ORIGINAL ARTICLE The Influence of Aortic Valve Obstruction on the Hyperemic Intracoronary Physiology: Difference Between Resting Pd/Pa and FFR in Aortic Stenosis Roberto Scarsini 1,2 & Giovanni L. De Maria 1,3 & Giuseppe Di Gioia 4,5 & Rafail A. Kotronias 1 & Cristina Aurigemma 3 & Giuseppe Zimbardo 3 & Francesco Burzotta 3 & Antonio M. Leone 3 & Gabriele Pesarini 2 & Carlo Trani 3 & Filippo Crea 3 & Rajesh K. Kharbanda 1 & Bernard De Bruyne 4 & Emanuele Barbato 4,5 & Adrian Banning 1 & Flavio Ribichini 2 Received: 10 January 2019 /Accepted: 21 April 2019 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract The reliability of fractional flow reserve (FFR) in aortic stenosis (AS) has been questioned because of the uncertain response to vasodilators. A retrospective multicenter cohort of 114 AS patients who underwent coronary physiology assessment was com- pared with 154 controls before and after propensity matching adjustment. The difference between resting distal coronary vs aortic pressure ratio (Pd/Pa) and FFR (ΔPd/Pa-FFR) was tested against the severity of AS. ΔPd/Pa-FFR was not influenced by the severity of AS in terms of aortic valve area (r = - 0.02, p = 0.83) and gradient (r = - 0.05, p = 0.64) or by the left ventricle hypertrophy (r = - 0.03, p = 0.88). Conversely, ΔPd/Pa-FFR was influenced by the presence of diabetes (r = - 0.24, p = 0.005), peripheral vascular disease (r = - 0.16, p = 0.047), and chronic kidney disease (r = - 0.19, p = 0.03). No significant difference was observed in the ΔPd/Pa-FFR between patients with AS and matched controls. Further studies are warranted to validate the FFR-guided revascularization in patients with AS. Keywords Fractional flow reserve . Coronary artery disease . Aortic stenosis . Transcatheter aortic valve implantation Abbreviations AS Aortic stenosis CAD Coronary artery disease CKD Chronic kidney disease DS Diameter stenosis FFR Fractional flow reserve iFR Instantaneous wave-free ratio LAD Left anterior descending artery LV Left ventricle Pd/Pa Distal vs proximal coronary pressure ratio QCA Quantitative coronary analysis TAVI Transcatheter aortic valve implantation Introduction Intracoronary physiology is superior to angiography alone in guiding myocardial revascularization [1]. However, fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) have not been validated in aortic stenosis (AS) and patients with significant valvular heart disease have been excluded from clinical trials involving physiological indices [1–5]. Therefore, the best tool for physiological assessment of Roberto Scarsini and Giovanni L. De Maria contributed equally to this work. Associate Editor Ana Barac oversaw the review of this article. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12265-019-09890-5) contains supplementary material, which is available to authorized users. * Flavio Ribichini flavio.ribichini@univr.it 1 Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK 2 Department of Medicine, Division of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37126 Verona, Italy 3 Department of Cardiology, Policlinico Gemelli, Università La Sapienza, Rome, Italy 4 Department of Cardiology, Cardiovascular Research Centre, OLV Hospital, Aalst, Belgium 5 Division of Cardiology, Department of Advanced Biomedical Science, University of Naples Federico II, Naples, Italy Journal of Cardiovascular Translational Research https://doi.org/10.1007/s12265-019-09890-5