A research team led by Professor Zhao Qiang from the Department of Cardiovascular Surgery at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, has published a landmark study in The Lancet, one of the world’s most prestigious medical journals. The study demonstrates that a quantitative flow ratio (QFR)-guided functional strategy, compared with conventional angiography-guided decision-making, significantly improves postoperative clinical outcomes in patients undergoing valve surgery with concomitant coronary artery disease. This marks the department’s third publication in one of the world’s top four general medical journals, following JAMA in 2018 and The BMJ in 2024.
Professor Zhao Qiang served as the principal investigator and senior corresponding author. Chief Physician Zhu Yunpeng was the lead investigator and first author. The study was supported by Ruijin Hospital, the Shanghai Jiao Tong University Medical-Engineering Interdisciplinary Research Fund, the Shanghai Hospital Development Center, the Shanghai Municipal Commission of Science and Technology, and the Ministry of Science and Technology.
This study marks a historic first for Chinese cardiovascular surgery, representing the country’s inaugural publication in The Lancet. As a national leader in clinical research, Professor Zhao’s team has consistently advanced the field through evidence-based innovation. The team has led the establishment of a national research network for precision surgical treatment of coronary artery disease, while also serving as a key driver of international collaboration. Through a series of high-impact prospective randomized controlled trials, their work has contributed to successive updates of international clinical guidelines in coronary surgery. These achievements have not only advanced technical frontiers but also elevated China’s role in global standard-setting, offering both “China-driven insights” and the “Ruijin approach” to the evolution of cardiovascular treatment worldwide.
Clinical Challenge: Anatomical “Blockage” on Angiography Does Not Equal Functional Ischemia
Coronary artery bypass grafting (CABG) remains the gold standard for treating coronary artery disease. However, for patients undergoing concurrent valve surgery, the decision to perform bypass grafting has traditionally relied on angiographic assessment of anatomical stenosis, typically defined as ≥50% narrowing.
Yet anatomical stenosis does not always correspond to functional ischemia. Lesions appearing severe on angiography may not impair myocardial perfusion, while moderate lesions can be hemodynamically significant. Although fractional flow reserve (FFR) has become the gold standard in percutaneous coronary intervention (PCI), high-quality randomized evidence supporting functional guidance in coronary artery bypass grafting (CABG) has long been lacking.
A Seven-Year, Multi-Center Effort Powered by Chinese Innovation
The study was enabled by quantitative flow ratio (QFR), an innovative computational physiology technology developed by Professor Tu Shengxian’s team at the School of Biomedical Engineering, Shanghai Jiao Tong University. Unlike traditional FFR, which requires invasive pressure wires and pharmacologic hyperemia, QFR provides a rapid and accurate assessment of coronary physiology using standard angiographic images alone. Notably, 85% of patients in the study were evaluated using next-generation AI-powered QFR (µQFR), enabling full coronary functional assessment within one minute from a single angiographic view, delivering a rapid, non-invasive, and highly precise assessment.
The cardiovascular surgery team at Ruijin Hospital recognized early on the potential of this technology to address a key clinical challenge: decision-making for concomitant coronary artery bypass grafting (CABG) in patients undergoing valve surgery with coexisting coronary artery disease. This insight quickly led to close collaboration between clinicians and biomedical engineers; clinicians articulated real-world clinical needs, while engineers provided innovative technological solutions. Together, they designed and conducted a large-scale clinical validation study.
To evaluate the clinical value of a QFR-guided strategy, Professor Zhao Qiang and colleagues, in collaboration with 12 leading cardiac centers across China, initiated the FAVOR IV–QVAS study in 2019. A total of 793 patients scheduled for valve surgery with concomitant coronary artery stenosis were enrolled. The trial employed a rigorous triple-blind design, in which patients, operating surgeons, and follow-up physicians were all unaware of group allocation. Participants were randomly assigned to one of two groups: QFR-guided group: Only vessels with a QFR value ≤0.80, indicating functionally significant myocardial ischemia, were selected for grafting. Angiography-guided group: All vessels with ≥50% stenosis as determined by coronary angiography were grafted.
