Outcomes of Fractional Flow Reserve-Based Deferral in Saphenous Vein Graft Narrowing

Diagnostic and Management Strategies in Patients with Late Recurrent Angina after Coronary Artery Bypass Grafting

PURPOSE OF REVIEW

This review will outline the current evidence on the anatomical, functional, and physiological tools that may be applied in the evaluation of patients with late recurrent angina after coronary artery bypass grafting (CABG). Furthermore, we discuss management strategies and propose an algorithm to guide decision-making for this complex patient population.

RECENT FINDINGS

Patients with prior CABG often present with late recurrent angina as a result of bypass graft failure and progression of native coronary artery disease (CAD). These patients are generally older, have a higher prevalence of comorbidities, and more complex atherosclerotic lesion morphology compared to CABG-naïve patients. In addition, guideline recommendations are based on studies in which post-CABG patients have been largely excluded. Several invasive and non-invasive diagnostic tools are currently available to assess graft patency, the hemodynamic significance of native CAD progression, left ventricular function, and myocardial viability. Such tools, in particular the latest generation coronary computed tomography angiography, are part of a systematic diagnostic work-up to guide optimal repeat revascularization strategy in patients presenting with late recurrent angina after CABG.

Long-term outcome after deferred revascularization due to negative fractional flow reserve in intermediate coronary lesions

Objectives

The aim was to assess long‐term outcome after deferring intervention of coronary lesions with a fractional flow reserve (FFR) value of >0.80 in a real‐world patient population and then to identify factors associated with deferred target lesion failure (DTLF).

Background

Deferring coronary interventions of intermediate lesions based on FFR measurement is safe, irrespective of the extent of coronary artery disease. However, FFR values near the cut‐off of >0.80 may have less favorable outcome.

Methods

A retrospective analysis was performed in patients with deferred coronary intervention based on FFR value >0.80. The primary endpoint was DTLF, a composite of acute coronary syndrome (ACS) and any coronary revascularization, related to the initially deferred stenosis.

Results

A total of 600 patients, mean age of 66 ± 10 years, and 751 coronary lesions with negative FFR values (mean 0.88 ± 0.04) were included. The mean follow‐up was 27 ± 15 months. DTLF occurred in 44 patients (7.3%), revascularization in 42 (7%), and ACS without revascularization in 2 patients (0.3%). Patients with DTLF more often had diabetes mellitus, previous coronary artery bypass grafting, multivessel disease (MVD), and lower FFR at inclusion. Multivariable regression analysis showed that lower deferred FFR values [FFR 0.81–0.85: hazard ratio (HR) 2.79 (95% CI [confidence interval]; 1.46–5.32), p .002], MVD [HR 1.98 (95% CI; 1.05–3.75), p .036], distal lesions [HR 2.43 (95% CI; 1.29–4.57), p .006], and lesions located in a saphenous vein graft (SVG) [HR 6.35 (95% CI; 1.81–22.28), p .004] were independent predictors for DTLF.

Conclusions

The long‐term rate of DTLF of initially deferred coronary lesions was 7.3%. Independent predictors for DTLF are lower deferred FFR value, the presence of MVD, distal lesions, and lesions in SVG.