Shunt dysfunction is a consequence of tactical and technical errors of the surgeon and requires quality control of coronary shunts, which ensures improved outcomes. Transit time flowmetry (TTFM) and epicardial ultrasound (ECUS) are methods directly developed for the intraoperative viability of conduits. The aim of our study was to evaluate the possibility of using TTFM in combination with ECUS for intraoperative assessment of the quality of superimposed anastomoses.
Material and methods. The study included 150 patients with ishemic heart diseases, who underwent 460 shunts, including 150 mammarocoronary and 310 autovenous ones. To assess the functional viability of the shunts, patients underwent intraoperative TTFM, ECUS, and angiography.
Results. In angiography, 54 cases of shunt dysfunction were identified. According to the TTFM in 60 cases the shunt was invalid and in 22 cases the result was regarded as doubtful. According to the ECUS, 27 defects were detected during the bypass surgery of the primary left anterior descending artery. Isolated use of TTFM or ECUS had low sensitivity (65.5% and 51.7%, respectively), with high specificity (90.9% and 95.8%, respectively). The combined use of TTFM and ECUS was accompanied by an increase in sensitivity (up to 93.1%), with a specificity of 94.2%. Significant predictors of a high risk of shunt dysfunction according to TTFM were a decrease in the volumetric blood flow rate (Q mean) < 20.5 ml / min and an increase in the pulsation index (PI) > 2.65.
Conclusion. The combined use of TTFM and ECUS is accompanied by an increase in sensitivity to 93.1% and specificity to 94.2%, having a high predictor ability for the detection of shunt dysfunction. In our study, a decrease in Q mean < 20.5 ml/min was accompanied by an 8.18 – fold increase in the relative risk of shunt dysfunction (hazard ratio (HR) 8.18; 95% confidencial internal (CI) 4.4–15.19). An increase in pulsation index > 2.65 resulted in a 3.3 – fold increase in the relative risk of dysfunction (HR 3.3; 95% CI 2.17–5.08).
- Bockeria L.A., Sigaev I.Yu., Katsia G.V., Berishvili I.I., Piskun A.V., Buziashvili Yu.I. et al. Results of hospital bypass angiography in patients with coronary artery disease undergoing arterial and vein myocardial revascularization. Angiology and Vascular Surgery. 2003; 9 (2): 32–8 (in Russ.).
- Taggart D.P. Biochemical assessment of myocardial injury after cardiac surgery: effects of a platelet activating factor antagonist, bilateral internal thoracic artery grafts, and coronary endarterectomy. J. Thorac. Cardiovasc. Surg. 2000; 120 (4): 651–9. DOI: 10.1067/mtc.2000.106325
- Bockeria L.A., Pursanov M.G., Petrosyan K.V., Sobolev A.V., Vartanov P.V., Bockeria O.L. et al. Intraoperative bypass angiography: an optimal solution in determination of coronary bypass graft patience and improvement of long-term results of surgical myocardial revascularization. Russian Journal of Thoracic and Cardiovascular Diseases. 2018; 60 (3): 233–41 (in Russ.). DOI: 10.24022/0236-2791-2018-60-3-233-241
