The promising role of OCT-VFR in guiding post-PCI optimization in CHIP patients: a VISION trial subanalysis

Abstract Background The integration of imaging and physiological assessments may provide optimal guidance for complex procedures (CHIP). Objectives To assess differences in post-percutaneous coronary intervention (post-PCI) management recommendations in CHIP patients using Optical Coherence Tomography (OCT), Quantitative Flow Ratio (QFR), and the combination of imaging and physiology by means of Optical Coherence Tomography plus Virtual Flow Reserve (OCT-VFR). Methods Among patients enrolled in the VISION trial (Virtual Flow Reserve Versus Angiography-Derived FFR for Stent Implantation), we selected those with available post-PCI OCT-VFR data (n=71). Initially, we compared the post-PCI management recommendations based on each individual modality. Subsequently, we analyzed discrepancies between management plans suggested by OCT-VFR, QFR, and OCT. Results A total of 71 patients were included in the analysis. OCT recommended further intervention in 24 patients (33%), OCT-VFR in 11 patients (12.7%), and QFR in 1 patient (1.4%). OCT identified stent malapposition in 15 patients and stent underexpansion in 5, indicating the need for post-dilatation (PD). In 3 cases, OCT showed dissection at the proximal stent edge, recommending additional stent implantation and PD. In 1 case, OCT revealed both proximal stent edge dissection and stent malapposition, suggesting stent implantation with PD. All patients for whom OCT-VFR recommended treatment should also be managed according to OCT findings. OCT-VFR recommended a different post-PCI management plan than QFR in 8 patients: OCT-VFR proposed treatment for 5 patients with proximal stent edge dissection, 2 with stent underexpansion, and 1 with stent malapposition, whereas QFR did not suggest further intervention. Additionally, OCT-VFR provided a different management strategy compared to OCT in 14 patients. Specifically, OCT identified 10 cases of stent malapposition and 4 cases of stent underexpansion, all of which were considered treatable by OCT, whereas OCT-VFR did not recommend any further intervention. Conclusion There are significant discrepancies in post-PCI management recommendations when using different modalities, particularly between OCT, QFR, and OCT-VFR. While OCT identified more cases requiring intervention, both OCT-VFR and QFR suggested fewer instances of treatment, with OCT-VFR showing a more conservative approach in certain cases. These findings highlight the potential value of combining imaging and physiological assessment, such as OCT-VFR, for a more comprehensive evaluation of post-PCI outcomes and to guide personalized treatment strategies in CHIP patients. Further studies are necessary to determine the clinical implications of these differences and to optimize decision-making in complex coronary interventions.