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Background: There is limited evidence that fractional flow reserve (FFR) is effective in guiding therapeutic strategy in multivessel coronary artery disease (CAD) beyond prespecified percutaneous coronary intervention or coronary graft surgery candidates.Objectives: The FUTURE (FUnctional Testing Underlying coronary REvascularization) trial aimed to evaluate whether a treatment strategy based on FFR was superior to a traditional strategy without FFR in the treatment of multivessel CAD.Methods: The FUTURE trial is a prospective, randomized, open-label superiority trial. Multivessel CAD candidates were randomly assigned (1:1) to treatment strategy based on FFR in all stenotic (≥50%) coronary arteries or to a traditional strategy without FFR. In the FFR group, revascularization (percutaneous coronary intervention or surgery) was indicated for FFR ≤0.80 lesions. The primary endpoint was a composite of major adverse cardiac or cerebrovascular events at 1 year.Results: The trial was stopped prematurely by the data safety and monitoring board after a safety analysis and 927 patients were enrolled. At 1-year follow-up, by intention to treat, there were no significant differences in major adverse cardiac or cerebrovascular events rates between groups (14.6% in the FFR group vs 14.4% in the control group; hazard ratio: 0.97; 95% confidence interval: 0.69-1.36; P = 0.85). The difference in all-cause mortality was nonsignificant, 3.7% in the FFR group versus 1.5% in the control group (hazard ratio: 2.34; 95% confidence interval: 0.97-5.18; P = 0.06), and this was confirmed with a 24 months' extended follow-up. FFR significantly reduced the proportion of revascularized patients, with more patients referred to exclusively medical treatment (P = 0.02).Conclusions: In patients with multivessel CAD, we did not find evidence that an FFR-guided treatment strategy reduced the risk of ischemic cardiovascular events or death at 1-year follow-up. (Functional Testing Underlying Coronary Revascularisation; NCT01881555). [ABSTRACT FROM AUTHOR]

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The proximal optimization technique (POT) in coronary bifurcation stenting improves apposition and side-branch obstruction. The POT balloon should be positioned with the distal radio-opaque marker at the carina cut plane. However, the real impact of positioning remains unknown. Synergy ™ stents (Boston Scientific, USA) were implanted on left-main fractal bench models. Initial POT was performed in 3 positions according to distal shoulder position (loss of balloon parallelism) relative to the carina cut plane (n = 5/group): i) "proximal", 1 mm before carina; ii) "medium", just at carina; iii) "distal", 1 mm after carina. Results were quantified on 2D- and 3D-OCT. Compared to implantation, initial POT improved malapposition in all positions ("proximal": 61.5 ± 1.4% vs. 5.1 ± 2.7%; "medium": 60.2 ± 2.4% vs. 1.3 ± 0.6%; "distal": 60.5 ± 2.9% vs. 1.1 ± 1.8%, p < 0.05). However, residual malapposition was greater in "proximal" position (p < 0.05). "Proximal", unlike "medium" or "distal" POT, also failed to improve side-branch obstruction. Conversely, "distal" POT significantly overstretched the main-branch ostium, with stent/artery ratio 1.22 ± 0.04 vs. 1.11 ± 0.07 for "medium" POT (p < 0.05). Shoulder positioning is essential to optimize the mechanical benefit of POT without main-branch overstretch (too distal position). Experimentally, the best position is just at the carina cut plane ("medium"). • POT balloon positioning is crucial in optimizing mechanical benefit in terms of apposition and side-branch obstruction. • The POT balloon should be positioned so that distal loss of parallelism occurs just at the carina cut plane. • Achieving this requires perfect knowledge of the specific balloon characteristics. [ABSTRACT FROM AUTHOR]

Abstract Aims Initial proximal optimization technique (POT) in provisional stenting improves global malapposition, side-branch (SB) obstruction (SBO) and conservation of arterial circularity. The specific mechanical effects of a final POT sequence concluding the main provisional stenting techniques, on the other hand, are unknown. Methods and results Synergy™ stents were implanted on fractal coronary bifurcation bench models using the main provisional stenting techniques (n = 5 per group): kissing-balloon inflation (KBI), snuggle, and rePOT (initial POT + SB inflation + final POT). Final results were quantified on 2D and 3D OCT before and after final POT. Whichever the technique, final POT significantly decreased global malapposition (from 7.6 ± 5.3% to 2.2 ± 2.5%, p < 0.05) and proximal elliptic deformation (from 1.15 ± 0.07 to 1.09 ± 0.04, p < 0.05), without impact on SBO (from 11.5 ± 9.6% to 12.9 ± 10.6%, NS). However, final POT failed to completely correct the elliptic deformation induced by balloon juxtaposition during the KBI and snuggle techniques, with final elliptic ratios of 1.11 ± 0.03 and 1.11 ± 0.04 respectively, significantly higher than with the complete rePOT sequence: 1.05 ± 0.02 (p < 0.05). Conclusions Like initial POT, final POT is recommended whatever the provisional stenting technique used. However, final POT fails to completely correct all proximal elliptic deformation associated with "kissing-like" techniques, in contrast to results with the rePOT sequence. [ABSTRACT FROM AUTHOR]