strategies for revascularization in patients undergoing heart valve surgery with concomitant coronary artery disease

Conditions: Coronary Artery Disease; Valvular Heart Disease

Summary: the purpose of this study is to determine whether, in patients undergoing elective valvular heart surgery, revascularization of concomitant coronary artery disease (cad) guided by ffr (fractional flow reserve) would be superior to standard angiography-guided-revascularization approach on major efficacy and safety outcomes

the save-it trial is a multicenter, international, randomized, controlled, superiority trial. patients scheduled to undergo elective valvular heart surgery will be screened for presence of concomitant coronary artery disease (cad) by invasive coronary angiography. patients with a stenosis \> 50% in at least one epicardial vessel (excluding left main) considered suitable for surgical revascularization will be randomized to ffr guided- or standard angiography-guided surgical revascularization. a proportion of patients with no concomitant cad will be followed in a parallel registry baseline clinical, laboratory, electrocardiographic and echocardiographic data will be obtained. coronary anatomy severity will be assessed by quantitative coronary angiography (qca) and synergy between percutaneous coronary intervention with taxus and cardiac surgery (syntax) score. surgical risk will be assessed by euroscore. patients randomized to ffr-guided arm will have functional severity of the angiographic stenosis assessed by a st. jude medical coronary pressure wire measurement under hyperemic conditions using intravenous or intracoronary adenosine administration. if the ffr is ≤0.8 then a graft will be placed distal to the coronary stenosis. if the ffr is \>0.8 no grafting will be performed to the epicardial vessel containing the stenosis. patients will receive cardiac surgery no later than 8 weeks after randomization. peri-operative data will be collected. clinical follow-up data will be collected at 1, 6 and 12 month after surgery. graft patency at 12 months will be assessed by cardiac computed angiography (ccta) for all patients who received at least one graft, except if an invasive coronary angiography has been performed in the preceding 3 months based on clinical grounds.

Eligibility criteria:
inclusion criteria: * age \> 18 years * severe heart valve disease with indication for an elective cardiac with a st. jude medical heart valve * concomitant significant cad (at least one epicardial vessel with a stenosis\> 50%) * willing and able to provide informed written consent exclusion criteria: * previous cabg * angiographic significant lesion involving left main lesion (patient is still eligible if right coronary artery is candidate for ffr measurement and surgical revascularization) * all lesions in extremely tortuous or calcified coronary vessels * recent myocardial infarction (\< 30 days) * cardiogenic shock or clinical instability (i.e. nyha 4, uncontrolled arrhythmias, unexplained hypotension severe bradycardia or any other medical condition considered as a sign of instability by the assisting physician) * severe left ventricular dysfunction (ef \< 35%) * pregnant or are planning to become pregnant during the duration of the investigation * chronic renal dysfunction as defined as estimated glomerular filtration rate \< 60 ml/min * life expectancy \< 12 months * currently participating in any other clinical investigation

Keywords: coronary artery disease valvular heart disease fractional flow reserve coronary artery bypass surgery coronary graft failure or patency