- Jaber S.F., Koenig S.C., Bhasker Rao B., Van Himbergen D.J., Cerrito P.B., Ewert D.J. et al. Role of graft flow measurement technique in anastomotic quality assessment in minimally invasive CABG. Ann. Thorac. Surg. 1998; 66 (3): 1087–92. DOI: 10.1016/s0003-4975(98)00752-8
- Lazzara R.R., McLellan B.A., Kidwell F.E., Combs D.T., Hanlon J.T., Young E.K. Intraoperative angiography during minimally invasive direct coronary artery bypass operations. Ann. Thorac. Surg. 1997; 64 (6): 1725–7. DOI: 10.1016/s0003- 4975(97)00995-8
- Lazzara R.R., Kidwell F.E. Minimally invasive direct coronary bypass versus cardiopulmonary technique: angiographic comparison. Ann. Thorac. Surg. 1999; 67 (2): 500–3. DOI: 10.1016/s0003-4975(98)01251-x
- Zhao D.X., Leacche M., Balaguer J.M., Boudoulas K.D., Damp J.A., Greelish J.P. et al. Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room. J. Am. Coll. Cardiol. 2009. 20; 53 (3): 232–41. DOI: 10.1016/j.jacc.2008.10.011
- Hol P.K., Lingaas P.S., Lundblad R., Rein K.A., Vatne K., Smith H.J. et al. Intraoperative angiography leads to graft revision in coronary artery bypass surgery. Ann. Thorac. Surg. 2004; 78 (2): 502–5; disc. 505. DOI: 10.1016/j.athoracsur. 2004.03.004
- Beldi G., Bosshard A., Hess O.M., Althaus U., Walpoth B.H. Transit time flow measurement: experimental validation and comparison of three different systems. Ann. Thorac. Surg. 2000; 70 (1): 212–7. DOI: 10.1016/s0003-4975(00)01246-7
- Hirotani T., Kameda T., Shirota S., Nakao Y. An evaluation of the intraoperative transit time measurements of coronary bypass flow. Eur. J. Cardiothorac. Surg. 2001; 19 (6): 848–52. DOI: 10.1016/s1010-7940(01)00700-x
- Kjaergard H.K., Irmukhamedov A., Christensen J.B., Schmidt T.A. Flow in coronary bypass conduits on-pump and off-pump. Ann. Thorac. Surg. 2004; 78 (6): 2054–6. DOI: 10.1016/j.athoracsur.2004.06.009
- Onorati F., Pezzo F., Esposito A., Impiombato B., Comi M.C., Polistina M., Renzulli A. Single versus sequential saphenous vein grafting of the circumflex system: a flowmetric study. Scand. Cardiovasc. J. 2007; 41 (4): 265–71. DOI: 10.1080/14017430701283864
- D'Ancona G., Karamanoukian H.L., Salerno T.A., Ricci M., Bergsland J. Flow measurement in coronary artery surgery. Ann. Thorac. Surg. 2000; 69 (4): 1300–1. DOI: 10.1016/s0003-4975(99)01547-7
- Kieser T.M., Rose S., Kowalewski R., Belenkie I. Transit-time flow predicts outcomes in coronary artery bypass graft patients: a series of 1000 consecutive arterial grafts. Eur. J. Cardiothorac. Surg. 2010; 38: 155–62. DOI: 10.1016/j.ejcts.2010.01.026
- Kieser T.M., Taggart D.P. Current status of intra-operative graft assessment: Should I be the standard of care for coronary artery bypass graft surgery? J. Card. Surg. 2018; 33: 219–28. DOI: 10.1111/jocs.13546
- Kolh P., Wijns W., Danchin N. et al. Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS); European Association for Percutaneous Cardiovascular Interventions (EAPCI), Guidelines on myocardial revascularization. Eur. J. Cardiothorac. Surg. 2010; 38, Suppl: S1–52.
