Long-Term Clinical Outcomes After Physiology-Guided vs Angiography-Guided Coronary Artery Bypass Grafting: From the FARGO Trial

BACKGROUND: Fractional flow reserve (FFR)-guided coronary artery bypass grafting (CABG) may reduce unnecessary grafts and improve outcomes. However, in the FARGO (Fractional Flow Reserve vs Angiography Randomization for Graft Optimization) trial, FFR was reduced significantly after 6 months in deferred lesions. OBJECTIVES: The purpose of this study was to evaluate long-term clinical outcomes after FFR-guided CABG compared to angiography-guided CABG. METHODS: In this multicenter randomized clinical trial, 100 patients were randomized to FFR-guided (n = 50) or angiography-guided CABG (n = 50). Patients underwent a 6-month follow-up coronary angiography with FFR in deferred lesions. In this extended long-term follow-up revascularization, myocardial infarction, stroke, death, and major adverse cardiac and cerebrovascular events (MACCE), a composite of the individual endpoints, were assessed. RESULTS: After a median follow-up of 8.8 years (IQR: 8.3, 9.3), patients in the FFR-guided group had significantly more MACCE compared to the angiography-guided group, (26 [52%] vs 16 [32%], log-rank test P = 0.03). This difference was driven by significantly more long-term revascularization, FFR-guided CABG 32% vs angiography-guided 12%, log-rank test P = 0.01. The revascularization rate was significantly higher from 0 to 1 year (12 [24%] vs 3 [6%], log-rank test P = 0.01), whereas beyond 1 year, rates were similar (4 [8%] vs 3 [6%], log-rank test P = 0.47). Most patients had stable symptoms, and revascularization was symptom-driven. Myocardial infarction (6 [12%] vs 3 [6%]), death (10 [20%] vs 7 [14%]), and stroke (6 [12%] vs 6 [12%]) did not differ significantly between the groups. CONCLUSIONS: FFR-guided CABG was associated with a significantly higher rate of MACCE after CABG, driven by more revascularization within the first year.