Validating Graft Patency. Patency coronary bypass grafts (CABG). Devinder Bhatia MD

Video:Lecture and discussion on using different methods and tools to evaluate the quality and patency coronary bypass grafts. (CABG)Faculty:Devinder Bhatia MDHost:Joseph Basha7:40—Distal anastomosis7:45—Occlusive problem with bypass graft8:10—Why evaluate grafts?8:28—Rationale for graft assessment: Improve patient outcomes Instruct surgeons in training Documentations for peers, stuff and insurance Peace of mind Protect referral network Predictive of outcomes Standardize Care Even though the majority of cardiac surgeons are happy with less then 3% CABG mortality rates, patients are looking for angina relief and a hope of no additional invasive treatment.10:15—Stents vs grafting10:30—The prevention of additional intervention represents a socioeconomic benefit to payers (Medicare, private insurers) – and society10:59—Abnormal grafts and mortality: Poorly function bypass grafts are known to be associated with postoperative morbidity and mortality.* Weman ET AL.** reported that 54.7% of 223 patients who died early after CABG surgery had gross technical problems in the bypasses (unrecognized twisted conduits, stenotic anastomoses and dissections). * Kieser TM, Rose S. et at “Transit time flow predicts outcomes in coronary artery bypass graft patients; a series of 1000 consecutive arterial grafts. Eur Assoc Cardio – thoracic Surg (2010) ** Weiman SM, Salmienen US Penthil – Post mortem cast angiography in the diagnostics of graft complications in patients with fatal outcome following coronary artery bypass12:00—Prevalence of abnormal grafts 19% of grafts are sub-optimal – in study of 985 cardiac surgery patients with both arterial and venous conduits found abnormal grafts in 19% of patients. 12:26 Transit time flow measurement is a cost effective, safe and easy to use method to access graft patency12:47—Flow measurement: be suspicious of – any flow less then 15ml/min – high retrograde flow bigger then 3% assess competitive flow – occlude native vessel proximal to anastomosis – graft flow will be bigger and PI will be smaller13:46—Diastolic filling percentage: (DF) always grater then 50% in coronaries more balanced with systolic filling on right side if heart, DF 50% +/- on left side of heart filling pattern is predominantly diastolic, DF 70% +/-15:05—how to spot a bad graft: occluded LIMA – DIAG example15:33—Abnormal diastolic filling pattern and percentage15:51—Low mean flow value – high pulsatility index16:17—Measured curve differs from the FloWizard flow curve and values16:19—how to spot a bad graft examples: Occluded LIMA and LAD graft – revised LIMA and LAD graft16:29—Unexpected results: The surgeon – a gifted local CT surgeon – ME Single vessel OPCAB – LIMA to LAD No surgical complications Clinical observation normal TEE appeared normal Hemodynamics appeared normal Palpation – Pulsatile Conclusions Patent graft16:32—Kinked Graft – before and after17:52—What we do? Acoustic Coupling Index (ACI) should be green Mean Arterial Pressure (MAP) near 80mm hg Probe placement: No curves Not near proximal anastomosis Probe size correct for vessel size: IMA : 2-3 mm SVG : 3-5mm19:20—Spasm – spikey wave form kinks – low flow / high PI twists – low flow high PI length – low / flat DF% 19:46—Low mean arterial pressure (MAP) Vascular resistance Competitive flow Time point Arterial spasm22:32—Real exampleFaculty:Devinder Bhatia MDHost:Joseph Basha

Video:Lecture and discussion on using different methods and tools to evaluate the quality and patency coronary bypass grafts. (CABG)

Video: Lecture and discussion on using different methods and tools to evaluate the quality and patency coronary bypass grafts. (CABG)

