Intraoperative transit-time flow measurement and high-frequency ultrasound in coronary artery bypass grafting: impact in off versus on-pump, arterial versus venous grafting and cardiac territory grafted

Transit time flow management as a management strategy in high-risk groups undergoing coronary artery bypass grafting

BACKGROUND

We evaluated the surgical outcomes in three groups of individuals with diabetes mellitus (DM), end-stage renal disease (ESRD), and on (ONCAB) vs. off-pump (OPCAB) coronary artery bypass grafting (CABG). We also examined the changes in intraoperative decision-making when ultrasound and transit-time flow measurement was utilized in the operating room. This study will aim to identify the utility of HFUS and TTFM in high-risk patient categories.

METHODS

Data from the multicenter REQUEST (Registry for Quality assessment with ultrasound imaging and TTFM measurement in cardiac bypass surgery) had recently been compiled in three separate papers examining outcomes in patients with DM, ESRD, and on vs. off-pump bypass grafting. Data was extrapolated to determine the impact of HFUS and TTFM in patients with diabetes, ESRD, ONCAB and OPCAB. The primary outcome measured in in the REQUEST study is any change in planned surgical procedure. Secondary end points include rate of changes, coronary targets, completed grafts, and in-hospital morbidity and mortality.

RESULTS

Outcomes were predicated upon patient population surveyed. The REQUEST registry reported 1016 individuals who underwent CABG. For individuals with DM, any surgical change to the coronary target was slightly lower, measured at a change rate of 11.6% vs. 9.5% (OR 0.80, 95% CI 0.53-1.21, P = 0.288). In diabetics, the aortic component of the operation underwent a higher rate of surgical strategy change with TTFM compared to without (10.2% vs. 6.4%, OR 1.67, 95% CI 1.06-2.65; P = 0.026). In patients with ESRD, TTFM increased the rate of strategy changes compared to no TTFM (33.7% vs. 24.3%, 95% CI 1.01-2.48, P = 0.047) and number of revisions per graft (7.0% vs. 3.4%, OR 2.14, 95% CI 1.17-3.71). In the 1016 individuals who underwent CABG, 402 (39.6%) underwent OPCAB and 614 (60.4%) undergoing ONCAB. When TTFM and HFUS were utilized, OPCAB resulted in greater number of strategy changes for aortic portion of the procedure (14.7% vs. 3.4%, OR 4.03, CI 2.32-7.20) without a difference in coronary target or graft revision. In the REQUEST study, in-hospital mortality was published at 0.6%.

CONCLUSIONS

TTFM use demonstrates a statistically significant impact on intra-operative decision making and operative strategy changes in patients with concomitant ESRD, DM and who are undergoing OPCAB relative to ONCAB. This difference in OPCAB vs. ONCAB may be related to higher mean graft flows in OPCAB in the setting of a standardized TTFM cutoff for determination of graft quality. This data cumulatively suggests there a role for TTFM in CABG, namely due to its positive impact on outcome and statistically significant impact on intra-operative decision making.

Hybrid coronary revascularization: position paper of the European Society of Cardiology Working Group on Cardiovascular Surgery and European Association of Percutaneous Cardiovascular Interventions

Myocardial revascularization in coronary artery disease via percutaneous coronary intervention or coronary artery bypass graft (CABG) surgery effectively relieves symptoms, significantly improves prognosis and quality of life when combined with guideline-directed medical therapy. Hybrid coronary revascularization is a promising alternative to percutaneous coronary intervention or CABG in selected patients and is defined as a planned and/or intended combination of consecutive CABG surgery using at least 1 internal mammary artery to the left anterior descending (LAD), and catheter-based coronary intervention to the non-LAD vessels for the treatment of multivessel disease. The main indications for hybrid coronary revascularization are (i) to achieve complete revascularization in patients who cannot undergo conventional CABG, (ii) to treat patients with acute coronary syndromes and multivessel disease with a non-LAD vessel as the culprit lesion that needs revascularization and (iii) in highly select patients with multivessel disease with complex LAD lesions and simple percutaneous coronary intervention targets for all other vessels. Hybrid coronary revascularization patients receive a left internal mammary artery graft to the LAD artery through a minimal incision along with percutaneous coronary intervention to the remaining diseased coronary vessels using latest generation drug-eluting stents. A collaborative environment with a dedicated heart team is the optimal platform to perform such interventions, which aim to improve the quality and outcome of myocardial revascularization. This position paper analyses the rationale of hybrid coronary revascularization and the currently available evidence on the various techniques and delves into the sequence of the interventions and pharmacological management during and after the procedure.

Transient time flow measurement in arterial grafts

Coronary artery bypass grafting (CABG) is one of the foundations of treatment for coronary artery disease. While it has improved substantially since its inception more than 50 years ago, including a rising use of multiple arterial grafting, intraoperative quality assessment is yet to be disseminated as an integral part of the procedure. Herein we review the fundamentals of intraoperative quality assessment in CABG using transient time flow measurement (TTFM) with a focus on its use in arterial grafting.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2021

This special article is the fourteenth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the Editor-in-Chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series; namely, the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2021 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in the specialty for 2021 begin with an update on structural heart disease, with a focus on updates in arrhythmia and aortic valve disorders. The second major theme is an update on coronary artery disease, with discussion of both medical and procedural management. The third major theme is focused on the perioperative management of patients with COVID-19, with the authors highlighting literature discussing the impact of the disease on the right ventricle and thromboembolic events. The fourth and final theme is an update in heart failure, with discussion of diverse aspects of this area. The themes selected for this fourteenth special article are only a few of the diverse advances in the specialty during 2021. These highlights will inform the reader of key updates on a variety of topics, leading to improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.