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CARDIOLOGIE ARTIKELS
ABSTRACT 2
ABSTRACT 1
Graft patency after FFR-guided versus angiographyguided coronary artery bypass grafting: the GRAFFITI trial.
Image focus: renovascular hypertension. Dhont S, De Niel C, Van Mieghem C, et al. Acta Cardiologica, 2019, [Epub ahead of print], 1-2
Toth G, De Bruyne B, Van Mieghem C, et al. EuroIntervention, 2019, 15(11), e999-e1005
OBJECTIVE INTRODUCTION/BACKGROUND Four out of ten adults worldwide have arterial hypertension, in about 5–10% there is an identifiable cause named as secondary hypertension. Early detection and treatment of these entities are important to minimize/prevent irreversible changes in the vasculature and target organs. Renovascular hypertension results from a lesion that impairs blood flow to one or both kidneys.
CONCLUSION A 56-year-old man was referred because of resistant arterial hypertension. Lab results showed renal impairment after recently adding an angiotensin converting enzyme inhibitor: creatinine 1.83 mg/dL (baseline creatinine 0.93 mg/dL) corresponding to a calculated clearance of 41 ml/ min/1.73m2 according to the formula of CKD-EPI. A computer tomographic examination of the abdominal blood vessels showed an osteal occlusion of the right renal artery with a hypotrophic occurrence of the right kidney (Figure 1). Renin level on serum was 24.6 ug/L/h; normal values for patients older than 40 years are 0.6–3.0 ug/L/h. Additionally, a dimercaptosuccinic acid (DMSA) renal scan was performed to measure the kidney function: the right kidney turned out to be non-functional (almost absent captation, Figure 2). Studies with DMSA-scan present high specificity and are useful in patients with high probability for renovascular hypertension. After laparoscopic nephrectomy, the antihypertensive drugs could be systematically phased out. During the operation, the renal artery was dissected and confirmed the presence of severe atherosclerosis. Peri-operative renin levels showed extremely high values at the right renal vein and immeasurably low dosage at left renal vein (Table 1). The arterial stenosis thus causes local renal ischaemia which stimulates renin release and activation of the renin-angiotensinaldosterone system, which in turn results in secondary hypertension.
The aim of this study was to assess prospectively the clinical benefits of fractional flow reserve (FFR) in guiding coronary artery bypass grafting (CABG).
MATERIALS/METHODS GRAFFITI is a single-blinded, prospective, multicentre, randomised controlled trial of FFR-guided versus angiography-guided CABG. We enrolled patients undergoing coronary angiography, having a significantly diseased left anterior descending artery or left main stem and at least one more major coronary artery with intermediate stenosis, assessed by FFR. Surgical strategy was defined based on angiography, blinded to FFR values prior to randomisation. After randomisation, patients were operated on either following the angiography-based strategy (angiography-guided group) or according to FFR, i.e., with an FFR ≤0.80 as cutoff for grafting (FFR-guided group). The primary endpoint was graft patency at 12 months. Between March 2012 and December 2016, 172 patients were randomised either to the angiography-guided group (84 patients) or to the FFR-guided group (88 patients). The patients had a median of three [3; 4] lesions; diameter stenosis was 65% (50%; 80%), FFR was 0.72 (0.50; 0.82). Compared to the angiography-guided group, the FFR-guided group received fewer anastomoses (3 [3; 3] vs 2 [2; 3], respectively; p=0.004). One-year angiographic follow-up showed no difference in overall graft patency (126 [80%] vs 113 [81%], respectively; p=0.885). One-year clinical follow-up, available in 98% of patients, showed no difference in the composite of death, myocardial infarction, target vessel revascularisation and stroke.
CONCLUSION FFR guidance of CABG has no impact on one-year graft patency, but it is associated with a simplified surgical procedure.
CARDIOLOGIE
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