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(Circulation. 2009;120:1505-1512.)
© 2009 American Heart Association, Inc.

Interventional Cardiology

Long-Term Clinical Outcome After Fractional Flow Reserve–Guided Treatment in Patients With Angiographically Equivocal Left Main Coronary Artery Stenosis

Michalis Hamilos, MD, PhD^*; Olivier Muller, MD, PhD^*; Thomas Cuisset, MD; Argyrios Ntalianis, MD, PhD; Gregory Chlouverakis, PhD; Giovanna Sarno, MD; Olivier Nelis, RN; Jozef Bartunek, MD, PhD; Marc Vanderheyden, MD; Eric Wyffels, MD; Emanuele Barbato, MD, PhD; Guy R. Heyndrickx, MD, PhD; William Wijns, MD, PhD; Bernard De Bruyne, MD, PhD

From the Cardiovascular Centre Aalst, Aalst, Belgium (M.H., O.M., T.C., A.N., G.S., O.N., J.B., M.V., E.W., E.B., G.R.H., W.W., B.D.B.), and Laboratory of Biostatistics, Medical School, University of Crete, Crete, Greece (G.C.).

Correspondence to Bernard De Bruyne, MD, PhD, Cardiovascular Center Aalst, OLV Hospital, Moorselbaan, 164, B-9300 Aalst, Belgium. E-mail bernard.de.bruyne{at}olvz-aalst.be

Received September 4, 2008; accepted July 31, 2009.

Background— 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.

Methods and Results— In 213 patients with an angiographically equivocal left main coronary artery stenosis, FFR measurements and quantitative coronary angiography were performed. When FFR was 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.

Conclusions— 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.

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CLINICAL PERSPECTIVE

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Clinical Summaries
Circulation 2009 120: 1457-1458. [Extract] [Full Text]