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Ann Thorac Surg 2005;79:857-858
© 2005 The Society of Thoracic Surgeons
Service of Cardiovascular Surgery, Department of Surgery, University Hospital of Geneva, Geneva, CH 1211 Switzerland
(E-mail: beat.walpoth{at}hcuge.ch).
Transit-time flow measurement (TTFM), a new quantitative volume-flow Doppler technique, has been used for the last 10 years in clinical revascularization procedures. In vitro and in vivo validation studies have described good accuracy and high precision for clinical use [1]. TTFM enables the surgeon to obtain immediate quality control of bypass surgery. The technique is simple and rapid to use, and is certainly less costly and cumbersome than other methods such as intraoperative coronary angiography. In addition, TTFM allows the measurement of the quantity of blood passing through a newly grafted vessel to the myocardium at risk. Data obtained from flow measurements are dependent on several factors that all interact, such as cardiac output, arterial pressure, peripheral vascular resistance, residual antegrade coronary artery flow, size of the myocardium at risk, microvascular tonus, type of grafts used, length and diameter of grafts, hematocrit, and temperature, just to name a few. Thus, normal values may vary considerably. In my view, the most important result for the surgeon, and consequently for the patient, is a mean basal flow value above a certain limit, ie, 20 mL per minute with a diastolic filling pattern and a pulsatility index below 5. All the modern measuring devices calculate automatically these measurements online. A major dilemma arises when graft flow is below 10 mL per minute, with an elevated pulsatility index and a predominant systolic flow pattern. This suggests technical failure at the distal anastomosis. In certain cases, severe vasospasm can mimic a similar result when arterial grafts are used. In such cases the application of local vasodilators may solve the problem; in all other conditions, a re-do of the distal anastomosis is mandatory.
Using TTFM technique several authors have reported excellent results in diagnosing technical failures during coronary artery bypass grafting and resolving the problem during the same operation. The studies by D'Ancona, as well as our group, have reported that in 6% to 8% of all patients a technical failure can be diagnosed with TTFM and resolved during the same procedure [2, 3]. This is of great benefit for the patient avoiding unnecessary perioperative complications.
Thus, we strongly recommend the use of intraoperative flow measurements for all types of revascularization in order to obtain high quality bypass surgery as well as to improve the outcome of the patients.
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