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Should functional assessment of lesion severity be used to guide coronary bypass?

Yanagawa, Bobbya; Verma, Subodha; Bagai, Akshayb; Puskas, John D.c

doi: 10.1097/HCO.0000000000000549
COMPLEX ISSUES IN CORONARY REVASCULARIZATION: Edited by Subodh Verma and Bobby Yanagawa
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Purpose of review The purpose of this article is to investigate the potential role of fractional flow reserve (FFR) to guide surgical revascularization.

Recent findings Coronary artery bypass is planned and executed primarily based on angiographic coronary anatomy. FFR is the most well-established tool for functional assessment of coronary lesions. Randomized trials have demonstrated the benefit of FFR-guided percutaneous coronary intervention (PCI) to determine the ischemic burden of intermediate lesions. Surgically, FFR is predominantly used to determine the functional severity of intermediate lesions of the left anterior descending (LAD) coronary artery to establish candidacy for multivessel coronary bypass. The broader use of FFR will likely downgrade a proportion of coronary lesions, which may alter the overall management plan. Whether this will improve clinical outcomes remains to be seen. Importantly, bypass of functionally nonsignificant lesions predicts graft failure. However, graft failure in the context of sufficient native coronary flow may not impact negatively on clinical outcome. Thus, at this time, there are insufficient data to support the wider use of FFR to guide surgical grafting of non-LAD targets. It remains to be seen whether FFR can be used to optimize the use of arterial grafts or to guide complex revascularization strategies such as hybrid coronary revascularization.

Summary FFR has become an invaluable tool for decision making for PCI in patients with stable ischemic heart disease. Beyond its use to assess an intermediate LAD lesion to establish candidacy for coronary bypass, at present there are insufficient data to support its wider use to guide surgical revascularization.

aDivision of Cardiac Surgery, Department of Surgery

bCardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada

cDepartment of Cardiovascular Surgery, Mount Sinai Heart at Mount Sinai Saint Luke's, New York City, New York, USA

Correspondence to Bobby Yanagawa, MD, PhD, FRCSC, Assistant Professor, Division of Cardiac Surgery, Department of Surgery, University of Toronto, St. Michael's Hospital, 30 Bond Street, 8th Floor, Bond Wing, Toronto, ON M5B 1W8, Canada. Tel: +1 416 864 5706; fax: +1 416 864 5031; e-mail: yanagawab@smh.ca

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