Coronary flow reserve early and late after minimally invasive coronary artery bypass grafting in patients with totally occluded left anterior descending coronary artery

Paulis, Ruggero De; Tomai, Fabrizio; Gaspardone, Achille; Colagrande, Luisa; Nardi, Paolo; Ghini, Anna S.; Versaci, Francesco; Peppo, Alfonso Penta de; Gioffrè, Pier Agostino; Chiariello, Luigi

doi:10.1016/s0022-5223(99)70004-8

Cited by 8 publications

(7 citation statements)

References 25 publications

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“…It has been reported that the early postoperative graft flow reserve of the LITA may at times be insufficient because of vasospasm or the effect of cardiopulmonary bypass, 6 so in the present study graft flow was measured immediately before and after repair of stenosis of the LITA graft. Because the myocardial ischemic time was shortened by the use of a continuous coronary blood perfusion system, we believe there was ischemic or reperfusion damage to the myocardium and moreover, the ITA graft was not affected by native LAD flow because there was total occlusion in the proximal native LAD.…”

Section: Discussionmentioning

confidence: 98%

Impact of Ostial Stenosis on the Doppler Flow Profiles in Internal Thoracic Artery Graft

Yoshitatsu

Nomura

Izutani

et al. 2005

Circ J

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everal studies have reported that evaluation of graft patency by transthoracic Doppler echocardiography (TTDE) is useful in patients who undergo left internal thoracic artery (ITA) to left anterior descending coronary artery (LAD) bypass, 1-5 but as those reports did not include patients with ITA proximal stenosis, little is known about the Doppler flow profile in such grafts. We performed surgical repair of a left ITA (LITA) graft proximal stenosis after coronary artery bypass grafting (CABG) and report the changes in the Doppler flow profile of the graft after repair of proximal stenosis using intraoperative ultrasonography. Case ReportA 54-year-old male patient underwent elective CABG in June 2000, in which the LITA was anastomosed to the LAD segments 7 and 8 sequentially, the free right ITA to the distal circumflex and first diagonal branch of the left coronary artery sequentially, and the right gastroepiploic artery to segment 4PD of the right coronary artery. The follow-up coronary angiography in January 2001 revealed no ostial stenosis of the LITA graft. Soon after, the patient developed effort angina, so coronary angiography was repeated in July 2001 and a 90% ostial stenosis of the LITA was detected. He underwent surgical intervention, including stent implantation to this lesion 5 times. For a while the symptoms were relieved, but recurrent effort angina developed. The latest coronary angiography examination revealed 90%Circulation Journal Vol. 69, February 2005 stenosis in the stent implanted to the ITA with total occlusion in the proximal LAD ( Fig 1A). It also showed good run-off in the distal LAD. Scintigraphy showed reversible ischemia in the anteroseptal region. Surgical repair of the LITA proximal stenosis was recommended and the patient underwent elective surgery. The left radial artery was taken down in a skeletonized fashion. An arterial catheter was inserted in the femoral artery for continuous coronary artery perfusion. Left lateral thoracotomy was performed because median sternotomy was thought to have a risk of injuring the LITA graft, which was the main vessel perfusing the LAD region. An ultrasonographic probe was attached to the ITA directly and Doppler signals of ITA flow were recorded (Fig 2A). The measurement site was in the middle portion of the ITA graft. Intraoperative ultrasonography was performed with a 7.5 MHz linear array transducer that had been sterilized and connected to an Aloka SSD 5500 Prosound ultrasound system. We placed sterilized jelly between the ITA graft and the transducer for clear visualization. The graft flow pattern obtained consisted of 2 phases of flow corresponding to systole and diastole, as reported previously 1-5 and shown in Table 1. All parameters of ITA flow showed an increase by 2-fold or more compared with before repair, except for peak diastolic-to-systolic velocity ratio, mean diastolic-to-systolic velocity ratio and diastolic fraction, which were almost the same as before repair.After dissecting out the LITA for the anastomosis, it was cut dow...

