Necip BECİT, Münacettin CEVİZ, Hikmet KOCAK, Uğur KAYA, Abdurrahim ÇOLAK

Pompa ile yapılan koroner arter baypas greft cerrahisinde ameliyat sırası transit time akım ölçümü: Tek merkez deneyimi

Amaç: Bu çalışmada greft disfonksiyonunun ameliyat sırası transit time akım ölçümü ile saptanmasının pompa ile yapılan koroner arter baypas greft cerrahisi sonuçları üzerindeki etkileri değerlendirildi. Çalışma planı: Aynı cerrahi ekip tarafından gerçekleştirilen median sternotomi yoluyla pompa ile yapılan izole koroner arter baypas greft cerrahisi uygulanan toplam 1240 hasta (856 erkek, 384 kadın; ort. yaş 57.4±12.1 yıl; dağılım, 47-74 yıl) retrospektif olarak incelendi. Transit time akım ölçümünün 2006 yılında kliniğimizde kullanılmaya başlanması ile birlikte, greft açıklığının değerlendirilmesi için ameliyat sırasında tüm hastalara transit time akım ölçümü düzenli olarak uygulandı. Cerrahi uygulanan hastalarda transit time akım ölçümü kullanılarak elde edilen verinin yorumlanması, greft revizyonu uygulayıp uygulamama kararımızı yönlendirdi. Hastalar erken ve geç dönem mortalite/morbidite, perioperatif veya ameliyat sonrası miyokard enfarktüsü ve intraaortik balon gereksinimi açısından değerlendirildi. Bulgular: Perioperatif dönemde toplam 3596 greft transit time akım ölçümü kullanılarak değerlendirildi. Transit time akım ölçümünün yetersiz açıklık gösterdiği 143 hastanın 146 greftinde anastomoz/ greft revizyonu, distal nativ artere yeni anastomoz/yama plasti veya serbest sol internal meme arteri grefti uygulandı. Perioperatif veya ameliyat sonrası miyokard enfarktüsü gelişen altı hastanın dördünde sternum kapatılmadan önce perioperatif hipotansiyon, ST elevasyonu ve transözofageal ekokardiyografide duvar hareket bozukluğu tespit edildi. Transit time akım ölçümü sonrası yetersiz akımlı greftlerin kısa olan boyları uzatılarak akım düzeltildi ve bu dört greftin transit time akım ölçümlerinin normal değerlerde olduğu kaydedildi. İki hastada ameliyat sonrası dönemde akut miyokard enfarktüsü gelişti ve her hastanın bir damarına stent uygulandı, ancak bu hastalardan biri kaybedildi. Dördüne ameliyat öncesi dönemde olmak üzere 16 hastaya intraaortik balon pompası yerleştirildi. Elli altı hastada kanama, 12 hastada sternal enfeksiyon nedeni ile revizyon cerrahisi uygulandı. Tüm hastaların 28’i (%2.3) ameliyat sonrası erken dönemde kaybedildi. Sonuç: Transit time akım ölçümünün greft fonksiyonunun değerlendirilmesinde önemli bir araç olabileceğini ve ameliyat sırasında greft başarısızlığının nedenlerini gidermeye katkıda bulunabileceğini düşünüyoruz.

Intraoperative transit-time flow measurement in on-pump coronary artery bypass graft surgery: Single center experience

Background: This study aims to evaluate the effects of graft dysfunction detected by intraoperative transit-time flow measurement on the outcomes of on-pump coronary artery bypass graft surgery.Methods: A total of 1,240 patients (856 males, 384 females; mean age 57.4±12.1 years; range, 47 to 74 years), who underwent isolated on-pump coronary artery bypass graft surgery via median sternotomy performed by the same surgical team, were reviewed retrospectively. With the introduction of transit- time flow measurement into practice at our clinic in 2006, all patients regularly underwent transit-time flow measurement during surgery in order to evaluate the graft patency. Interpretation of the data obtained using the transit-time flow measurement in patients who underwent surgery has directed our decision as to whether to perform graft revision. Patients were evaluated for early- and late- period mortality/ morbidity, perioperative and postoperative myocardial infarction, and intraaortic balloon requirement.Results: A total of 3,596 grafts in the perioperative period was evaluated using transit-time flow measurement. Anastomosis/graft revision, new anastomosis/patch plasty to distal native artery or free left internal mammary artery graft was performed in 146 grafts of 143 patients in whom transit-time flow measurement showed insufficient patency. Four of six patients who developed peri/postoperative myocardial infarction were found to have perioperative hypotension, ST elevation, and wall motion abnormality on transesophageal echocardiography before closure of the sternum. The flow was corrected by extending the short length of the grafts with insufficient flow after transit-time flow measurement and it was recorded that transit-time flow measurements were at normal values at these four grafts. Two patients developed acute myocardial infarction in the postoperative period and stent was applied in one vessel of each patient; however, one of these patients died. Sixteen patients were inserted intraaortic balloon pump, four of which being in the preoperative period. Revision surgery was performed due to bleeding in 56 patients and sternal infection in 12 patients. Of all patients, 28 (2.3%) died in the early postoperative period.Conclusion: We believe that transit-time flow measurement may be an important tool in evaluating graft function and contribute to eliminate thecauses of graft failure during surgery.

