The REVOLUTION project: planning and performing surgical revascularization based solely on coronary computed tomography angiography.

Coronary computed tomography angiography (CCTA) is a non-invasive diagnostic tool that is increasingly being used as an alternative to invasive coronary angiography (ICA) in patients with suspected coronary artery disease (CAD), providing important information on the extent and severity of CAD. Furthermore, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been recently introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses. ICA has been the preferred diagnostic method to guide the decision-making process between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). Recently, two studies have investigated the feasibility of using CCTA rather than ICA to plan CABG. In patients with three-vessel disease and/or left main CAD, the SYNTAX III REVOLUTION trial concluded that clinical decision-making between CABG and PCI using CCTA had a high level of agreement with treatment decisions based on ICA. In the FASTTRACK study, CABG procedures were planned based on CCTA without knowledge of ICA. CABG guided by CCTA showed to be feasible with an acceptable safety profile in a selected population of complex CAD. These intriguing findings should be confirmed in a large randomized trial on the revascularization outcome by comparing patients who underwent a novel non-invasive vs. a traditional invasive roadmap.