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Section: Discussionmentioning

confidence: 98%

Impact of Ostial Stenosis on the Doppler Flow Profiles in Internal Thoracic Artery Graft

Yoshitatsu

Nomura

Izutani

et al. 2005

Circ J

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“…Healthy endothelium modulates the vasomotor tone of the ITA in response to changes in blood flow and to the shear stress caused by the high‐velocity laminar flow, favoring vascular remodeling, and the release of nitric oxide. These changes largely determine subsequent velocities and lower baseline flow values, suggesting adaptation to a lower metabolic demand and resulting in higher values of coronary reserve …”

Section: Discussionmentioning

confidence: 99%

“…The pharmacological stimulation of hyperemia performed 6 months after the CABG enabled the assessment of the functional status of the anastomosed artery based on the analysis of the CFR values …”

Section: Discussionmentioning

confidence: 99%

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The impact of ligation of proximal side branches on blood flow and functional status of the internal thoracic artery in coronary anastomosis

et al. 2016

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“…13, 14 However, the ITA graft can adapt to the higher flow demands of the relevant myocardial area, thus resulting in an increased graft diameter, usually identifiable within 1 month. [15][16][17][18][19] Many studies on the coronary flow reserve of the ITA graft after pharmacological intervention with adenosine, dipyridamole, papaverine, and nitroglycerin, …”

Section: Physiological and Metabolic Effects Of Grafts In Cabgmentioning

confidence: 99%

Physiological and Metabolic Effects of Grafts in Coronary Artery Bypass Surgery

Kitamura

2011

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp oronary artery bypass grafting (CABG) surgery initially utilizing a saphenous vein graft (SVG) and later the internal thoracic artery (ITA) has gained world-wide acceptance as a highly effective operation that not only ameliorates angina pectoris, but also improves both cardiac function and patient longevity. On the other hand, percutaneous coronary intervention (PCI) utilizing metallic or drug-eluting stents has also obtained rapid and world-wide popularity as a less invasive method of treating coronary artery obstructive disease, and many randomized clinical trials (RCT) are being conducted to compare the efficacy of CABG vs. PCI from the various clinical aspects of the different grades of illness. The endpoints of the trials include the occurrence of death, myocardial infarction, cerebral stroke and need for reintervention.I have long questioned why an ITA -left anterior descending artery (LAD) bypass can prolong a patient's life better than a SVG -LAD bypass, 1-3 why the use of bilateral ITAs can prolong life better than unilateral use, 4,5 and why CABG using the ITA can prolong life better than PCI in specific groups of patients, such as those with diabetes and elderly patients with triple-vessel disease, as has been demonstrated in the recent prospective RCT or retrospective risk-matched clinical studies. 6-9Furthermore, I have long considered that there are fundamental benefits of CABG with the use of ITAs, not only due to graft patency alone, but also due to differences in the endothelial metabolic effects of the ITA, SVG and coronary stents, particularly in patients with severe coronary endothelial dysfunction, such as multivessel coronary artery disease, 8 elderly patients 9 and diabetic patients. 6,7 Here, I review previous publications on these topics, while focusing on the physiological and metabolic function of the graft transplanted into the coronary artery systems by CABG surgery. Intraoperative Graft Flow and Postoperative Coronary Flow ReserveThe ITA graft flow is about 50-60% of the SVG flow when measured intraoperatively by electromagnetic flow meter 10 or a transit-time Doppler flow meter. 11 The limited flow of the ITA graft is attributed to its small luminal caliber and the length of the graft originating from the subclavian artery; both of which result in higher physiologic conduit resistance than with the SVG, which has a larger lumen and shorter length, usually originating from the ascending aorta. When CABG is performed under cardiopulmonary bypass and anoxic cardiac arrest, ITA malperfusion syndrome 12 occurs very rarely, which is when the ITA graft flow cannot meet the increased post-cardiac arrest hyperemic flow demand. In this setting, either a pharmacological or surgical addition is required to compensate for the hypoperfusion. Pharmacologically, an increase in the perfusion pressure and relief from coronary and/or graft spasm are necessary, and can be achieved with the administration...

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Coronary flow reserve early and late after minimally invasive coronary artery bypass grafting in patients with totally occluded left anterior descending coronary artery

Abstract: Our findings suggest that the late improvement in coronary flow reserve is independent of the diameter of the graft and probably reflects an early distal coronary vessel dysfunction, which normalizes with time.

Cited by 8 publications

References 25 publications

Impact of Ostial Stenosis on the Doppler Flow Profiles in Internal Thoracic Artery Graft

Impact of Ostial Stenosis on the Doppler Flow Profiles in Internal Thoracic Artery Graft

The impact of ligation of proximal side branches on blood flow and functional status of the internal thoracic artery in coronary anastomosis

Physiological and Metabolic Effects of Grafts in Coronary Artery Bypass Surgery

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