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. 2001 Nov;86(5):547–552. doi: 10.1136/heart.86.5.547

Value of fractional flow reserve in making decisions about bypass surgery for equivocal left main coronary artery disease

G Bech 1, H Droste 1, N Pijls 1, B De Bruyne 1, J Bonnier 1, H Michels 1, K Peels 1, J Koolen 1
PMCID: PMC1729979  PMID: 11602550

Abstract

OBJECTIVE—To investigate the value of coronary pressure derived fractional flow reserve (FFR) measurements in supporting decisions about medical or surgical treatment in patients with angiographically equivocal left main coronary artery stenosis.
DESIGN—A two centre prospective single cohort follow up study.
INTERVENTIONS—FFR of the left main coronary artery was determined in 54 consecutive patients with angiographically equivocal left main coronary artery disease. If FFR was ⩾ 0.75, medical treatment was chosen; if FFR was < 0.75, surgical treatment was chosen.
MAIN OUTCOME MEASURES—Freedom from death, myocardial infarction, or any coronary revascularisation procedure.
RESULTS—In 24 patients (44%), FFR was ⩾ 0.75 and medical treatment was chosen (medical group). In the remaining 30 patients (56%), FFR was < 0.75 and bypass surgery was performed (surgical group). Mean (SD) follow up was 29 (15) months (range 12-65 months). Survival among patients at three years of follow up was 100% in the medical group and 97% in the surgical group. Event-free survival was 76% in the medical group and 83% in the surgical group.
CONCLUSIONS—FFR supports decision making in equivocal left main coronary artery disease. If FFR is below 0.75, the decision for bypass surgery is supported. If FFR is above 0.75, a conservative approach is justified.


Keywords: coronary artery disease; left main coronary artery; fractional flow reserve; coronary artery bypass

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Figure 1  .

Figure 1  

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(A) Coronary angiogram in the right anterior oblique projection of a 58 year old man with anginal complaints, a reversible defect on exercise perfusion scintigraphy in the anterior wall, a 40% stenosis (arrow) at the transition of the distal left main coronary artery (LM), and an 80% stenosis of the proximal left anterior descending coronary artery (LAD). The dilemma was to decide whether the ischaemia was caused by the proximal LAD disease only or also by the left main stenosis, and consequently if bypass surgery should be performed or only percutaneous transluminal coronary angioplasty (PTCA) of the proximal LAD. (B) Paper speed is 25 mm/s. The pressure wire is advanced until the sensor is close to the tip of the guiding catheter to confirm that two identical signals are obtained. Pa is the pressure as measured by the guiding catheter and Pd the pressure as measured by the pressure wire. The pressure wire is then advanced across the LM stenosis into the large intermediate branch and no gradient is observed at rest. (C) Paper speed is 5 mm/s. About 20 seconds after the start of the intravenous adenosine infusion (140 µg/kg/min) a pressure gradient gradually develops (arrow) and at steady state, maximum coronary hyperaemic myocardial fractional flow reserve is calculated by the ratio between Pd and Pa [80/86 = 0.93], indicating that this left main lesion in itself was not significant from a functional point of view. (D) About 30 seconds after cessation of adenosine infusion the pressure gradient disappears and returns to baseline. In this patient bypass surgery was deferred and he underwent PTCA of the proximal left anterior descending stenosis only. FFR of the LAD was 0.63 before and 0.94 after PTCA.

Figure 2  .

Figure 2  

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(A) Coronary angiogram in the right anterior oblique projection from a 36 year old man who experienced an anterior wall myocardial infarct, successfully treated by thrombolysis. At angiography only a 40% stenosis (arrow) of the distal left main coronary artery (LM) was visible, and there was mild hypokinesia of the anterior wall segments. Perfusion scintigraphy performed several weeks later was negative. The dilemma was whether to perform bypass surgery or to leave this lesion untreated. (B) A pressure wire is advanced to the tip of the coronary catheter, and equal pressures are registered at that position by the guiding catheter (Pa) and the pressure sensor (Pd ). (C) The pressure wire is advanced across the left main stenosis into the left circumflex coronary artery and a large gradient is observed at rest. After start of intravenous adenosine infusion (140 µg/kg/min), this gradient gradually further increases and at steady state maximum coronary hyperaemic myocardial fractional flow reserve is calculated by the ratio between Pd and Pa [40/90 = 0.44], indicating that this left main lesion is physiologically highly significant. (D) Shows how the wire is positioned in the left anterior descending coronary artery and slowly withdrawn and advanced across the left main stenosis. Because the pressure sensor is located at 3 cm from the tip of the wire, this pull-back/push-up procedure can be performed repeatedly under fluoroscopy. It confirms the presence and exact location of a stenosis. This patient was treated by bypass surgery.

Figure 3  .

Figure 3  

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Relation between reference diameter, minimum lumen diameter, and per cent diameter stenosis versus myocardial fractional flow reserve. Empty circles represent the 24 patients in the medical group with left main coronary artery FFR ⩾ 0.75; filled circles represent the 30 patients in the surgical group with left main coronary artery FFR < 0.75. 

Figure 4  .

Figure 4  

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Estimated survival and event-free survival curves after three years of follow up (Kaplan-Meier) for the two study groups. The medical group consisted of 24 patients with an equivocal left main coronary artery stenosis in whom bypass surgery was deferred on the basis of a left main coronary artery FFR of ⩾ 0.75. The surgical group consisted of 30 patients with an equivocal left main coronary artery stenosis in whom bypass surgery was performed on the basis of a left main coronary artery FFR of < 0.75. Numbers below the x axis represent patients at risk at one, two, and three years of follow up.

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