At present, coronary heart disease affects approximately 20% of patients undergoing valvular surgery. Long-standing clinical guidelines have recommended anatomical stenosis severity shown on coronary angiography as the decision-making criterion for concomitant coronary artery bypass grafting (CABG, commonly known as bypass surgery). However, clinical practice has proven that anatomical stenosis does not fully equate to functional myocardial ischemia. Cases frequently emerge where severe stenosis presents no ischemic manifestations, while mild stenosis carries substantial ischemic risks.

For this high-risk population of patients with combined valvular disease and coronary heart disease, the clinical value of functionally guided bypass surgery has long lacked high-grade evidence from large-scale randomized controlled trials. The traditional one-size-fits-all anatomical decision-making model easily leads to excessive bypass grafting, increased surgical trauma and higher complication risks, forming a core bottleneck restricting precision treatment in valvular surgery.

The FAVORIV-QVAS trial is a multicenter, triple-blind randomized controlled study led by Ruijin Hospital, Shanghai, with participation of 12 national medical centers including The Second Xiangya Hospital. Spanning five years (August 2019 – August 2024), the trial enrolled 793 patients scheduled for valvular surgery complicated with coronary heart disease, who were randomly assigned to either the QFR/μQFR-guided group or the conventional angiography-guided group. As a core participating center, the Department of Cardiovascular Surgery of The Second Xiangya Hospital leveraged its strengths as a National Key Clinical Specialty to engage deeply throughout the entire trial. The team completed high-quality patient screening, precise surgical intervention and long-term follow-up, with rigorous quality control that strongly guaranteed smooth trial progression.

For the first time, this large-scale multicenter triple-blind RCT verified that bypass surgery guided by QFR/μQFR, a China-originated angiography-derived fractional flow reserve technology, significantly improves clinical outcomes in patients receiving valvular surgery combined with coronary heart disease, with three core benefits:

First, markedly enhanced perioperative safety. The 30-day postoperative adverse event rate stood at only 7.8% in the QFR/μQFR-guided group, a 42% significant reduction compared with 13.4% in the conventional group, driven mainly by lowered risks of myocardial infarction and acute kidney injury.

Second, sustained long-term prognostic benefits. Data from a median 27-month follow-up revealed persistently lower adverse event rates in the QFR/μQFR group, confirming that this strategy reduces long-term cardiovascular risks for patients.

Third, effective avoidance of overtreatment. Only 56% of patients in the QFR/μQFR group received concomitant bypass surgery, far lower than the 98% in the control group, with the average number of graft vessels per patient halved. The approach shortens operative time, minimizes surgical trauma and achieves the clinical goal of precise bypass grafting.

This is the world’s first randomized controlled trial confirming definite clinical benefits of functional guidance for bypass surgery in patients with combined valvular and coronary heart disease, filling an evidence gap in relevant international clinical guidelines. The findings are expected to directly revise clinical pathways for bypass surgery in such patients and facilitate the inclusion of QFR/μQFR-guided precise revascularization into routine global clinical recommendations. Developed in China with fully independent intellectual property rights, QFR/μQFR requires no additional invasive procedures and enables rapid myocardial ischemia assessment solely based on coronary angiographic images, featuring four major merits: precision, convenience, non-invasiveness and cost-effectiveness.

A National Key Clinical Specialty with decades of dedicated development, the Department of Cardiovascular Surgery of The Second Xiangya Hospital has long focused on the diagnosis, treatment and research of complicated cardiovascular disorders including coronary heart disease, complex valvular heart disease and great vessel diseases. It has established an integrated four-in-one disciplinary development system covering clinical care, scientific innovation, talent training and research translation.

First Reviewer: Fan Jingyi

Second Reviewer: Zhao Xiaohua

Final Reviewer: Liu Minghui