Weekly Journal Scan: The five-year follow-up of FAME 3 keeps open the never-ending debate about coronary artery bypass grafting vs percutaneous coronary intervention in patients with three-vessel disease

This comment refers to ‘Outcomes after fractional flow reserve-guided percutaneous coronary intervention versus coronary artery bypass grafting (FAME 3): 5-year follow-up of a multicentre, open-label, randomised trial’, published in The Lancet, https://doi.org/10.1016/S0140-6736(25)00505-7. Prior seminal randomized controlled trials (RCTs) have demonstrated that myocardial revascularization with coronary artery bypass grafting (CABG) is associated with a prognostic advantage compared with percutaneous coronary intervention (PCI) in patients with three-vessel coronary artery disease (CAD), particularly in patients with higher disease burden and lesion complexity, and in the presence of diabetes.3 However, these studies were based on angiographic guidance only, and were conducted using revascularization techniques and materials that are no longer contemporary. Yet, PCI has demonstrated non-inferiority to surgery in patients with low anatomical complexity (SYNTAX score < 22).4 Based on the available evidence that a PCI strategy guided by functional assessment with fractional flow reserve (FFR) is associated with better clinical outcomes as compared with an angiography-guided PCI strategy, the FAME 3 trial tested the hypothesis that FFR-guided PCI might be non-inferior to CABG with respect to hard cardiovascular outcomes in patients with three-vessel CAD.1 At 1-year follow-up, the FAME 3 trial failed to demonstrate the non-inferiority of FFR-guided PCI compared with CABG.1