- Kolh P., Windecker S., Alfonso F. et al. Task Force on Myocardial Revascularization of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery; European Association of Percutaneous Cardiovascular Interventions. 2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur. J. Cardiothorac. Surg. 2014; 46: 517–92. DOI: 10.1093/ejcts/eru366
- Windecker S., Kolh P., Alfonso F., Collet J.-P., Cremer J., Falk V. et al. ESC/EACTS Guidelines myocardial revascularization 2014. Eur. Heart J. 2014; 1; 35 (37): 2541–619. DOI: 10.1093/eurheartj/ehu278
- Guidelines ESC/EACTS on myocardial revascularization. Russian Journal of Cardiology. 2019; 24 (8): 151–226 (in Russ.). DOI: 10.15829/1560-4071-2019-8-151-226
- Shoniya Z.D., Sigaev I.Yu. The role of transit time flowmetry in assessing coronary anastomoses. Clinical Physiology of Circulation. 2020; 17 (3): 189–94 (in Russ.). DOI: 10.24022/1814-6910-2020-17-3-189-194
- Wijns W., Kolh P., Danchin N., Di Mario C., Falk V., Folliguet T. et al. Guidelines on myocardial revascularization. Eur. Heart J. 2010; 31: 2501–55. DOI: 10.1093/eurheartj/ehq277
- Lehnert P., Moller C.H., Damgaard S., Gerds T.A., Steinbruchel D.A. Transit-time flow measurement as a predictor of coronary bypass graft failure at one year angiographic follow-up. J. Card. Surg. 2015; 30 (1): 47–52. DOI: 10.1111/jocs.12471
- Handa T., Orihashi K., Nishimori H., Fukutomi T., Yamamoto M., Kondo N. et al. Maximal blood flow acceleration analysis in the early diastolic phase for in situ internal thoracic artery bypass grafts: a new transit-time flow measurement predictor of graft failure following coronary artery bypass grafting. Interact. Cardiovasc. Thorac. Surg. 2015; 20 (4): 449–57. DOI: 10.1093/icvts/ivu448
- Walker P.F., Daniel W.T., Moss E., Thourani V.H., Kilgoc P., Liberman H.A. et al. The accuracy of transit time flow measurement in predicting graft patency after coronary artery bypass grafting. Innovations (Phila). 2013; 8 (6): 416–9. DOI: 10.1097/IMI.0000000000000021
- D'Ancona G., Karamanoukian H.L., Salerno T.A., Schmid S., Bergsland J. Flow measurement in coronary surgery. Heart Surg. Forum. 1999; 2 (2): 121–4.
- Uehara M., Muraki S., Takagi N., Yanase Y., Tabuchi M., Tachibana K. et al. Evaluation of gastroepiploic arterial grafts to right coronary artery using transit-time flow measurement. Eur. J. Cardiothorac. Surg. 2015; 47 (3): 459–63. DOI: 10.1093/ejcts/ezu229
- Bazylev V.V., Nemchenko E.V., Rosseykin E.V., Mikulyak A.I. Flowmetric and angiographic predictors of occlusion of coronary bypass grafts. Angiology and Vascular Surgery. 2018; 2: 49–55 (in Russ.).
- Desai N.D., Miwa S., Kodama D., Koyama T., Cohen G., Pelletier M.P. et al. A randomized comparison of intraoperative indocyanine green angiography and transit-time flow measurement to detect technical errors in coronary bypass grafts. J. Thorac. Cardiovasc. Surg. 2006; 132 (3): 585–94. DOI: 10.1016/j.jtcvs.2005.09.061
- Di Giammarco G., Pano M., Cirmeni S., Pelini P., Vitolla G., DiMauro M. Predictive value of intraoperative transit-time flow measurement for short-term graft patency in coronary surgery. J. Thorac. Cardiovasc. Surg. 2006; 132 (3): 468–74. DOI: 10.1016/j.jtcvs.2006.02.014
- Kim K.-B., Kang C.H., Lim C. Prediction of graft flow impairment by intraoperative transit time flow measurement in offpump coronary artery bypass using arterial grafts. Ann. Thorac. Surg. 2005; 80 (2): 594–8. DOI: 10.1016/j.athoracsur.2005.02.047
- Tokuda Y., Song M., Ueda Y., Usui A., Akita T. Predicting early coronary artery bypass graft failure by intraoperative transit time flow measurement. Ann. Thorac. Surg. 2007; 84 (6): 1928–33. DOI: 10.1016/j.athoracsur.2007.07.040
- Di Giammarco G., Canosa C., Foschi M., Rabozzi R., Marinelli D., Masuyama S. et al. Intraoperative graft verification in coronary surgery: increased diagnostic accuracy adding highresolution epicardial ultrasonography to transit-time flow measurement. Eur. J. Cardiothorac. Surg. 2014; 45 (3): e41–5. DOI: 10.1093/ejcts/ezt58
About the authors
- Igor’ Yu. Sigaev, Dr. Med. Sc., Professor, Head of Department, ORCID
- Milena A. Keren, Dr. Med. Sc., Researcher ORCID
- Zviadi D. Shoniya, Postgraduate, ORCID