title: The impact of left ventricular ejection fraction on fractional flow reserve: Insights from the FAME (Fractional flow reserve versus Angiography for Multivessel Evaluation) trial.
abstract: BACKGROUND
  Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) significantly improves outcomes compared with angio-guided PCI in patients with multivessel coronary artery disease. However, there is a theoretical concern that in patients with reduced left ventricular ejection fraction (EF) FFR may be less accurate and FFR-guided PCI less beneficial.
  
  
  METHODS
  From the FAME (Fractional flow reserve versus Angiography for Multivessel Evaluation) trial database, we compared FFR values between patients with reduced EF (both ≤ 40%, n = 90 and ≤ 50%, n = 252) and preserved EF (> 40%, n = 825 and > 50%, n = 663) according to the angiographic stenosis severity. We also compared differences in 1 year outcomes between FFR- vs. angio-guided PCI in patients with reduced and preserved EF.
  
  
  RESULTS
  Both groups had similar FFR values in lesions with 50-70% stenosis (p = 0.49) and with 71-90% stenosis (p = 0.89). The reduced EF group had a higher mean FFR compared to the preserved EF group across lesions with 91-99% stenosis (0.55 vs. 0.50, p = 0.02), although the vast majority of FFR values remained ≤ 0.80. There was a similar reduction in the composite end point of death, nonfatal myocardial infarction, and repeat revascularization with FFR-guided compared to angio-guided PCI for both the reduced (14.5% vs. 19.0%, relative risk = 0.76, p = 0.34) and the preserved EF group (13.8 vs. 17.0%, relative risk = 0.81, p = 0.25). The results were similar with an EF cutoff of 40%.
  
  
  CONCLUSIONS
  Reduced EF has no influence on the FFR value unless the stenosis is very tight, in which case a theoretically explainable, but clinically irrelevant overestimation might occur. As a result, FFR-guided PCI remains beneficial regardless of EF.
authors.affiliation: Stanford University Medical Center, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford, CA, USA.
authors.forename: Yuhei
authors.initials: Y
authors.lastname: Kobayashi
authors.affiliation: Catharina Hospital, Eindhoven, the Netherlands.
authors.forename: Pim A L
authors.initials: PA
authors.lastname: Tonino
authors.affiliation: Cardiovascular Center Aalst, Aalst, Belgium.
authors.forename: Bernard
authors.initials: B
authors.lastname: De Bruyne
authors.affiliation: Stanford University Medical Center, Stanford, CA, USA; Ajou University School of Medicine, Suwon, Republic of Korea.
authors.forename: Hyoung-Mo
authors.initials: HM
authors.lastname: Yang
authors.affiliation: Stanford University Medical Center, Stanford, CA, USA; Ajou University School of Medicine, Suwon, Republic of Korea.
authors.forename: Hong-Seok
authors.initials: HS
authors.lastname: Lim
authors.affiliation: Catharina Hospital, Eindhoven, the Netherlands.
authors.forename: Nico H J
authors.initials: NH
authors.lastname: Pijls
authors.affiliation: Stanford University Medical Center, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford, CA, USA. Electronic address: wfearon@stanford.edu.
authors.forename: William F
authors.initials: WF
authors.lastname: Fearon
mesh_terms: D000368:Aged; D017023:Coronary Angiography / Q000379:methods; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D005260:Female; D053805:Fractional Flow Reserve, Myocardial / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000379:methods; D011446:Prospective Studies; D013318:Stroke Volume / Q000502:physiology*; D016896:Treatment Outcome; D016277:Ventricular Function, Left / Q000502:physiology*
keywords: Ejection fraction; Fractional flow reserve; Multivessel revascularization