a comparison of fractional flow reserve-guided percutaneous coronary intervention and coronary artery bypass graft surgery in patients with multivessel coronary artery disease

Conditions: Coronary Disease; Coronary Stenosis

Summary: the purpose of this study is to determine whether fractional flow reserve (ffr, (coronary pressure wire-based index for assessing the ischemic potential of a coronary lesion)-guided percutaneous coronary intervention (pci) in patients with multivessel coronary artery disease (cad) will result in similar outcomes to coronary artery bypass graft surgery (cabg).

the fame 3 trial is a multicenter, international, randomized, controlled noninferiority trial. all patients with multivessel cad (not involving the left main) will be screened by the site's heart team (including but not limited to an interventional cardiologist, cardiac surgeon and research coordinator). if all agree that the patient can be treated either with ffr-guided pci or cabg, and all inclusion criteria are met and no exclusion criteria are met, then the patient will be randomized. baseline clinical, functional, laboratory and electrocardiographic data will be obtained. patients will receive treatment within 4 weeks of randomization. patients randomized to cabg will receive state of the art therapy at the discretion of the local surgeon with a strong emphasis on arterial revascularization. patients undergoing pci will have ffr measured with a st. jude medical coronary pressure wire across all lesions. if the ffr is ≤0.80, then pci will be performed with the medtronic resolute integrity drug-eluting stent (des) as per usual routine. if the ffr is \>0.80 then pci will be deferred. all patients will receive medical therapy as per published guidelines. patients will follow-up at 1 and 6 months, and 1 and 3 years with an evaluation of clinical status, functional status, medications and events. follow-up may be extended to 5 years, if funding allows. core lab analyses will include formal quantitative coronary angiography (qca) of the baseline angiograms with calculation of the synergy between percutaneous coronary intervention with taxus and cardiac surgery (syntax) score and functional syntax score.

Eligibility criteria:
inclusion criteria: * 1. age ≥ 21 years with angina and/or evidence of myocardial ischemia * 2. three vessel cad, defined as ≥ 50% diameter stenosis by visual estimation in each of the three major epicardial vessels or major side branches, but not involving left main coronary artery, and amenable to revascularization by both pci and cabg as determined by the heart team. patients with a non-dominant right coronary artery may be included if only the left anterior descending artery (lad) and left circumflex have ≥50% stenosis * 3. willing and able to provide informed, written consent exclusion criteria: * 1. requirement for other cardiac or non-cardiac surgical procedure (e.g., valve replacement, carotid revascularization) * 2. cardiogenic shock and/or need for mechanical/pharmacologic hemodynamic support * 3. recent stemi (\<5 days prior to randomization) * 4. ongoing non stemi with biomarkers (cardiac troponin) still rising * 5. known left ventricular ejection fraction \<30% * 6. life expectancy \< 2 years * 7. requiring renal replacement therapy * 8. undergoing evaluation for organ transplantation * 9. participation or planned participation in another clinical trial, except for observational registries * 10. pregnancy * 11. inability to take dual antiplatelet therapy for six months * 12. previous cabg * 13. left main disease requiring revascularization * 14. extremely calcified or tortuous vessels precluding ffr measurement * 15. any target lesion with in-stent drug-eluting stent restenosis