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Page 4 of 9 Van der Merwe et al. Vessel Plus 2019;3:24 I http://dx.doi.org/10.20517/2574-1209.2019.17

may provide graft protection for lesions in which FFR values were greater than 0.78. Antegrade flow in
angiographic stenosed target vessels with large diameters, especially the right coronary artery (RCA), may
still be adequate to cause significant competitive flow in arterial grafts and it is therefor suggested that the
most appropriate FFR value for optimal RCA graft outcome was less than 0.71. The right ITA is often used
for non-left anterior descending artery target vessels with poor distal run-off and apart from technical
aspects, potentially explain the inferior graft patency.

NEW DEVELOPMENT AND CONCERNS OF ROUTINELY APPLYING FRACTIONAL FLOW

RESERVE-GUIDED CORONARY ARTERY BYPASS GRAFTING
[36]
The recently published FARGO trial evaluated graft patency and clinical outcome of 100 patients referred
for CABG by a heart team after randomly being assigned to either FFR- or angiography-guided CABG.
In FFR-guided CABG, coronary lesions with FFR > 0.80 were deferred, and a new graft plan was designed
accordingly, whereas the surgeon was blinded to the FFR values in patients who underwent angiography-
guided CABG. Angiographic follow-up at 6 months were available for 39 and 33 patients in the FFR- and
angiography-guided groups respectively. Graft failures of all grafts, death, myocardial infarction, stroke
and repeat revascularization were similar in both groups (16% vs. 12%; P = 0.97). After 6 months, deferred
lesions (n = 24) showed a significant reduction in mean FFR from index to follow-up (0.89 ± 0.05 vs. 0.81 ±
0.11; P = 0.002). The authors concluded that FFR-guided CABG had similar graft failure rates and clinical
outcomes as angiography-guided CABG. However, FFR was reduced significantly after 6 months in
deferred lesions and may potentially result in adverse events over longer follow-up.

[37]
The GRAFFITI trial , of which the 12 month outcomes were presented at Euro-PCR in 2018 (Paris,
France), was a prospective randomized trial that investigated the potential clinical benefits of FFR-
guided vs. angiography-guided CABG in patients with left anterior descending or left mainstem disease
and at least one other major coronary artery with angiographic intermediate stenosis (30%-90% diameter
stenosis). The study design is described in Figure 1. The intended CABG strategy was based solely on
coronary angiography after which patients underwent FFR- or angiography-guided randomization. In the
FFR group, the surgical planning was revised according to the functional significance of each coronary
stenosis after the FFR values were disclosed to the surgeons. After 12 months follow-up, the rate of graft
occlusion (20% and 19% in angiography- and FFR-guided groups respectively, P = 0.885, 64.5% complete),
rate of death (2% and 3% in angiography- and FFR-guided groups respectively, P = 0.65), myocardial
infarction (2% and 0% in angiography- and FFR-guided groups respectively, P = 0.15), stroke (0% and 2%
in angiography- and FFR-guided groups respectively, P = 0.16) and repeat revascularization (5% and 2% in
angiography- and FFR-guided groups respectively, P = 0.35) were reported to be similar for both groups.
Lesions with FFR measurement less than 0.8 were deferred in 53% and 29% in the angiography-guided and
FFR-guided groups respectively, which suggested that FFR-guidance was associated with higher functional
appropriateness (69% and 79% in angiography- and FFR-guided groups respectively). CABG was performed
on 44% of stenotic lesions with preserved FFR and deferred on 53% of lesions with abnormal FFR, which
translated to a significant reduced number of grafts.

Despite the paradigm shift toward physiological revascularization with all the benefits described, the
[38]
value of complete anatomical revascularization remains relevant. Mulukutla and colleagues recently
reported a propensity-matched retrospective, observational analysis of patients with multi-vessel CAD who
underwent angiography-guided CABG or FFR-PCI with second generation drug eluting stents between
2010 and 2018 and for whom data were available through the National Cardiovascular Data Registry or
The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Of the initial 6163 patients identified,
the propensity-matched cohort included 844 in each group. The estimated 1-year mortality was 11.5% and
7.2% (P < 0.001) in the PCI and CABG groups respectively and overall MACE and individual outcomes of