Fractional Flow–Guided Coronary Artery Bypass Grafting

The traditional basis for all forms of coronary artery revascularization has been the percent stenosis resulting from an atherosclerotic plaque or thrombotic occlusion based on coronary angiography. With the introduction of fractional flow reserve (FFR) technology, a new gold standard has been developed to assess the severity of a coronary artery stenosis that takes into account the physiology of that stenosis.Article see p 1405FFR is defined as the ratio of maximal blood flow across a stenotic lesion compared with normal maximal flow. It is measured with a coronary pressure guidewire and is compared with the aortic pressure measured simultaneously with the guide catheter during maximum hyperemia. An FFR value of 90%.1 The FFR technique requires some extra manipulation during the catheterization, and a central line may be necessary if intravenous adenosine is used to elicit the maximal hyperemic response. Although there is potential for trauma to the coronary vessel, this complication is rarely reported.Initially, FFR was used to determine the applicability of stenting for patients with single-vessel disease. In a study involving 67 patients with multivessel disease, Melikian and coworkers2 showed that FFR measurements were not influenced by either the presence or absence of stenosis in other adjacent vessels and could be used to assess coronary stenosis in patients with multivessel disease. The Fractional Flow Reserve Versus Angiography in Multivessel Evaluation (FAME) I trial used FFR to determine the need for stent deployment in 1005 patients with ≥2 diseased coronary arteries compared with decisions based on angiography alone.3 The primary end point, a combination of death, myocardial infarction, and the need for repeat revascularization, occurred in 18.3% of patients in the angiography group compared with 13.2% in the FFR group ( P …