Ann Thorac Surg 2000;70:981-982
© 2000 The Society of Thoracic Surgeons
Case report
Changes in graft flow pattern from the descending aorta due to intraaortic balloon pump
Masanori Tsuchida, MDa,
Yasushi Yamato, MDa,
Takehiro Watanabe, MDa,
Hajime Ohzeki, MDb,
Jun-ichi Hayashi, MDa
a Department of Thoracic and Cardiovascular Surgery, Niigata University School of Medicine, Niigata, Japan
b Department of Thoracic and Cardiovascular Surgery, Niigata Prefectural Shibata Hospital, Niigata, Japan
Address reprint requests to Dr Tsuchida, Department of Thoracic and Cardiovascular Surgery, Niigata University School of Medicine, Asahimaci-dori, Niigata, 951-0850, Japan
e-mail: kentsuchi{at}hotmail.com
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Abstract
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During surgery for lung cancer in a patient who had undergone coronary artery bypass grafting through the descending aorta by left thoracotomy, we measured graft bypass blood flow from the descending aorta under intraaortic pump (IABP) assistance. Under IABP assistance, the diastolic waveform changed to a spiky pattern with a sharp drop in blood flow of approximately 16% compared to that without IABP assistance. We report changes in graft flow pattern during IABP assistance when the graft is placed from the descending aorta.
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Introduction
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Coronary artery bypass grafting (CABG) using the saphenous vein is generally performed from the ascending aorta. However, under certain circumstances such as redo CABG, the graft is performed through the descending aorta by left thoracotomy [1, 2]. When low output syndrome occurs after the operation, an intraaortic balloon pump (IABP) is the device of choice because it is known to decrease the afterload and increase the graft flow mainly during diastolic phase. However, the use of IABP for grafts from the descending aorta has not been clarified. In theory, graft flow may decrease during IABP assistance if the IABP catheter occludes the proximal orifice of the graft. We measured graft blood flow from the descending aorta under IABP assistance in a 56-year-old man who had undergone two prior CABGs at another hospital.
A 56-year-old man had undergone saphenous vein grafting to the left anterior descending artery (LAD) for an 80% occlusion of the left main trunk and total occlusion of circumflex coronary arterial lesions in September 1993. Recurrent angina appeared 6 months after the first operation. Through catheterization, we were able to demonstrate total obstruction of the right coronary artery and an 80% occlusion of the native LAD just proximal to the anastomosis site of the vein graft, as well as the patency of the previous graft to the LAD. He underwent grafting through a left thoracotomy to both the right coronary artery and proximal site of LAD using a Y-shape sequential vein graft with proximal anastomosis to the descending aorta. The graft was anastomosed to the descending aorta at the level of the lower pulmonary vein. On October 1998, the patient presented with bloody sputum and was diagnosed with a large cell carcinoma on his left upper lung. Cardiac catheterization revealed total occlusion of the native right coronary artery. In addition, the previous graft to the LAD remained clear, but the two additional grafts showed 50% stenosis at the anastomosis site with an ejection fraction of only 41%. The patient underwent pneumonectomy under IABP assistance on the basis of beneficial effects reported by Bonchek and Olinger [3]. The patient remained hemodynamically stable throughout the operation. During the operation, the vein graft placed from the descending aorta was identified and isolated. Graft flow was measured by a transit-time ultrasonic blood flow meter (Transonic System, Ithaca, NY). The blood flow pattern of the vein graft with and without IABP assistance is shown in Figure 1. Under IABP assistance, the diastolic waveform changed to a spiky pattern with a sharp drop in blood flow of approximately 16% compared to that without IABP assistance. However, hemodynamic parameters including cardiac output, blood pressure, and electrocardiography did not differ between the two conditions. The postoperative course was uneventful and IABP was discontinued on the 1st postoperative day.
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Fig 1. Waveform pattern of blood flow in the descending aorto-coronary bypass graft (A) in the absence or (B) during 1:1 intraaortic balloon pump assistance. Total flow (mean) decreased from 80 ml to 67 ml, due primarily to decreased diastolic flow. The measurement was done in an elapsed time with at least 3 minutes interval.
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Comment
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To the best of our knowledge, this is the first clinical report of blood flow measurement in a graft from the descending aorta under IABP assistance. Tedoriya and associates [4] studied the effects of IABP and left ventricular assist device on blood flow in three different types of coronary artery bypass grafts including the descending aorto-coronary bypass graft in a canine model. They anastomosed the graft to the descending aorta at the level of the first lumbar vertebra as a model of a gastroepiploic artery graft. They demonstrated an increase in blood flow of 21% under IABP assistance. However, in our case, the graft was anastomosed to the descending aorta at the level of the lower pulmonary vein. In this case, the IABP catheter with a 30-ml balloon volume may occlude the anastomosis site during the diastolic phase, leading to a spiky pattern in the blood flow measurement associated with a sharp drop in blood flow. Graft flow pattern presented in Figure 1B is that of a transient increase in flow with balloon inflation in diastolic phase, as blood is forced into the graft, followed by a sharp and sudden drop, as graft orifice is occluded. Graft flow pattern is affected, depending on whether the balloon occludes the orifice of the proximal side of the vein graft when the graft is placed from the descending aorta. Although the net change may be measurable by the transonic flow meter, the value of a 16% decrease in mean graft flow is difficult to interpret. Because there may be various factors that affect the blood flow changes including collateral circulations, systolic and diastolic, and peak diastolic flow due to balloon inflation, the total blood flow to myocardium may have increased, decreased, or remained unchanged in each case. In our case, despite changes in graft flow pattern with the use of IABP, there were no untoward effects on cardiac hemodynamics. In summary, we showed that graft flow pattern from the descending aorta might change during IABP assistance. It is not certain how this change affects hemodynamics in each case.
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References
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Faro R.S., Javid H., Najafi H., Serry C. Left thoracotomy for reoperation for coronary revascularization. J Thorac Cardiovasc Surg 1982;84:453-455.[Medline]
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Burlingame M.W., Bonchek L.I., Vazales B.E. Left thoracotomy for reoperative coronary bypass. J Thorac Cardiovasc Surg 1988;95:508-510.[Abstract]
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Bonchek L.I., Olinger G.N. Intra-aortic balloon counterpulsation for cardiac support during noncardiac operations. J Thorac Cardiovasc Surg 1979;78:147-149.[Abstract]
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Tedoriya T., Kawasuji M., Sakakibara N., Takemura H., Watanabe Y., Hetzer R. Coronary bypass flow during use of intraaortic balloon pumping and left ventricular assist device. Ann Thorac Surg 1998;66:477-481.[Abstract/Free Full Text]
Accepted for publication March 2, 2000.
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