Faculty:Devinder Bhatia MD

Faculty: Devinder Bhatia MD

Host:Joseph Basha

Host: Joseph Basha

7:40—Distal anastomosis7:45—Occlusive problem with bypass graft8:10—Why evaluate grafts?8:28—Rationale for graft assessment: Improve patient outcomes Instruct surgeons in training Documentations for peers, stuff and insurance Peace of mind Protect referral network Predictive of outcomes Standardize Care Even though the majority of cardiac surgeons are happy with less then 3% CABG mortality rates, patients are looking for angina relief and a hope of no additional invasive treatment.10:15—Stents vs grafting10:30—The prevention of additional intervention represents a socioeconomic benefit to payers (Medicare, private insurers) – and society10:59—Abnormal grafts and mortality: Poorly function bypass grafts are known to be associated with postoperative morbidity and mortality.* Weman ET AL.** reported that 54.7% of 223 patients who died early after CABG surgery had gross technical problems in the bypasses (unrecognized twisted conduits, stenotic anastomoses and dissections). * Kieser TM, Rose S. et at “Transit time flow predicts outcomes in coronary artery bypass graft patients; a series of 1000 consecutive arterial grafts. Eur Assoc Cardio – thoracic Surg (2010) ** Weiman SM, Salmienen US Penthil – Post mortem cast angiography in the diagnostics of graft complications in patients with fatal outcome following coronary artery bypass12:00—Prevalence of abnormal grafts 19% of grafts are sub-optimal – in study of 985 cardiac surgery patients with both arterial and venous conduits found abnormal grafts in 19% of patients. 12:26 Transit time flow measurement is a cost effective, safe and easy to use method to access graft patency12:47—Flow measurement: be suspicious of – any flow less then 15ml/min – high retrograde flow bigger then 3% assess competitive flow – occlude native vessel proximal to anastomosis – graft flow will be bigger and PI will be smaller13:46—Diastolic filling percentage: (DF) always grater then 50% in coronaries more balanced with systolic filling on right side if heart, DF 50% +/- on left side of heart filling pattern is predominantly diastolic, DF 70% +/-15:05—how to spot a bad graft: occluded LIMA – DIAG example15:33—Abnormal diastolic filling pattern and percentage15:51—Low mean flow value – high pulsatility index16:17—Measured curve differs from the FloWizard flow curve and values16:19—how to spot a bad graft examples: Occluded LIMA and LAD graft – revised LIMA and LAD graft16:29—Unexpected results: The surgeon – a gifted local CT surgeon – ME Single vessel OPCAB – LIMA to LAD No surgical complications Clinical observation normal TEE appeared normal Hemodynamics appeared normal Palpation – Pulsatile Conclusions Patent graft16:32—Kinked Graft – before and after17:52—What we do? Acoustic Coupling Index (ACI) should be green Mean Arterial Pressure (MAP) near 80mm hg Probe placement: No curves Not near proximal anastomosis Probe size correct for vessel size: IMA : 2-3 mm SVG : 3-5mm19:20—Spasm – spikey wave form kinks – low flow / high PI twists – low flow high PI length – low / flat DF% 19:46—Low mean arterial pressure (MAP) Vascular resistance Competitive flow Time point Arterial spasm22:32—Real example

7:40 —Distal anastomosis

7:45 —Occlusive problem with bypass graft

8:10 —Why evaluate grafts?

8:28 —Rationale for graft assessment: Improve patient outcomes Instruct surgeons in training Documentations for peers, stuff and insurance Peace of mind Protect referral network Predictive of outcomes Standardize Care Even though the majority of cardiac surgeons are happy with less then 3% CABG mortality rates, patients are looking for angina relief and a hope of no additional invasive treatment.

10:15 —Stents vs grafting

10:30 —The prevention of additional intervention represents a socioeconomic benefit to payers (Medicare, private insurers) – and society

10:59 —Abnormal grafts and mortality: Poorly function bypass grafts are known to be associated with postoperative morbidity and mortality.* Weman ET AL.** reported that 54.7% of 223 patients who died early after CABG surgery had gross technical problems in the bypasses (unrecognized twisted conduits, stenotic anastomoses and dissections). * Kieser TM, Rose S. et at “Transit time flow predicts outcomes in coronary artery bypass graft patients; a series of 1000 consecutive arterial grafts. Eur Assoc Cardio – thoracic Surg (2010) ** Weiman SM, Salmienen US Penthil – Post mortem cast angiography in the diagnostics of graft complications in patients with fatal outcome following coronary artery bypass

