Hansson Emma C, Omerovic Elmir, Venetsanos Dimitrios, Alfredsson Joakim, Martinsson Andreas, Redfors Björn, Taha Amar, Nielsen Susanne J, Jeppsson Anders
Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Blå Stråket 5, plan 5, Gothenburg S-413 45, Sweden.
Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, SU Sahlgrenska, Gothenburg S-413 45, Sweden.
Eur Heart J. 2025 Aug 21;46(32):3214-3223. doi: 10.1093/eurheartj/ehaf327.
Physiological flow assessment of coronary stenoses, such as fractional flow reserve, are routinely used to guide percutaneous coronary intervention, but it has not been equally recognized to guide coronary artery bypass grafting (CABG). Mid-term outcomes in CABG patients with and without preoperative flow assessment were compared.
All patients with first-time isolated CABG in Sweden 2013-2020 were identified in the SWEDEHEART registry (n = 18 211), which also provided information on flow assessment. Data were linked with three mandatory national registries. Median follow-up was 3.6 years (range 0-7.5). Incidence of all-cause mortality, stroke, new myocardial infarction, new coronary angiography, and new revascularization was compared using adjusted Cox regression models. The proportional hazard assumption was violated for new angiography and revascularization. Hence, follow-up was divided into 0-2 and >2 years.
Overall, 2869 patients (15.8%) had flow assessment before surgery, increasing from 7.1% in 2013% to 21.5% in 2020. Patients with flow assessment were younger, had a lower EuroSCORE II, and received fewer distal anastomoses (3.0 ± 0.9 vs 3.2 ± 1, P < .001). There were no associations between flow assessment and mortality, post-discharge myocardial infarction, or stroke. New angiography and new revascularization were not significantly different 0-2 years, but preoperative flow assessment was associated with a higher risk for new angiography [adjusted hazard ratio (aHR) 1.32, 95% confidence interval (CI) 1.08-1.62, P = .008] and new revascularization (aHR 1.55, 95% CI 1.18-2.04, P = .002) >2 years after CABG.
Preoperative flow assessment was not associated with improved clinical outcomes but with a higher risk for new angiography and new revascularization >2 years after CABG. The results suggest that the use of flow assessment with current cut-off levels may not be applicable in CABG, and further studies are needed.
冠状动脉狭窄的生理血流评估，如血流储备分数，常用于指导经皮冠状动脉介入治疗，但在指导冠状动脉旁路移植术（CABG）方面尚未得到同等认可。比较了术前进行血流评估和未进行血流评估的CABG患者的中期结局。
在瑞典心脏注册研究（SWEDEHEART registry，n = 18211）中识别出2013 - 2020年所有首次进行孤立性CABG的患者，该研究还提供了血流评估信息。数据与三个强制性国家注册机构相关联。中位随访时间为3.6年（范围0 - 7.5年）。使用校正后的Cox回归模型比较全因死亡率、中风、新发心肌梗死、新发冠状动脉造影和新发血运重建的发生率。新发造影和血运重建违反了比例风险假设。因此，随访分为0 - 2年和>2年。
总体而言，2869例患者（15.8%）在手术前进行了血流评估，从2013年的7.1%增至2020年的21.5%。进行血流评估的患者更年轻，欧洲心脏手术风险评估系统II（EuroSCORE II）更低，且接受的远端吻合术更少（3.0±0.9对3.2±1，P <.001）。血流评估与死亡率、出院后心肌梗死或中风之间无关联。新发冠状动脉造影和新发血运重建在0 - 2年时无显著差异，但术前血流评估与CABG后>2年新发冠状动脉造影的较高风险相关[校正风险比（aHR）1.32，95%置信区间（CI）1.08 - 1.62，P =.008]和新发血运重建（aHR 1.55，95% CI 1.18 - 2.04，P =.002）。
术前血流评估与改善临床结局无关，但与CABG后>2年新发冠状动脉造影和新发血运重建的较高风险相关。结果表明，使用当前截断水平的血流评估可能不适用于CABG，需要进一步研究。
