paz L, van Leeuwen M, et al. JACC Cardiovasc Interv:May 24:[Epub ahead of print].

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Results showed that of the 38 patients included (20 BVS and 18 EES), over 60 percent exhibited paradoxical vasoconstriction to acetylcholine in the periscaffold or stent segments at three years. Vasoconstriction to acetylcholine and vasodilatation to nitroglycerin were found to be more often observed in the scaffold or stent segment with BVS than with EES (77.8 vs. 25.0 percent; p=0.008, and 61.1 vs. 18.8 percent; p=0.018).

For IRA-dependent microcirculation, the findings showed similar index of resistance (23.8 vs. 22.4; p=0.781), coronary flow reserve (2.4 vs. 1.9; p=0.523), fractional flow reserve (0.91 vs. 0.93; p=0.317) and absolute flow (135.5 ml/min vs. 147.3 ml/min; p=0.791). Optical coherence tomography showed remaining strut footprints and larger number of intraluminal scaffold dismantling (26.3 vs. 0 percent; p=0.049) in the BVS group.

The clinical implications of these findings require further investigations note the authors.

In an accompanying editorial comment, Hiroyuki Jinnouchi, MD, et al., state these data are “valuable because they enhance our knowledge of the long-term vascular responses to this technology and might serve to temper enthusiasm.” However, they add, “the promise of BVS remains more fiction than fact, and if its future is to be realized, long-term responses such as vasomotion and compensatory dilation will need to be conclusively shown.”

Gomez-Lara J, Brugaletta S, Ortega-Paz L, et al. JACC Cardiovasc Interv:May 24:[Epub ahead of print].

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Overall, 140 operators provided 1,400 decisions about stenosis significance. Of these, 52 percent were based on visual assessment only and these decisions were consistent with the intracoronary pressure measurement in 46 percent of cases. In the other 48 percent of cases, operators acknowledged the need for an additional diagnostic tool, mostly intracoronary pressure measurement.

According to the authors, this is the first study to collect operators’ rationale for not performing the physiology assessment at the time of the clinical decision-making process in real-life cases.

In an accompanying editorial comment, Nils P. Johnson, MD, FACC, et al., write this study helps us to critically evaluate potential responses to the question “‘Why don’t interventional cardiologists use coronary physiology?’... Although operators can be reluctant to admit it, the fundamental reason has received different labels: attitude, belief, local practice, ‘experience’ and culture. Put simply, we as a profession do not yet emotionally accept coronary physiology to guide treatment.”

Tebaldi M, Biscaglia S, Fineschi M, et al. JACC Cardiovasc Interv:May 23:[Epub ahead of print].

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Device landing zone calcification was stratified as severe, moderate or mild. Anatomic and procedural predictors of second-degree or greater paravalvular leakage (PVL) and permanent pacemaker implantation (PPI) were assessed. A stepwise logistic regression analysis (forward logistic regression) was carried out to specify independent predictors of second-degree or greater PVL and PPI.

Postprocedural second-degree or greater PVL was more frequent with increasing device landing zone calcification (mild 0.8 percent vs. moderate 5.0 percent vs. severe 13.0 percent; p<0.001). However, PPI was independent of device landing zone calcification.

Independent predictors of second-degree or greater PVL were more severe periannular calcification (odds ratio [OR], 1.007; p<0.001); less oversizing (OR, 0.867; p=0.014); presence of annular plaque protrusions (OR, 2.756; p= 0.025); aortic movement of the delivery system after full deployment (OR, 5.593; p=0.02); and sinotubular junction height (OR, 1.156; p=0.04).

Predictors of PPI were preexisting right bundle branch block (OR, 3.122; p=0.01) and more oversizing (OR, 1.111; p=0.03).

The investigators write that less aggressive predilatation may help reduce PPI rates, and maintaining forward pressure on the delivery system during deployment may decrease the likelihood of postprocedural PVL.

Validation of these results are needed in randomized studies. The comparative effectiveness of the ACURATE neo valve is being studied in two ongoing studies within the SCOPE trial program, with the balloon expandable SAPIEN 3 device and the self-expanding Evolut R device. “If results of randomized controlled trials, such as SCOPE I and II, are able to properly characterize patient- and procedure-related factors, which could predict device and procedural success as well as long-term outcome, this would represent a major step forward to precision medicine in TAVR,” write Christian Hengstenberg, MD, and Jolanta M. Siller-Matula, MD, in an accompanying editorial comment.

Kim W-K, Mollmann H, Liebetrau C, et al. JACC Cardiovasc Interv 2018;May 22;[Epub ahead of print].

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