| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1999;67:1173-1174
© 1999 The Society of Thoracic Surgeons
a Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois, USA
b Division of Cardiac Surgery, Department of Surgery, The University of Chicago, Chicago, Illinois, USA
Accepted for publication October 9, 1998.
Address reprint requests to Dr Aronson, Department of Anesthesia and Critical Care, The University of Chicago, 5841 S. Maryland Ave, MC 4028, Chicago, IL 60637
 |
Abstract |
|---|
 Top Abstract IntroductionCommentReferences |
|---|
|
Introduction |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
Assessment of regional myocardial function remains the mainstay for evaluating adequacy of myocardial flow by inferring a direct relationship between regional flow and regional function. We describe a case when assessment of changes in regional endocardial wall motion proved to be an unsatisfactory test of flow adequacy until we instituted an Allens test equivalent.
The patient, a 49-year-old, 90-kg woman with coronary artery disease, had minimally invasive coronary artery bypass to her left anterior descending coronary artery (LAD). Intraoperative transesophageal echocardiography monitoring showed normal baseline regional function and regional anterior wall akinesia caused by the stabilizing retractor at the time of anastomosis, which resolved immediately after completion of the anastomosis and release of the retractor. The graft integrity was assessed after anastomosis by direct palpation and monitoring of regional wall motion; both were normal. The wound was closed and the patient was brought to the catheterization laboratory (by protocol) for confirmation of graft patency. Cardiac catheterization after LAD-left internal mammary artery (LIMA) anastomosis showed a large (more than 95%) eccentric lesion in the distal LIMA. After an unsuccessful percutaneous translumenal coronary angioplasty attempt, the patient was taken back to the operating room and the LIMA was reanastomosed to the LAD. After reanastomosis, we sequentially occluded the native and grafted LAD vascular beds during assessment of regional wall motion changes with transesophageal echocardiography. Occlusion of either the native LAD or LIMA-LAD vessel independent of the other did not elicit a regional wall motion abnormality. When both were occluded simultaneously, however, an acute segmental wall motion disturbance occurred, but resolved immediately upon release of the LAD-LIMA graft.
The patient was extubated again and discharged to the intensive care unit. Her postoperative electrocardiogram was isoelectric and she had no clinical signs of myocardial oxygen debt. Approximately 12 hours later, acute chest pain developed with anterior-lead electrocardiographic changes (T-wave inversion V1-V5), and she was consequently returned to the catheterization laboratory. Angiography showed a patent LAD-LIMA anastomosis and a secondary distal LAD occlusion. A percutaneous transluminal coronary angioplasty was successfully performed and her symptoms resolved.
This case enabled us to do both an initial and second evaluation of the coronary anatomy at the LIMA-LAD anastomosis site, which was assessed intraoperatively with conventional and provocative tests, respectively, of flow-function interdependence. The conventional test found a false-negative relationship between regional wall motion and adequate anastomosis integrity, whereas the provocative test found concordance. Because the patient subsequently later had symptoms of angina (unrelated to the graft anastomosis at operation), reevaluation of the graft, otherwise not likely, was obtained.
|
Comment |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
In 1929, E.V. Allen [5] first reported a technique to determine the site and severity of arterial stenosis distal to the wrist in patients with thromboarteritis obliterans. In that description he states, "The patient closes his hand as tightly as possible for a period of one minute in order to squeeze blood out of the hand; the examiner compresses the wrist between his thumb and fingers, thus occluding the radial artery; the patient quickly extends his fingers partially while compression of the radial artery is maintained by the examiner. The return of color to the hand and fingers is noted. In individuals with an intact arterial tree, the pallor is quickly replaced by rubor of a higher degree than normal, which gradually fades to the normal color. If the ulnar artery is occluded, pallor is maintained for a variable period, due to obstruction to arterial flow in the two main channels—repetition of the test with the examiners thumb compressing the ulnar artery demonstrates the presence or absence of such a lesion in the radial artery."
We adapted the principal described by Allen for detecting ischemia distal to the wrist to the myocardium, as follows: During observation (with intraoperative echocardiography) of the normal contraction and relaxation cycle of the heart, the surgeon simultaneously occludes the native LAD circulation and the LIMA-to-LAD anastomosis for a period of 10 to 15 seconds, thus occluding blood flow to the myocardial region subtended by the LAD coronary artery. Evaluation of regional wall motion continues throughout occlusion of the native and graft LAD flow. The appearance of a new regional wall motion abnormality implies ischemically induced changes. In patients with extensive collateral circulation beyond the contribution of the LAD vascular bed, new acute regional wall motion abnormalities would not be expected. If adequate collateral flow to the region supplied by the LAD does not exist, then persistent regional wall motion abnormalities will be observed because of obstruction to the two main channels (native LAD and graft LAD) supplying the myocardial region of interest. Upon release of the LIMA-LAD graft, if regional wall motion returns to normal, then adequate flow through the graft can be presumed. Whereas, if upon release of the graft, regional wall motion abnormalities persist, then inadequate graft flow is suspected. In our report of this intraoperative adaptation of Allen’s test, an intact LIMA-to-LAD graft was confirmed by postoperative angiography.
As with any clinical innovation, experience will likely improve outcomes, however, gaining experience will also be dependent on demonstrating good results. Currently, methods available to verify patency of LIMA-to-LAD anastomosis are evolving as are techniques for the procedure itself. We reported another method to help evaluate flow from the bypass graft. If this method proves reliable and simple, then operating rooms will be used more efficiently. Ultimately, quality of care will be enhanced by intraoperative verification of graft flow.
|
References |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  L. J. Goldstein and S. Gupta Use of the Radial Artery for Hemodialysis Access Arch Surg, October 1, 2003; 138(10): 1130 - 1134. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
