Coronary Physiology-Guided Bypass Grafting: A Systematic Review and Evidence Synthesis

INTRODUCTION: The role of coronary physiology in planning coronary artery bypass grafting (CABG) remains uncertain. We assessed clinical, procedural, and graft outcomes of physiology-guided CABG, separating isolated CABG from valve surgery with concomitant CABG. METHODS: PubMed/MEDLINE was searched for reports published or indexed during the preceding 10 years and last updated on 15 July 2026. Two reviewers independently screened titles, abstracts, and full texts. Invasive fractional flow reserve (FFR)-guided isolated CABG formed the core analysis. Mixed or registry-defined physiology and computed tomography-derived FFR were supportive evidence; quantitative flow ratio studies in valve surgery were analysed separately. Risk of bias was assessed with RoB 2 or ROBINS-I, and certainty with GRADE. Owing to clinical heterogeneity, study-specific estimates were presented without pooling. RESULTS: The original search identified 329 records, and the final update added one eligible randomized report. Twelve reports representing nine comparative datasets were included. FARGO and GRAFFITI reported fewer anastomoses with FFR guidance but no improvement in graft patency or short-term clinical outcomes. The Aalst cohort reported lower death or myocardial infarction at 6 years (HR, 0.59; 95% CI, 0.38-0.93), whereas SWEDEHEART found no reduction in death, myocardial infarction, or stroke. CABG-COREA reported less early competitive graft flow with CT-derived FFR. FAVOR IV-QVAS favored physiology guidance in valve surgery, but its population and modality were indirect for isolated CABG. CONCLUSION: Physiology-guided planning modifies graft selection and may reduce competitive flow, but current evidence does not establish improved hard outcomes after isolated CABG.