FAME 3 fails to defame coronary artery bypass grafting: what went wrong in the percutaneous coronary intervention arm?
Alexandru Achim, Gregor Leibundgut
Abstract
The primary results of the landmark Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) 1 trial found in 2010 that case selection using physiological assessment of stenosis severity by measurement of fractional flow reserve (FFR) improves outcomes compared with angiography-guided percutaneous coronary intervention (PCI) [1]. Results were confirmed at 5 years follow-up [2, 3] influencing the current revascularization guidelines [4]. A subanalysis of the same study found a worrisome proportion of patients with angiographically 3 vessel coronary artery disease (3-VD) who actually, by functional significance, turned out to have either no stenoses or have been downgraded to one- or two-vessel coronary artery disease and received different treatment [5]. Because hypothetically, this whole group of angiographically 3-VD patients would have been candidates for coronary artery bypass grafting (CABG) but in retrospect would not have benefitted from it, the FAME 3 trial was conducted to address this question, if stenting of only the functionally significant lesions in patients with multivessel disease overcomes the ‘universal’ grafting, or at least matches it. Because current guideline recommendations for CABG were determined by older large randomized studies where PCI was done using bare-metal stents or first-generation drug-eluting stents [6–8], a contemporary assessment of the role of PCI in 3-VD has been eagerly awaited by the medical community.