In the daily practice and in randomized studies such as Syntax or Freedom, most cardiovascular surgeons across the world use angiography guided CABG to teat 50% coronary stenosis. Many of these lesions might not be functionally significant.

There is abundant evidence in favor of fractional flow reserve (FFR) guided PCI, but FFR guided CABG is something altogether different. There is little evidence to support the latter, but even if there were enough data, convincing surgeons to make this paradigm shift would take time.

So far, FFR guided CABG has been associated to lower number of graft anastomoses, lower rate of on-pump surgery, and higher graft patency rate compared to angiography guided CABG.

Read also: First Results for Ticagrelor in Elective Coronary Angioplasty.

This recent retrospective study published in Circ. Cardiovasc. Interv. included 627 consecutive patients undergoing CABG between 2006 and 2010. In 198 patients at least one stenosis was grafted according to FFR, whereas in the remaining 429, all lesions were grafted based on angiography. In the FFR guided group, patients were younger and less often had diabetes, compared against the angiography group, which is why they used propensity score.

At 6-year follow-up, global mortality rate, or acute myocardial infarction rate, was significantly lower in the FFR guided group (n=31 (16%) vs n=49 (25%); HR 0.59; p=0.02) compared against the angiography guided group.

Read also: Great Dispersion in the Prognosis of Patients with Angina and No Coronary Lesions.

A few days ago, we commented on the study published in J Am Coll Cardiol Intv which sets only half of interventional cardiologists systematically use FFR in the daily practice; the other half, despite supporting evidence and despite the tools available, simply consider conventional angiography to be enough. Surgeons seem even harder to convince.

Conclusion

FFR guided myocardial revascularization surgery is associated to a significant reduction of death or acute myocardial infarction at 6 years, compared against angiography guided CABG.

Original title: Six-Year Follow-Up of Fractional Flow Reserve-Guided Versus Angiography-Guided Coronary Artery Bypass Graft Surgery.

Reference: Stephane Fournier et al. Circ Cardiovasc Interv. 2018 Jun;11(6):e006368.

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