Intraoperative Bypass Flow Measurement Reduces the Incidence of Postoperative Ventricular Fibrillation and Myocardial Markers After Coronary Revascularisation[1]

Abstract

Objective: Sudden ventricular fibrillation (VF) and myocardial infarction (MI) are life-threatening complications after coronary artery bypass grafting (CABG). We prospectively analysed the impact of intraoperative bypass flow measurement with the transit time flow Doppler method (TTFD) on the incidence and outcome of postoperative VF and MI. Methods: In 1995 a standardized algorithm for the treatment of postoperative VF was introduced in our institution. The rate of postoperative VF was therefore exactly registered. In 1998 the TTFD method was implemented as a standard in all CABG cases. Whenever insufficient bypass graft flow was detected, anastomoses were redone and technical problems affecting the grafts were excluded. The incidence of postoperative VF and CK/CK-MB fraction was observed prospectively and the new data was compared to the data from 1995 to 1998. Results: From 1/95 to 7/98 a total of 4321 patients (group A) were operated on with isolated CABG procedures using extracorporeal circulation. In the period from 8/98 to 10/02 a total of 3421 patients (group B) was operated on with isolated CABG procedures under the same conditions, except that the TTFD method was used in every case. The treatment of VF was standardised in both groups according to the algorithm. The most striking effect was the significant reduction of VF from 0.66 % to 0.44 % when TTFD was introduced and the steep decrease in mortality from 30 % to 12.2 % in patients with VF when the algorithm and TTFD were routinely applied. Furthermore the rate of insufficient bypass flow detected by angiography was reduced by 66 %. Conclusion: Routinely the use of TTFD significantly reduced the incidence of postoperative VF, postoperative CK/CK-MB fraction, and angiographically detected bypass malfunction. A simultaneously implemented algorithm reduced the mortality with VF after CABG. The consequent use of TTFD intraoperatively reduced the incidence of postoperative anastomosis and technically related complications of bypass surgery and led to a significant reduction of postoperative mortality in CABG procedures.

Key words

Bypass flow measurement - CABG - myocardial infarction - ventricular fibrillation - quality in bypass surgery

1 Paper was previously presented at the Congress of Thoracic, Cardiac, and Cardiovascular Surgery in Leipzig 2002 (Main Session)

References

• 1 D'Ancona G, Karamanoukian H, Ricci M, Bergsland J, Salerno T A. Preoperative angiography and intraoperative transit time flow measurement to detect coronary graft patency in reoperation an integrated approach - a case report.  Angiology. 2000;  51 777-780
• 2 D'Ancona G, Karamanoukian H L, Ricci M. et al . Graft revision after transit time flow measurement in off-pump coronary artery bypass grafting.  Eur J Cardiothorac Surg. 2000;  17 287-293
• 3 Bardell T, Hamilton G, Bergstrome D. et al . Anastomotic quality in CABG: when life depends on millimeters.  CMAJ. 2002;  167 783
• 4 Belboul A, Radberg G, Roberts D, Dernevik L. Intraoperative assessment of coronary flow and coronary vascular resistance during coronary bypass surgery.  Scand Cardiovasc J. 1999;  33 23-28
• 5 Carrier M, Pellerin M, Perrault L B. et al . Troponin levels in patients with myocardial infarction after coronary artery bypass surgery.  Ann Thorac Surg. 2000;  69 435-440
• 6 Caputo M, Bryan A J, Calafiore A M. et al . Intermittent antegrade hypercalaemic warm blood cardioplegia supplemented with magnesium prevents myocardial substrate derangement in patients undergoing coronary artery bypass grafting.  Eur J Cardiovasc Surg. 1999;  14 596-601
• 7 Frassen E J, Davis J HC, Maessen J G. et al . Evaluation of “new” cardiac markers for ruling out myocardial infarction after coronary artery bypass grafting.  Chest. 2002;  122 1316-1321
• 8 Jaber S F, Koenig S C, Bhasker R B. et al . Can visual assessment of flow waveform morphology detect anastomotic error in off-pump coronary artery bypass grafting?.  Eur J Cardiothorac Surg. 1998;  14 476-479
• 9 Kaul T K, Fields B L, Riggins L S. et al . Ventricular arrhythmia following successful myocardial revascularisation: incidence, predictors and prevention.  Eur J Cardiovasc Surg. 1999;  13 629-636
• 10 Morota T, Duhanylonmgrod F G, Burfeind W R. et al . Intraoperative evaluation of coronary anastomosis by transit time ultrasonic flow measurement.  Ann Thorac Surg. 2002;  73 1446-1450
• 11 Oh J K. Echocardiography in adult cardiac surgery.  Asian Cardiovasc Thorac Ann. 2000;  8 204
• 12 Ricci M, Karamanoukian H L, Salerno T A, D'Ancona G, Bergsland J. Role of coronary bypass flow measurement during reoperation for early graft failure after off-pump coronary revascularisation.  J Card Surg. 1999;  14 342-347
• 13 Roques F, Nashef S AM, Michel P. et al . Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19 030 patients.  Eur J Cardiovasc Surg. 1999;  15 816-823
• 14 Shin H, Yozu R, Mitsumaru A. et al . Intraoperative assessment of coronary artery bypass grafts: transit time flowmetry versus angiography.  Ann Thorac Surg. 2001;  72 1562-1565
• 15 Speziale G, Ruvolo G, Coppola R, Marino B. Intraoperative flow measurement in composite Y arterial grafts.  Eur J Cardiothorac Surg. 2000;  17 505-508
• 16 Svedjeholm R, Dahlin L G, Lundberg C. et al . Are electrocardiographic Q-wave criteria reliable for diagnosis of perioperative myocardial infarction after coronary surgery?.  Eur J Cardiovasc Surg. 1999;  13 655-661
• 17 Takami Y, Ina H. Relation of intraoperative flow measurement with postoperative quantitative angiographic assessment of coronary artery bypass grafting.  Ann Thorac Surg. 2001;  72 1270-1274
• 18 Takami Y, Ina H. A simple method to determine anastomotic quality of coronary artery bypass grafting in the operating room.  Cardiovasc Surg. 2001;  9 499-503
• 19 Tasi T P, Ueng K C, Yu J M, Chang Y C, Wu Y L. Comparison of the postoperative blood flow waveforms of the bypassing grafts in patients following minimally invasive direct coronary artery bypass.  Chest. 2002;  121 951-956
• 20 Voigtländer T, Dahm M, Kreitner K F. et al . Intraoperative flow measurement of coronary bypass grafts using the ultrasound transit time flowmeter.  Z Kardiologie. 1999;  88 773-779
• 21 Walpoth B H, Muller M F, Genyk I. et al . Evaluation of coronary bypass flow with color Doppler and magnetic resonance imaging techniques: comparison with intraoperative flow measurements.  Eur J Cardiothorac Surg. 1999;  15 795-802
• 22 Wolfe J A. The coronary artery bypass conduit: II. Assessment of the quality of the distal anastomosis.  Ann Thorac Surg. 2001;  72 S 2253-2258

1 Paper was previously presented at the Congress of Thoracic, Cardiac, and Cardiovascular Surgery in Leipzig 2002 (Main Session)