Changes in surgical revascularization strategy after fractional flow reserve

Abstract

Aims: In the randomized GRAFFITI trial, surgeons drew their strategy based on coronary angiography. When patients were randomized to fractional flow reserve (FFR)guidance, surgeons were informed of the FFR values and asked to redraw their strategy. The aim of this study was to investigate the changes induced by FFR knowledge.Methods and Results: The intended and performed strategy (before and after FFR) were compared. Among 172 patients, 84 with 300 lesions were randomized to the FFR-guided group. The intended strategy was to bypass 236 stenoses:108 with a venous and 128 with an arterial graft. After disclosing FFR, a change in strategy occurred in 64 lesions (21.3%) of 48 (55%) patients. Among 64 lesions for which the intended strategy was medical therapy, 16 (25%) were bypassed after disclosing FFR.The number of procedures with >1 venous graft planned was significantly reduced from 37 to 27 patients (p = .031). The proportion of on-pump surgery was significantly reduced from 71 to 61 patients (p = .006). The rates of clinical events at 1 year were similar between patients with or without at least one change in strategy.Discussion: FFR-guided CABG is associated with a simplified surgical procedure in 55% of the patients, with similar clinical outcomes.

Coronary physiology in the catheterisation laboratory: an A to Z practical guide

“…Coronary artery bypass grafting (CABG) is an invasive procedure that supplies extra blood flow to the heart in patients with extensive CAD via surgical implantation of additional conduits. Whilst observational studies have shown a significant correlation between preoperative FFR and graft patency at follow-up, RCTs have failed to confirm such findings 22,23 . The FARGO and the GRAFFITI RCTs, comparing FFR-and angio-guided surgical strategies, failed to demonstrate improved 6-12 month graft patency nor advantages in terms of clinical events 22 .…”

“…Whilst observational studies have shown a significant correlation between preoperative FFR and graft patency at follow-up, RCTs have failed to confirm such findings 22,23 . The FARGO and the GRAFFITI RCTs, comparing FFR-and angio-guided surgical strategies, failed to demonstrate improved 6-12 month graft patency nor advantages in terms of clinical events 22 . In GRAFFITI, FFR-guidance allowed a simplification of the surgical intervention in up to 50% of patients, by reducing the number of anastomoses and by increasing off-pump grafting and minimally invasive surgery 22,24 .…”