Coronary Physiologic Burden Assessed by Mean Angiography‐Derived Fractional Flow Reserve Predicts Outcomes After Transcatheter Aortic Valve Implantation

BACKGROUND: Coronary artery disease frequently coexists with severe aortic stenosis (AS) and contributes to adverse outcomes after transcatheter aortic valve implantation (TAVI). Conventional lesion-based assessments may underestimate the cumulative impact of diffuse coronary physiologic impairment in this population. This study evaluated the prognostic significance of mean angiography-derived fractional flow reserve (vFFR) as a patient-level marker of coronary physiologic burden in patients undergoing TAVI. METHODS: Between January 2017 and April 2022, 164 patients with severe AS who underwent coronary angiography prior to TAVI without significant epicardial stenosis (< 70%) were retrospectively analyzed. vFFR values were computed for all three major coronary arteries, and mean vFFR was calculated for each patient. The primary endpoint was a composite of all-cause death or heart failure hospitalization (HFH). Mean vFFR was analyzed as a continuous variable. RESULTS: Patients had an overall mean vFFR of 0.89 ± 0.07 and were stratified into high (> 0.85) or low (≤ 0.85) vFFR cohorts. During a mean follow-up of 1241 ± 867 days, the primary endpoint occurred in 43 patients (26.2%). Lower mean vFFR, lower left ventricular ejection fraction, higher NT-proBNP levels, lower estimated glomerular filtration rate, and higher STS score were associated with adverse outcomes. In contrast, the lowest single-vessel vFFR was not associated with the primary endpoint. When analyzed as a continuous variable, each 0.1 decrease in mean vFFR was independently associated with a higher risk of the composite outcome (adjusted hazard ratio 1.62, 95% CI 1.03-2.55; p = 0.035). Restricted cubic spline analysis demonstrated a non-linear inverse relationship between mean vFFR and clinical risk. CONCLUSIONS: Lower mean vFFR, reflecting greater coronary physiologic burden, was independently associated with adverse clinical outcomes after TAVI, even in the absence of angiographically significant stenosis. These findings suggest that patient-level physiologic impairment may provide incremental prognostic information beyond lesion-based assessment, supporting a more physiology-informed approach to coronary evaluation in patients undergoing TAVI.