Changes in surgical revascularization strategy after fractional flow reserve

Area of Science:

• Cardiovascular Surgery
• Interventional Cardiology
• Medical Imaging

Background:

• Coronary angiography is the standard for surgical planning in coronary artery bypass grafting (CABG).
• Fractional flow reserve (FFR) provides physiological assessment of stenosis severity.
• The impact of FFR knowledge on surgical strategy in CABG is not fully elucidated.

Purpose of the Study:

• To investigate the changes in surgical strategy induced by fractional flow reserve (FFR) knowledge in patients undergoing CABG.
• To compare the intended versus performed surgical strategies before and after FFR assessment.
• To evaluate the impact of FFR-guided strategy changes on procedural characteristics and clinical outcomes.

Main Methods:

• The GRAFFITI trial randomized surgeons to either standard coronary angiography or FFR-guided strategy.
• Surgeons' initial strategies were compared with revised strategies after FFR values were disclosed.
• Changes in graft selection, number of grafts, and surgical approach (on-pump vs. off-pump) were analyzed.
• One-year clinical event rates were compared between patients with and without strategy changes.

Main Results:

• In the FFR-guided group (84 patients, 300 lesions), strategy changes occurred in 55% of patients (48/84) affecting 21.3% of lesions (64/300).
• Medical therapy was escalated to bypass grafting in 25% of lesions initially planned for medical management after FFR disclosure.
• FFR guidance significantly reduced the number of planned venous grafts and the proportion of on-pump surgeries.
• One-year clinical event rates were similar regardless of whether a strategy change occurred.

Conclusions:

• Fractional flow reserve (FFR)-guided CABG significantly alters surgical strategy in over half of patients.
• FFR guidance simplifies surgical procedures by reducing venous graft use and on-pump surgery.
• FFR-guided CABG demonstrates comparable clinical outcomes to standard angiography-guided procedures at one year.