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22. Ozkaynak B, Yıldırım O, Aksüt M, Alper OO, Kayalar N, Omeroğlu SN, et al. Very long-term angiographic results of off-pump coronary artery bypass graft surgery. Turk Gogus Kalp Dama 2014;22:260-5.
21. Gwozdziewicz M, Nemec P, Simek M, Hajek R, Troubil M. Sequential bypass grafting on the beating heart: blood flow characteristics. Ann Thorac Surg 2006;82:620-3.
20. Jakobsen HL, Kjaergard HK. Severe impairment of graft flow without electrocardiographic changes during coronary artery bypass grafting. Scand Cardiovasc J 1999;33:157-9.
19. Groom R, Tryzelaar J, Forest R, Niimi K, Cecere G, Donegan D, et al. Intra-operative quality assessment of coronary artery bypass grafts. Perfusion 2001;16:511-8.
18. Becit N, Erkut B, Ceviz M, Unlu Y, Colak A, Kocak H. The impact of intraoperative transit time flow measurement on the results of on-pump coronary surgery. Eur J Cardiothorac Surg 2007;32:313-8.
17. Walpoth BH, Bosshard A, Genyk I, Kipfer B, Berdat PA, Hess OM, et al. Transit-time flow measurement for detection of early graft failure during myocardial revascularization. Ann Thorac Surg 1998;66:1097-100.
16. Zhuang Y, Chen X, Lua Zq, Xu M, Jiang Ys, Xiao Lq. Evaluation of graft flow between on-pump and off-pump coronary artery bypass grafting. Asian Biomedicine 2012;6:265-71.
15. Schmitz C, Ashraf O, Schiller W, Preusse CJ, Esmailzadeh B, Likungu JA, et al. Transit time flow measurement in on -pump and off-pump coronary artery surgery. J Thorac Cardiovasc Surg 2003;126:645-50.
14. Gwozdziewicz M. Cardiomed coronary flow meter for prevention of early occlusion in aortocoronary bypass grafting. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2004;148:59-61.
13. Kjaergard HK. Baseline flow in coronary bypass grafts. J Card Surg 2005;20:205-7.
12. Jokinen JJ, Werkkala K, Vainikka T, Peräkylä T, Simpanen J, Ihlberg L. Clinical value of intra -operative transit-time flow measurement for coronary artery bypass grafting: a prospective angiography-controlled study. Eur J Cardiothorac Surg 2011;39:918-23.
11. D’Ancona G, Karamanoukian HL, Ricci M, Schmid S, Bergsland J, Salerno TA. Graft revision after transit time flow measurement in off-pump coronary artery bypass grafting. Eur J Cardiothorac Surg 2000;17:287-93.
10. D’Ancona G, Karamanoukian HL, Bergsland J. Is intraoperative measurement of coronary blood flow a good predictor of graft patency? Eur J Cardiothorac Surg 2001;20:1075-7.
9. Hirotani T, Kameda T, Shirota S, Nakao Y. An evaluation of the intraoperative transit time measurements of coronary bypass flow. Eur J Cardiothorac Surg 2001;19:848-52.
8. Sönmez B, Arbatli H, Tansal S, Yagan N, Unal M, Demirsoy E, et al. Real-time patency control with thermal coronary angiography in 1401 coronary artery bypass grafting patients. Eur J Cardiothorac Surg 2003;24:961-6.
7. Di Giammarco G, Pano M, Cirmeni S, Pelini P, Vitolla G, Di Mauro M. Predictive value of intraoperative transit-time flow measurement for short-term graft patency in coronary surgery. J Thorac Cardiovasc Surg 2006;132:468-74.
6. Leong DK, Ashok V, Nishkantha A, Shan YH, Sim EK. Transit-time flow measurement is essential in coronary artery bypass grafting. Ann Thorac Surg 2005;79:854-7.
5. Stover EP, Siegel LC, Parks R, Levin J, Body SC, Maddi R, et al. Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology 1998;88:327-33.
4. Hu S, Wang X, Song Y, Lu F. Graft patency in off-pump and conventional coronary artery bypass grafting for treatment of triple vessel coronary disease. Chin Med J (Engl) 2003;116:436-9.
3. Mujanovic E, Kabil E, Hadziselimovic M, Softic M, Azabagic A, Bersland J. Transit time flow measurements in coronary surgery: the experience from a new center in Bosnia. Heart Surg Forum 2002;5:233 -6.
2. Sanisoglu I, Guden M, Balci C, Sagbas E, Duran C, Akpinar B. Comparison of intraoperative transit-time flow measurement with early postoperative magnetic resonance flow mapping in off-pump coronary artery surgery. Tex Heart Inst J 2003;30:31-7.
1. Bauer SF, Bauer K, Ennker IC, Rosendahl U, Ennker J. Intraoperative bypass flow measurement reduces the incidence of postoperative ventricular fibrillation and myocardial markers after coronary revascularisation. Thorac Cardiovasc Surg 2005;53:217-22.