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Background-Fractional P<0.001). At 3 years, major adverse cardiovascular events were not different between the angiography-guided and FFR-guided groups (12% versus 11%; hazard ratio, 1.030; 95% confidence interval, 0.627-1.692; P=0.908). However, the FFR-guided group compared with the angiography-guided group presented a significantly lower rate of angina (Canadian Cardiovascular Society class II-IV, 31% versus 47%; P<0.001). Conclusions-FFR-guided coronary artery bypass graft surgery was associated with a lower number of graft anastomoses and a lower rate of on-pump surgery compared with angiography-guided coronary artery bypass graft surgery. This did not result in a higher event rate during up to 36 months of follow-up and was associated with a lower rate of angina. Patients were divided into 2 groups: the angiography-guided group and the FFR-guided group. The angiography-guided group consisted of patients in whom no FFR was measured at the time of the preoperative coronary angiography and CABG was indicated solely on the basis of the angiographic severity of the coronary stenosis. The FFR-guided group consisted of patients in whom at least 1 intermediate stenosis was measured by FFR and grafted in the presence of FFR ≤0.80 or deferred with FFR >0.80. Coronary Angiography and FFR MeasurementCoronary angiography was performed by a standard percutaneous femoral or radial approach with 6F or 7F diagnostic or guiding catheters. After the administration of 200 to 300 µg intracoronary isosorbide dinitrate, the angiogram was repeated in the projection allowing the best possible visualization of the stenosis. Experienced operators not involved in the analysis of the data assessed stenosis severity. Multivessel disease was defined as the presence of stenosis in ≥2 major coronary arteries.Performance of FFR measurement was left to the operator's discretion. FFR was measured as previously described.11,12 Briefly, a pressuremonitoring guidewire (Certus PressureWire; St. Jude Medical Inc, St. Paul, MN) was advanced distal to the coronary artery stenosis. After the administration of intracoronary isosorbide dinitrate (200 μg), hyperemia was obtained with either intravenous infusion (140 μg·kg) or an intracoronary bolus of adenosine (70-100 μg). An FFR value ≤0.80 indicated an ischemia-producing coronary stenosis. Coronary Artery Bypass SurgeryThe type of surgery, namely on-pump or off-pump, and the number and type of grafts were left to the surgeon's discretion. Study End PointsPrimary end point of the study was the rate of major adverse cardiac events, defined as overall death, myocardial infarction, and target vessel revascularization occurring during up to 3 years of clinical followup. Secondary end points were all the individual end points included in major adverse cardiovascular events plus the number of graft anastomoses and symptoms at the last clinical follow-up available. Myocardial infarction was defined as previously described.13,14 Target vessel revascularization was defined as any percutaneous or surgical rev...

Background— There is an increasing interest in minimally invasive cardiac surgery. Methods and Results— Since February 1, 1997 till April 1, 2002, 306 patients underwent endoscopic mitral valve surgery (226 repair, MVP; 80 replacement, MVR). Predominant valve pathology was degenerative in MVP (83.6%) and rheumatic in MVR (65%). Mean age was 61.5±12.9 years. Median preoperative functional class (MVP+MVR) and mitral regurgitation (MVP) were II and 4+. Statistical analysis included Kaplan-Meier and Cox regression methods. Mean follow-up was 19.6±17.3 months and complete. The procedure was successfully performed in all but 6 patients. Hospital mortality included 3 patients (1%) and was technology related in one. Postoperative morbidity included aggressive re-exploration (8.5%), new onset atrial fibrillation (17.0%), and pacemaker implantation (2.3%). There were 1 early and 10 late reoperations, 5 of which were because of endocarditis. Freedom from mitral valve reoperation at 4 years was 91±3.5%. No risk factors for reoperation could be detected. Echocardiographic follow-up showed a median degree of mitral regurgitation (MVP) of 0 and a small paravalvular leak in four patients (MVR). Ninety-four percent of the patients reported no or mild postoperative pain and 99.3% felt they had an esthetically pleasing scar. Ninety-three percent would choose the same procedure again and 46.1% were back at work within 4 weeks. Conclusions— Endoscopic mitral valve surgery can be performed safely but definitely requires a learning curve. Good results and a high patient satisfaction are guaranteed. It is now our exclusive approach for isolated atrioventricular valve disease.

FFR-guided CABG is associated with a significant reduction in the rate of overall death or myocardial infarction at 6-year follow-up as compared with angiography-guided CABG.

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