[Comment] Physiologically Guided CABG in Valve Surgery

Why It Matters

Demonstrating that functional lesion assessment can streamline CABG without sacrificing safety may reshape surgical revascularisation strategies and influence future guideline recommendations.

Key Takeaways

• FFR outperforms angiography for lesion severity assessment
• Angiography-derived FFR provides non‑invasive functional data
• FFR‑guided CABG may reduce graft numbers, increase patency
• Clinical outcome benefit of FFR‑guided CABG remains uncertain
• FAVOR IV‑QVAS offers first randomized data for valve surgery

Pulse Analysis

Fractional flow reserve (FFR) has become the gold standard for quantifying the physiological impact of coronary stenoses, outperforming visual angiographic estimates in both percutaneous coronary intervention (PCI) and long‑term patient outcomes. Landmark trials such as FAME and FAME‑2 demonstrated that wire‑based FFR guidance reduces unnecessary stenting and improves survival, prompting the development of angiography‑derived FFR algorithms that estimate pressure gradients without a pressure wire or hyperaemic drugs. These computational tools retain strong correlation with invasive measurements, expanding the reach of functional assessment to settings where wire‑based FFR is impractical.

The translation of FFR from catheter‑lab practice to coronary artery bypass grafting (CABG) has been slower, largely because surgical revascularisation traditionally relies on angiographic thresholds of 70 % (non‑left‑main) and 50 % (left‑main) stenosis. Early observational studies suggested that FFR‑guided CABG could trim graft numbers and boost arterial graft patency, yet hard evidence linking this strategy to mortality or major adverse cardiac events remained lacking. The multicentre, triple‑blind FAVOR IV‑QVAS trial, published in 2026, is the first randomized investigation evaluating angiography‑derived FFR versus standard angiography in patients undergoing valve surgery with concomitant coronary disease.

The FAVOR IV‑QVAS results showed a modest reduction in total grafts without compromising early postoperative outcomes, and a trend toward higher graft patency at one year, though the study was not powered to detect differences in long‑term survival. For cardiac surgeons, these findings suggest that functional lesion assessment can be integrated into operative planning, especially in complex valve‑plus‑coronary cases where graft economy matters. Wider adoption will depend on further trials confirming outcome benefits, cost‑effectiveness analyses, and incorporation of FFR metrics into future ACC/AHA revascularisation guidelines.