Clinical Impact: Precision Decision-Making, Less Is More
The study found that among vessels deemed to require bypass based on conventional angiography, a substantial proportion were non-ischemic when assessed by QFR. Specifically, among lesions visually estimated at 50-69% stenosis, 4 of 5 were non-ischemic, indicating no ischemia; even among those assessed at 70-89% stenosis, nearly 1/3 were non-ischemic. These findings translated directly into improved clinical outcomes. The primary endpoint, a composite of adverse events within 30 days post-surgery (including death, myocardial infarction, stroke, repeat revascularization, and new-onset renal failure requiring dialysis), occurred in 13% of patients in the angiography-guided group, compared with 8% in the QFR-guided group, representing a 42% relative reduction in perioperative mortality and major complications.
Notably, this clinical benefit was sustained over time. At a median follow-up of 27 months, the incidence of key secondary endpoints, including death, myocardial infarction, stroke, repeat revascularization, unstable angina, or heart failure hospitalization, was 21% in the QFR-guided group, significantly lower than 27% in the angiography-guided group, corresponding to a 26% relative reduction in cardiovascular events.
QFR-guided strategy improves patient outcomes while simplifying CABG procedures. A recent study demonstrates that a QFR-guided approach not only enhances patient prognosis but also significantly streamlines coronary artery bypass grafting (CABG) procedures. Data show that only 56% of patients in the QFR-guided group underwent concomitant bypass grafting, compared with 98% in the angiography-guided group. The average number of grafts was 0.9 versus 1.8, the median cardiopulmonary bypass time was 127 minutes versus 150 minutes, and the median red blood cell transfusion was 0 units versus 2 units, respectively. Shorter operative times, reduced surgical trauma, and lower transfusion requirements translated into superior clinical outcomes. These findings reinforce the surgical principle of “precision decision-making and avoidance of unnecessary interventions”: for lesions that do not cause myocardial ischemia, forgoing grafting itself acts as a protective measure.
Cross-Disciplinary Innovation and International Collaboration: Chinese Evidence Shaping Guideline Updates
The FAVOR IV–QVAS study represents the largest and most rigorously designed randomized controlled trial to date evaluating the use of physiology-guided strategies in concomitant bypass grafting during valve surgery. Its publication fills a major evidence gap in the field and is expected to influence updates to international clinical guidelines, potentially incorporating function-based precision grafting strategies into routine practice.
“From DACAB to QVAS, our focus has always been on addressing real-world clinical challenges, using robust evidence-based medicine to answer unresolved questions,” said Professor Zhao Qiang. “We are deeply grateful to the 12 centers across China for their seamless collaboration, and to all patients and families who placed their trust in this research. We will continue to advance cardiovascular surgical research, contributing high-quality evidence from China to the global community.”
Reflecting on the seven-year study, Chief Physician Zhu Yunpeng shared, “When the study launched in 2019, coordinating 12 centers across the country was challenging, but no one gave up. The hardest part was maintaining strict quality standards. In a triple-blind study, each patient received two preplanned surgical strategies, with surgeons knowing only whether to perform Plan A or B. This created a heavy clinical workload, but for the sake of objective results, the team persevered. Conducting clinical research is like running a marathon—you cannot see the finish line and must keep moving step by step. Crossing the finish line, every step counts.”
Professor Tu Shengxian, inventor of QFR technology, co-principal investigator, and co-corresponding author of the study, stated, “The original goal of QFR technology was to make coronary physiology assessment simpler and more accessible. Seeing it truly improves patient outcomes is the greatest reward for cross-disciplinary teams. Moving forward, we will continue close collaboration with clinicians to bring more innovative technologies to benefit patients.”
The study has drawn significant international attention. Renowned cardiovascular surgeons, including Professor Mario Gaudino, the Immediate past Chair of the Coronary Artery Surgery Task Force of the European Association for Cardio-thoracic Surgery and professor at Weill Cornell Medicine, guided the research and served as co-corresponding author. Additional advisors included Professor Sigrid Sander, current Chair of the Coronary Artery Surgery Task Force of the European Association for Cardio-thoracic Surgery and professor at the Medical University of Vienna, and Professor William Wijns, President of the European Association of Percutaneous Cardiac Intervention (EAPCI).
