Fractional flow reserve guided versus angiographic guided surgical revascularization: A meta‐analysis

Abstract

Background Clinical benefits of FFR (Fraction Flow Reserve) driven CABG (Coronary Artery Bypass Graft) remain to be established. Methods All randomized controlled trials (RCTs) and observational studies with multivariable adjustement were included. MACE (Major Adverse Cardiac Events) was the primary end point, while its single components (death, myocardial infarction, and total vessel revascularization [TVR]) along with number of anastomoses, on pump procedures and graft occlusion at angiographic follow‐up were the secondary ones. Each analysis was stratified for RCTs versus observational studies. Results Four studies (two RCTs and two observational) were included, enrolling 983 patients, 542 angio‐guided and 441 FFR‐guided. Mean age was 68.45 years, 79% male, with a mean EuroSCORE I of 2.7. Coronary lesions were located in 37% of patients in the left anterior descending artery, 32% in the circumflex artery, and 26% in the right coronary artery. After a mean follow‐up of 40 months, risk of MACE did not differ (OR 0.86 [0.63–1.18]) as that of all cause death (OR 0.86 [0.59–1.25]), MI (OR 0.57 [0.30–1.11]) and TVR (OR 1.10 [0.65–1.85]). FFR‐driven CABG reduced on‐pump procedures (OR 0.58 [0.35–0.93]) and number of anastomoses (−0.40 [−0.80: −0.01]) while incidence of graft occlusion at follow‐up did not differ (OR 0.59 [0.30–1.15], all CI 95%). Conclusion Fraction flow reserve driven CABG reduced the number of anastomoses and of on‐pump procedures without increasing risk of MACE and without reducing graft occlusion at angiographic follow‐up. ID CRD42020211945.

Angiography versus fractional flow rate‐guided coronary artery bypass grafting

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To the Editor, We read with interest the meta-analysis by Bruno et al in the journal Catheterization and Cardiovascular Interventions on the topic of use of fractional flow rate (FFR) compared with angiography alone for coronary artery bypass graft (CABG) surgery decision-making. 1 This study shares similarities with the recent meta-analysis we performed on this subject. 2 Both studies showed overall similar outcomes for FFR based versus angiography-based CABG.

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Response to: Angiography versus FFR‐guided coronary artery bypass grafting

“…To the Editor, We thank the authors for their comment on our meta-analysis about fractional flow reserve (FFR) versus angiographic-guided coronary bypass graft (CABG). 1,2 The authors reported outcomes comparable with our findings, confirming that FFR-driven revascularizations entail a reduction in the number of anastomoses and the need for on-pump surgical procedures as compared with angiographic-driven ones, with a neutral impact on adverse events, including death, myocardial infarction, and target vessel revascularization at a mid-term follow-up ranging from 6 to 85 months. 2,3 Moreover, arterial conduits were more likely to be used in the FFR group.…”

Fractional Flow Reserve: Patient Selection and Perspectives

“…The FFR-guided patients received a lower number of anastomoses, more arterial grafts and more frequently underwent off-pump procedures, which are associated with a reduction of (short-term) complications. [59][60][61][62] Moreover, a significant improvement in graft patency compared to ICA-guided CABG is observed. 59 A possible explanation for the apparent lack of benefits for FFR-guided CABG can be found in a process called surgical collateralizationgrafting might protect against the effects of progression of coronary lesions in proximal segments.…”

“… 59 A possible explanation for the apparent lack of benefits for FFR-guided CABG can be found in a process called surgical collateralization – grafting might protect against the effects of progression of coronary lesions in proximal segments. 1 , 61 Grafting of non-critically diseased coronary arteries is associated with a higher rate of graft closure due to competitive flow in the grafted coronary artery. 1 , 21 Functional testing may help guide the surgical revascularization strategy in ambiguous lesions.…”

“… 1 Since FFR-guided CABG led to less complex procedures, FFR could be a useful tool for Heart Team discussions to choose the best and least invasive surgical approach for each individual patient. 61 …”