Abbasciano R G, Layton G R, Torre S, Abbaker N, Copperwheat A, Lucarelli C, Bhandari S, Nijjer S, Mikhail G, Casula R, Zakkar M, Viviano A
Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom.
Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.
Front Cardiovasc Med. 2024 Mar 7;11:1348341. doi: 10.3389/fcvm.2024.1348341. eCollection 2024.
Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are invasive methods to assess the functional significance of intermediate severity coronary lesions. Both indexes have been extensively validated in clinical trials in guiding revascularisation in patients with stable ischaemic heart disease undergoing percutaneous coronary intervention (PCI) with improved clinical outcomes. However, the role of these tools in coronary artery bypass grafting (CABG) is less clear.
A meta-analysis of randomised trials and observational studies was carried out to help in determining the optimal strategy for assessing lesion severity and selecting graft targets in patients undergoing CABG. Electronic searches were carried out on Embase, MEDLINE, and Web of Science. A group of four authors independently screened and then assessed the retrieved records. Cochrane's Risk of Bias and Robins-I tools were used for bias assessment. A survey was conducted among surgeons and cardiologists to describe current attitudes towards the preoperative use of functional coronary investigations in practice.
Clinical outcomes including mortality at 30 days, perioperative myocardial infarction, number of grafts, incidence of stroke, rate of further need for revascularisation, and patient-reported quality of life did not differ in CABG guided by functional testing from those guided by traditional angiography.The survey revealed that in half of the surgical and cardiology units functional assessment is performed in CABG patients; there is a general perception that functional testing has improved patient care and its use would clarify the role of moderate coronary lesions that often need multidisciplinary rediscussions; moderate stenosis are felt to be clinically relevant; and anatomical considerations need to be taken into account together with functional assessment.
At present, the evidence to support the routine use of functional testing in intermediate lesions for planning CABG is currently insufficient. The pooled data currently available do not show an increased risk in mortality, myocardial injury, and stroke in the FFR/iFR-guided group. Further trials with highly selected populations are needed to clarify the best strategy.
ClinicalTrials.gov, identifier (CRD42023414604).
血流储备分数（FFR）和瞬时无波比值（iFR）是评估中度严重冠状动脉病变功能意义的侵入性方法。这两个指标在临床试验中已得到广泛验证，可指导接受经皮冠状动脉介入治疗（PCI）的稳定型缺血性心脏病患者进行血运重建，改善临床结局。然而，这些工具在冠状动脉旁路移植术（CABG）中的作用尚不清楚。
进行了一项随机试验和观察性研究的荟萃分析，以帮助确定评估接受CABG患者病变严重程度和选择移植靶点的最佳策略。在Embase、MEDLINE和Web of Science上进行了电子检索。由四位作者组成的小组独立筛选并评估检索到的记录。采用Cochrane偏倚风险工具和Robins-I工具进行偏倚评估。对外科医生和心脏病专家进行了一项调查，以描述目前在实践中对术前使用功能性冠状动脉检查的态度。
在功能性测试指导下进行CABG的患者与传统血管造影指导下的患者相比，30天死亡率、围手术期心肌梗死、移植血管数量、中风发生率、再次血运重建需求率以及患者报告的生活质量等临床结局并无差异。调查显示，在一半的外科和心脏病科单位中，对接受CABG的患者进行了功能评估；普遍认为功能测试改善了患者护理，其应用将明确经常需要多学科重新讨论的中度冠状动脉病变的作用；认为中度狭窄具有临床相关性；并且在进行功能评估时需要考虑解剖因素。
目前，支持在中度病变中常规使用功能测试来规划CABG的证据不足。目前汇总的数据未显示FFR/iFR指导组的死亡率、心肌损伤和中风风险增加。需要对高度选择的人群进行进一步试验，以明确最佳策略。
ClinicalTrials.gov，标识符（CRD42023414604）。
