Hamilos Michalis, Muller Olivier, Cuisset Thomas, Ntalianis Argyrios, Chlouverakis Gregory, Sarno Giovanna, Nelis Olivier, Bartunek Jozef, Vanderheyden Marc, Wyffels Eric, Barbato Emanuele, Heyndrickx Guy R, Wijns William, De Bruyne Bernard
Cardiovascular Center Aalst, OLV Hospital, Moorselbaan, 164, B-9300 Aalst, Belgium.
Circulation. 2009 Oct 13;120(15):1505-12. doi: 10.1161/CIRCULATIONAHA.109.850073. Epub 2009 Sep 28.
Significant left main coronary artery stenosis is an accepted indication for surgical revascularization. The potential of angiography to evaluate the hemodynamic severity of a stenosis is limited. The aims of the present study were to assess the long-term clinical outcome of patients with an angiographically equivocal left main coronary artery stenosis in whom the revascularization strategy was based on fractional flow reserve (FFR) and to determine the relationship between quantitative coronary angiography and FFR.
In 213 patients with an angiographically equivocal left main coronary artery stenosis, FFR measurements and quantitative coronary angiography were performed. When FFR was > or =0.80, patients were treated medically or another stenosis was treated by coronary angioplasty (nonsurgical group; n=138). When FFR was <0.80, coronary artery bypass grafting was performed (surgical group; n=75). The 5-year survival estimates were 89.8% in the nonsurgical group and 85.4% in the surgical group (P=0.48). The 5-year event-free survival estimates were 74.2% and 82.8% in the nonsurgical and surgical groups, respectively (P=0.50). Percent diameter stenosis at quantitative coronary angiography correlated significantly with FFR (r=-0.38, P<0.001), but a very large scatter was observed. In 23% of patients with a diameter stenosis <50%, the left main coronary artery stenosis was hemodynamically significant by FFR.
In patients with equivocal stenosis of the left main coronary artery, angiography alone does not allow appropriate individual decision making about the need for revascularization and often underestimates the functional significance of the stenosis. The favorable outcome of an FFR-guided strategy suggests that FFR should be assessed in such patients before a decision is made "blindly" about the need for revascularization.
左主干冠状动脉严重狭窄是公认的外科血运重建指征。血管造影评估狭窄血流动力学严重程度的能力有限。本研究的目的是评估血管造影显示左主干冠状动脉狭窄情况不明确、血运重建策略基于血流储备分数（FFR）的患者的长期临床结局，并确定定量冠状动脉造影与FFR之间的关系。
对213例血管造影显示左主干冠状动脉狭窄情况不明确的患者进行了FFR测量和定量冠状动脉造影。当FFR≥0.80时，患者接受药物治疗或对另一处狭窄进行冠状动脉成形术（非手术组；n = 138）。当FFR<0.80时，进行冠状动脉旁路移植术（手术组；n = 75）。非手术组5年生存率估计为89.8%，手术组为85.4%（P = 0.48）。非手术组和手术组5年无事件生存率估计分别为74.2%和82.8%（P = 0.50）。定量冠状动脉造影时的直径狭窄百分比与FFR显著相关（r = -0.38，P<0.001），但观察到很大的离散度。在直径狭窄<50%的患者中，23%的左主干冠状动脉狭窄通过FFR评估具有血流动力学意义。
对于左主干冠状动脉狭窄情况不明确的患者，仅靠血管造影无法就血运重建的必要性做出恰当的个体化决策，且常常低估狭窄的功能意义。FFR指导策略的良好结局表明，在对这些患者“盲目”做出血运重建必要性决策之前，应评估FFR。