12:00 —Prevalence of abnormal grafts 19% of grafts are sub-optimal – in study of 985 cardiac surgery patients with both arterial and venous conduits found abnormal grafts in 19% of patients. 12:26 Transit time flow measurement is a cost effective, safe and easy to use method to access graft patency

12:47 —Flow measurement: be suspicious of – any flow less then 15ml/min – high retrograde flow bigger then 3% assess competitive flow – occlude native vessel proximal to anastomosis – graft flow will be bigger and PI will be smaller

13:46 —Diastolic filling percentage: (DF) always grater then 50% in coronaries more balanced with systolic filling on right side if heart, DF 50% +/- on left side of heart filling pattern is predominantly diastolic, DF 70% +/-

15:05 —how to spot a bad graft: occluded LIMA – DIAG example

15:33 —Abnormal diastolic filling pattern and percentage

15:51 —Low mean flow value – high pulsatility index

16:17 —Measured curve differs from the FloWizard flow curve and values

16:19 —how to spot a bad graft examples: Occluded LIMA and LAD graft – revised LIMA and LAD graft

16:29 —Unexpected results: The surgeon – a gifted local CT surgeon – ME Single vessel OPCAB – LIMA to LAD No surgical complications Clinical observation normal TEE appeared normal Hemodynamics appeared normal Palpation – Pulsatile Conclusions Patent graft

16:32 —Kinked Graft – before and after

17:52 —What we do? Acoustic Coupling Index (ACI) should be green Mean Arterial Pressure (MAP) near 80mm hg Probe placement: No curves Not near proximal anastomosis Probe size correct for vessel size: IMA : 2-3 mm SVG : 3-5mm

19:20 —Spasm – spikey wave form kinks – low flow / high PI twists – low flow high PI length – low / flat DF% 19:46—Low mean arterial pressure (MAP) Vascular resistance Competitive flow Time point Arterial spasm

22:32 —Real example

Faculty:Devinder Bhatia MDHost:Joseph Basha

Faculty: Devinder Bhatia MD

Host: Joseph Basha

2 Comments

Waheed Etmanon September 13, 2019 at 3:06 amHI. I am waheed etman from egypt .I am head of department of cardiothoracic surgery alexandrite university.. What is your opinion that some time the flow pattern of ttfm using verify q midstim device is not stable on screen and the PI value swing above 59 or 10 then become below 5 .is that device or probe problem or it might technical problem or competitive flow…Thanks a lot.ReplyJoseph Bashaon September 16, 2019 at 9:10 pmDear Dr. Etman:In speaking with Dr. Bhatia, this seems to be more indicative of a probe failure. It would be unusual to see the PI swing that much and unusual for competitive flow to be intermittent.Thank you for the question and the best of luck to you in your practice.Reply Waheed Etman on September 13, 2019 at 3:06 am

HI. I am waheed etman from egypt .I am head of department of cardiothoracic surgery alexandrite university.. What is your opinion that some time the flow pattern of ttfm using verify q midstim device is not stable on screen and the PI value swing above 59 or 10 then become below 5 .is that device or probe problem or it might technical problem or competitive flow…Thanks a lot.

Thanks a lot. Reply

Joseph Bashaon September 16, 2019 at 9:10 pmDear Dr. Etman:In speaking with Dr. Bhatia, this seems to be more indicative of a probe failure. It would be unusual to see the PI swing that much and unusual for competitive flow to be intermittent.Thank you for the question and the best of luck to you in your practice.Reply Joseph Basha on September 16, 2019 at 9:10 pm

Dear Dr. Etman:

In speaking with Dr. Bhatia, this seems to be more indicative of a probe failure. It would be unusual to see the PI swing that much and unusual for competitive flow to be intermittent.

Thank you for the question and the best of luck to you in your practice.

Thank you for the question and the best of luck to you in your practice. Reply