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

May 3, 2019Heart Surgery

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

Faculty: Devinder Bhatia MD

Host: Joseph Basha

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 MD
Host: Joseph Basha