Fractional flow reserve to decide between percutaneous transluminal coronary angioplasty or coronary artery bypass grafting in patients with angiographically multivessel disease: A tailored approach

Background: In multivessel disease, it is controversial whether complete revascularization by bypass surgery (CABG) is superior to PTCA of the culprit lesions only. Fractional flow reserve (FFR), calculated from coronary pressure measurement, is a reliable index to identify whether a stenosis is culprit (i.e., functionally significant). Aim: To compare selective PTCA of culprit lesions only (FFR less than 0.75) to CABG of all stenoses. Methods: In 130 patients, referred for CABG, FFR was determined in 322 coronary arteries which were all considered for bypass grafting based on angiographic information only. If FFR was less than 0.75 in 3 or 2 stenoses including those located in the proximal left anterior descending coronary artery (LAD), CABG was performed on all vessels for which bypass grafting was considered to be necessary as judged angiographically by the surgeon and cardiologist who were blinded to the FFR results (CABG group). If only 1 or 2 lesions not including proximal LAD were culprit, PTCA of those lesions only was performed (PTCA group). Results: So far a 2 year follow-up has been completed in 75 patients assigned to CABG and 55 to PTCA. After 2 years, no differences were seen in adverse events (event-free survival 84.1% in the CABG group and 83.9% in the PTCA group) and a similar number of patients were free from angina (85% in the CABG group and 82% in the PTCA group). Conclusion: In multivessel disease, coronary pressure measurement is an excellent tool to identify the culprit lesion(s) by FFR < 0.75. In this way, patients with otherwise similar angiographic characteristics can be stratified into 2 groups, according to the functional extent of disease: patients with one or 2 culprit lesions excluding proximal LAD (PTCA group) and patients with 2 including LAD or more culprit lesions (CABG group). Within the group of patients with angiographically identified multivessel disease, PTCA of culprit lesion(s) only, as discriminated by an FFR of less than 0.75, yields a similar 2-year outcome as complete revascularization by bypass surgery