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. 2024 May 27;45(20):1804-1815.
doi: 10.1093/eurheartj/ehae199.

Coronary bypass surgery guided by computed tomography in a low-risk population

Patrick W Serruys  1 , Shigetaka Kageyama  1 , Giulio Pompilio  2   3 , Daniele Andreini  4   5 , Gianluca Pontone  2 , Saima Mushtaq  2 , Mark La Meir  6 , Johan De Mey  7 , Kaoru Tanaka  8 , Torsten Doenst  9 , Ulf Teichgräber  10 , Ulrich Schneider  9 , John D Puskas  11 , Jagat Narula  12 , Himanshu Gupta  13 , Vikram Agarwal  11 , Jonathon Leipsic  14 , Shinichiro Masuda  1 , Nozomi Kotoku  1 , Tsung-Ying Tsai  1 , Scot Garg  15 , Marie-Angele Morel  1 , Yoshinobu Onuma  1
Affiliations

Coronary bypass surgery guided by computed tomography in a low-risk population

Patrick W Serruys et al. Eur Heart J. .

Abstract

Background and aims: In patients with three-vessel disease and/or left main disease, selecting revascularization strategy based on coronary computed tomography angiography (CCTA) has a high level of virtual agreement with treatment decisions based on invasive coronary angiography (ICA).

Methods: In this study, coronary artery bypass grafting (CABG) procedures were planned based on CCTA without knowledge of ICA. The CABG strategy was recommended by a central core laboratory assessing the anatomy and functionality of the coronary circulation. The primary feasibility endpoint was the percentage of operations performed without access to the ICA. The primary safety endpoint was graft patency on 30-day follow-up CCTA. Secondary endpoints included topographical adequacy of grafting, major adverse cardiac and cerebrovascular (MACCE), and major bleeding events at 30 days. The study was considered positive if the lower boundary of confidence intervals (CI) for feasibility was ≥75% (NCT04142021).

Results: The study enrolled 114 patients with a mean (standard deviation) anatomical SYNTAX score and Society of Thoracic Surgery score of 43.6 (15.3) and 0.81 (0.63), respectively. Unblinding ICA was required in one case yielding a feasibility of 99.1% (95% CI 95.2%-100%). The concordance and agreement in revascularization planning between the ICA- and CCTA-Heart Teams was 82.9% with a moderate kappa of 0.58 (95% CI 0.50-0.66) and between the CCTA-Heart Team and actual treatment was 83.7% with a substantial kappa of 0.61 (95% CI 0.53-0.68). The 30-day follow-up CCTA in 102 patients (91.9%) showed an anastomosis patency rate of 92.6%, whilst MACCE was 7.2% and major bleeding 2.7%.

Conclusions: CABG guided by CCTA is feasible and has an acceptable safety profile in a selected population of complex coronary artery disease.

Keywords: Coronary artery bypass grafting; Coronary computed tomography; Feasibility; First-in-human; Proof-of-concept; Safety.

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Figures

Structured Graphical Abstract
Structured Graphical Abstract
Overview of the FAST TRACK CABG trial. ICA, invasive coronary angiography; CABG, coronary artery bypass grafting; CCTA, coronary computed tomography angiography; LAD, left anterior descending coronary artery; RA, radial artery; OM, obtuse marginal branch; LIMA, left internal mammary artery; D1, diagonal branch.
Figure 1
Figure 1
Flow chart of the study and number of patients at each stage. CABG, coronary artery bypass grafting; CCTA, coronary computed tomography angiography
Figure 2
Figure 2
Agreement between revascularization planned by the Heart Teams against actual treatment by using major epicardial vessel territories (MEVTs). Text incorporated in the manuscript describing the Venn diagram: a total of 533 MEVTs (diameter stenosis ≥50% with reference diameter > 1.5 mm) were detected by CCTA in 111 operated patients. In a clockwise fashion, from 9 o’clock, the total number of bypassed MEVTs (367) consists of 292 bypassed MEVTs targeted both by ICA- and CCTA-Heart Teams (centre), 27 bypassed MEVTs targeted only by ICA-Heart Team (ten O'clock), 11 bypassed MEVTs but not originally targeted by ICA- and CCTA-Heart Teams (twelve O'clock), and 37 bypassed MEVTs targeted only by CCTA-Heart Team (two O'clock). Six MEVTs targeted only by CCTA-Heart Team but not bypassed are depicted at five O'clock, and 43 MEVTs targeted by both ICA- and CCTA-Heart Teams but not bypassed are depicted at seven O'clock. Twenty MEVTs targeted only by ICA-Heart Team but not bypassed are depicted at eight O'clock. Ninety-seven MEVTs have to be added to all the options depicted in the Venn diagram (436) and constitute the overall denominator of the kappa calculation. CCTA, coronary computed tomography angiography; ICA, invasive coronary angiography
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