Fractional Flow Reserve−Guided Versus Angiography-Guided Coronary Artery Bypass Graft Surgery

OBJECTIVES: Fractional flow reserve (FFR) is well established for patients undergoing percutaneous coronary intervention, yet little is known about candidates for coronary artery bypass graft surgery.

METHODS: From 2006 to 2010, we retrospectively included in this registry 627 consecutive patients treated by coronary arterybypass graft surgery having at least 1 angiographically intermediate stenosis. In 429 patients, coronary artery bypass graft surgery was based solely on angiography (angiography-guided group). In 198 patients, at least 1 intermediate stenosis was grafted with an FFR ≤0.80 or deferred with an FFR >0.80 (FFR-guided group). The end point was major adverse cardiovascular events at 3 years, defined as the composite of overall death, myocardial infarction, and target vessel revascularization.

RESULTS: The rate of angiographic multivessel disease was similar in the angiography-guided and FFR-guided groups (404 [94.2%] versus 186 [93.9%]; P=0.722). In the FFR-guided group, this was significantly downgraded after FFR measurements to 86.4% (P<0.001 versus before FFR) and was associated with a smaller number of anastomoses (3 [2-3] versus 3 [2-4]; P<0.001) and rate of on-pumpsurgery (49% versus 69%; 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. 

PMID: 23985788

Posted in Invasive Imaging and tagged , , , .


  1. Great paper that further supports the use of physiologic over anatomic guidance. A couple of interesting observations from the paper:

    “Grafted coronary arteries were equally distributed between the 2 groups except for a lower rate of right coronary artery grafting in the FFR-guided group. This is no surprise considering that intermediate stenosis of the right coronary artery can be found more frequently with a non-significant FFR value and can be attributed to the more limited subtended myocardial territory of the right coronary artery compared with the left coronary artery.”

    After seeing some of the incredible stuff that has been recently published on CT-FFR, this paragraph got me thinking…is it really the subtended myocardial territory or is it just that there is less microvascular resistance on the RV wall than the LV wall to account for this difference?

    “… rate of graft occlusion was 4 times lower in the FFR-guided group during up to 3 years of follow-up compared with the angiography-guided group.” WOW.

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