CORRESPONDENCE: LETTER TO THE EDITOR
Routine Intraoperative Completion Angiography After Coronary Artery Bypass Grafting or Routine Intraoperative Transit Time Flow Measurement to Check Graft's Quality?
Andrea Colli, MD* and
Xavier Ruyra, MD
* Department of Cardiac Surgery, Hospital Universitari Germans Trias i Pujol, Ctra. Canyet sn, Badalona, Barcelona 08916, Spain (Email: colli.andrea.bcn{at}gmail.com).
We have read with great interest the study by Zhao et al. (1), which concluded that intraoperative coronary angiography should perhaps eventually become the standard of care for coronary artery bypass grafting (CABG) surgery. We ask, is it really necessary to perform it routinely? They showed that a hybrid operating room is useful and provides a good quality control of CABG surgery. The hybrid revascularization procedure is certainly indicated for specific patient conditions (e.g., poor conduits, ungraftable vessels, stenting of the left subclavian artery). However, we have some concerns about the conclusion of this study.
Our group has begun to assess the surgical results of CABG surgery using transit time flow measurement. Our experience indicates that a meticulous method of assessing intraoperative flow measurements can improve the quality of the surgery performed and increases the accuracy of diagnosing technical problems with newly constructed bypass grafts for both off- and on-pump procedures (2). The transit time flow measurement has already been demonstrated to be safe, easy to perform, reproducible, and cheap. In a patent coronary graft, the hemodynamics are similar to those physiologically observed in the coronary circulation: blood flows mainly during diastole with minimal systolic peaks taking place during the isovolumetric ventricular contraction (QRS complex) (3).
In accordance with the interesting editorial comment (4), we do not currently see any clinical evidence that justifies the need to check all performed CABG with an immediate post-operative angiography, with the consequent significant increase in the costs and morbidity, when there is already available a useful and cheap device to assess the quality of the revascularization. We consider the post-operative angiography a very important tool that should be reserved for specific cases only (e.g., post-operative ischemia, low cardiac output syndrome, technical problems during surgery).
Finally, Zhao et al. (1) showed that the routine use of angiography revealed graft defects in 89 patients (12%) of their study population of 366 patients; they performed a total arterial revascularization with either double internal thoracic artery or radial artery in only 2% of cases. These data are completely in contrast to the general trend that is ongoing in cardiac surgery as recently shown by the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial and registry (27.6% and 16.1%, respectively) (5).
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1. Zhao DX, Leacche M, Balaguer JM, et al. Writing Group on behalf of the Cardiac Surgery, Cardiac Anesthesiology, and Interventional Cardiology Groups at the Vanderbilt Heart and Vascular Institute 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;53:232-241.[Abstract/Free Full Text]2. Fernandez M, Delgado L, Romero B, et al. Evaluacion hemodinamica de pacientes sintomaticos despues de cirugia coronaria: estado de los injertos. Somos competitivos (abstr). Cirugia Cardiovascular 2008;1:73. 3. Becit N, Erkut B, Ceviz M, et al. The impact of intraoperative transit time flow measurement on the results of on-pump coronary surgery Eur J Cardiothorac Surg 2007;32:313-318.[Abstract/Free Full Text] 4. Colombo A, Latib A. Surgeons and interventional cardiologists in a collaborative environment J Am Coll Cardiol 2009;53:242-243.[Free Full Text] 5. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease N Engl J Med 2009;360:961-972.[CrossRef][Medline]
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- Marzia Leacche, David X. Zhao, and John G. Byrne
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