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CLINICAL RESEARCH: ECHOCARDIOGRAPHY

Evaluation of flow in the left anterior descending coronary artery but not in the left internal mammary artery graft predicts significant stenosis of the arterial conduit

Francesco Pizzuto, MD^*,*, Paolo Voci, MD, PhD^*, Enrica Mariano, MD, Paolo Emilio Puddu, MD, FESC, FACC, Alessandro Aprile, MD and Francesco Romeo, MD, FESC, FACC

^* Cardiology
Cardio-Thoracic and Vascular Sciences "A. Reale," "La Sapienza" University
Department of Cardiology, "Tor Vergata" University, Rome, Italy

Manuscript received May 17, 2004; accepted September 16, 2004.

^* Reprint requests: Prof. Paolo Voci, Via San Giovanni Eudes, 27, 00163 Rome, Italy. E-mail: voci@uniroma1.it.Correspondence: Prof. Francesco Pizzuto, Cardiology, Medicine, via Nomentana 186, 00162 Rome, Italy (Email: francesco.pizzuto{at}uniroma1.it).

OBJECTIVES: The purpose of this study was to evaluate which Doppler-derived flow index best predicts new distal left anterior descending coronary artery (LAD) stenosis in patients with left internal mammary artery (LIMA) graft.

BACKGROUND: The LIMA flow measurement has been proposed to assess graft function, but it may be misleading in case of new distal LAD stenosis and/or competitive flow from native LAD. Distal LAD coronary flow reserve (CFR: hyperemic/baseline peak flow velocity ratio) may be more appropriate.

METHODS: The LIMA and distal LAD flow was measured by transthoracic Doppler echocardiography in 96 patients undergoing diagnostic/therapeutic coronary angiography, 7 ± 4 years after cardiac bypass surgery. The LIMA flow indexes (systolic-to-diastolic peak velocity ratio [SDPVr] >1, diastolic time velocity integral fraction [DTVIf] <0.5, and CFR <2) and LAD CFR <2 were used to predict 70% new LAD stenosis.

RESULTS: The LAD CFR <2 predicted new LAD stenosis, found in 21 of 77 patients without competitive flow from native LAD, with significantly higher diagnostic accuracy (98%) than LIMA flow indexes (SDPVr >1 = 61%, DTVIf <0.5 = 69%, and CFR <2 = 72%). The LIMA flow indexes were abnormal in 17 of 19 patients with competitive graft flow, but only 5 had graft restriction, and none had significant LAD stenosis. In a multivariate model of new distal LAD stenosis prediction, competitive flow from native LAD reduced the predictive role of LIMA but not of LAD CFR.

CONCLUSIONS: In patients without competitive flow from native LAD, LAD CFR is more accurate for the detection of LAD stenosis than LIMA CFR. In patients with competitive graft flow, abnormal LIMA flow patterns and blunted LIMA CFR do not reflect downstream LAD flow as LAD CFR does.

Abbreviations and Acronyms   CFR = coronary flow velocity reserve   DVTI = diastolic velocity time integral   LAD = left anterior descending coronary artery   LIMA = left internal mammary artery   SDPV = systolic-to-diastolic peak velocity

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