| Objective:In recent years,functional evaluations of the coronary artery stenosis,such as blood flow reserve fraction(FFR)and instantaneous wave-free ratio(iFR),have been shown to be useful in guiding coronary artery revascularization strategies,but the invasive manipulation and high cost of these procedures have limited their widespread clinical application.Quantitative flow ratio(QFR)is derived from the functional evaluation of coronary angiography,this index is calculated based solely on coronary angiography,and has satisfied consistency with FFR and has good clinical application prospects.However,limited studies and evidences provide definitive answer to the question of "whether the QFR can be used as a functional diagnostic tool to further guide the clinical results of coronary artery revascularization strategies combined with adult cardiac surgery".This study was a large-sample,single-center,retrospective study aiming to compare the relationship between functional complete or incomplete revascularization strategies,and between overtreatment or non-overtreatment revascularization strategies and clinical outcomes in adult cardiac surgery by selecting patients who intend to undergo adult cardiac surgery and diagnosed coronary heart disease with long-term follow-up.Methods:From January 1,2014,to December 31,2017,we retrospectively enrolled patients who underwent adult extracorporeal cardiac surgery at Fuwai Hospital,Chinese Academy of Medical Sciences,and whose preoperative coronary angiography reports suggested at least one coronary stenosis of 30%-90%.For each of the abovementioned coronary lesions,QFR calculation was performed by a qualified specialist.We divided the patients into two cohorts.Cohort 1 was designed to assess the outcomes in patients receiving clinically insufficient functional therapy(QFR≤0.8).Patients enrolled in cohort 1 were required to have at least one vessel with a QFR ≤0.8.To eliminate interference of QFR>0.8 lesions,patients were excluded when any QFR>0.8 lesions were re-vascularized.The patients in Cohort 1 were divided into two groups based on the following principles:if all of the QFR≤0.8 vessels were revascularized,it was defined as the complete revascularization group;if any of the QFR≤0.8 vessels were not revascularized,it was defined as the incomplete revascularization group.Cohort 2 was designed to assess the clinical outcomes in patients who had received functional overtreatment(QFR>0.8).Patients were included if all target vessels QFR>0.8,while patients with target vessels QFR ≤0.8 were to be excluded.The cohort was divided into two groups according to the following principles:if any QFR>0.8 vessel was revascularized,it was defined as the overtreatment group;if none of the QFR>0.8 vessels were revascularized,it was defined as the non-overtreatment group.We collected baseline information,surgical data,and followed up patients for long-term survival data.The primary endpoint was the composite outcome of major cardiovascular and cerebrovascular adverse events,including all-cause death,nonfatal myocardial infarction,stroke,and repeat revascularization.Results:A total of 884 consecutive patients were enrolled in this study.A total of 284 patients were enrolled for cohort 1,of which 89 patients were included in the incomplete revascularization group and 195 patients were included in the complete revascularization group.Compared to the incomplete revascularization group,a higher proportion of patients in the complete revascularization group underwent coronary revascularization simultaneously with cardiac surgery(195(100%)vs.89(40.4%),p<0.0001),extracorporeal circulation time(147.76 ± 50.56 vs.127.27±60.24,p=0.0060)and block time(109.65 ± 39.99 vs 92.39 ± 42.56,p=0.0011)were longer,and perioperative death(4(4.5%)vs 2(1.0%),p=0.0794),major perioperation complications such as perioperative myocardial infarction(8(4.1%)vs 5(5.6%),p = 0.5535),and Secondary open-heart exploration(0(0.0%)vs 2(1.0%),p=1.0000)were not statistically different,and postoperative IABP(4(4.5%)vs.0(0.0%),p=0.0092)was used less frequently.Mean follow-up time for cohort 1 patients was 68.7(57.6-77.4)months.We used the patients’ risk factors and surgical types through a COX retrospective model to adjust patient characteristics,the result showed the incidence of major adverse cerebral-cardiovascular event(MACCE)in the complete revascularization group(43(48.3%)vs.28(14.8%);risk ratio.0.253;95%confidence interval,0.157-0.408;p<0.0001),the incidence of all-cause death(26(29.2%)vs 12(6.3%);risk ratio,0.200;95%confidence interval,0.101-0.397;p<0.0001),and the incidence of cardiac death(9(10.1%)vs 3(1.6%);risk ratio,0.146;95%confidence interval,0.040-0.541;p=0.0040),and the incidence of nonfatal infarction(6(6.7%)vs 2(1.1%);risk ratio,0.128;95%confidence interval,0.026-0.636;p=0.0119)were significantly lower than in the incomplete revascularization group.Subgroup analysis revealed a lower rate of distant MACCE events in patients with complete revascularization for different subgroups of age,sex,preoperative SYNTAX score,whether valve surgery alone was performed,and type of coronary lesion.A total of 479 patients were eligible for cohort 2 enrollment,of which 156 patients were included in the overtreatment group and 323 patients were included in the non-overtreatment group.Compared to the overtreatment group,extracorporeal circulation time(102.13± 44.17 vs 138.08± 52.19,p<0.0001)and block time(73.02 ± 31.94 vs 101.58 ± 37.11,p=<0.0001)in the non-overtreatment group were shorter,and no statistical difference in the incidence of perioperative death(4(4.5%)vs 2(1.0%),p=0.0794),no statistical difference in the incidence of major complications such as perioperative myocardial infarction(1(0.6%)vs 1(0.3%),p=0.5457),secondary open heart exploration(1(0.6%)vs 1(0.3%),p=0.5457),and postoperative IABP(2(1.3%)vs 0(0.0%),p=0.1056).Follow-up time for cohort 2 patients was 69.5(61.1-80.0)months.We corrected for patient risk factors and type of procedure by COX retrospective model,which showed major adverse cerebral-cardiovascular event(MACCE)in the non-overtreatment group(27(17.4%)vs 37(11.9%);risk ratio,0.678.95%confidence interval,0.391-1.174;p=0.1656)was not statistically different from the incidence of the other secondary endpoints:all-cause death(9(5.8%)vs 16(5.1%);risk ratio,1.016;95%confidence interval,0.411-2.514;p=0.9724),cardiac death(2(1.3%)vs 4(1.3%);risk ratio,1.280;95%confidence interval,0.194-8.440;p=0.7976),nonfatal myocardial infarction(5(3.2%)vs 4(1.3%);risk ratio,0.373;95%confidence interval,0.085-1.637;p=0.1912),re-coronary revascularization(1(0.6%)vs 2(0.6%);risk ratio,15.078;95%confidence interval,0.130-1751.8;p=0.2634),and stroke(13(8.4%)vs 15(4.8%);risk ratio,0.518;95%confidence interval,0.230-1.166;p=0.1120),were not statistically different.Subgroup analysis showed no statistical difference in the incidence of MACCE between the two groups for different subgroups of age,male gender,preoperative SYNTAX score,whether valve surgery alone was performed or not,and type of coronary lesion,except for the subgroup of female patients.the incidence of MACCE in non-overtreatment group was lower.Conclusions:The results of this study showed that for adult cardiac surgery patients with coronary heart disease,the perioperative safety results of functional complete revascularization strategy were consistent with those of non-complete revascularization strategy,and the incidence of long-term major cardiovascular and cerebrovascular adverse events in patients with complete revascularization was significantly reduced.Compared with the functional overtreatment revascularization strategy,the cardiopulmonary bypass time and blocking time of the non-overtreatment revascularization strategy were significantly shorter,and the perioperative safety results and long-term major adverse cardiovascular and cerebrovascular events were consistent. |
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