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ICVTS on-line discussion AB1 Author's reply to comments of Aboul-Azm and of Iqbal

King Khalid University Hospital, Riyadh 11472, Saudi Arabia

An objective method for grading of distal disease in the grafted coronary arteries

eResponse: I welcome the comments made by AN Aboul-Azm and by MA Iqbal. The points raised by them are, in general, beyond the scope of this paper [1]. However, I would like to reply as briefly as possible.

1. Referring to Dr. Aboul-Azm, I am pleased to confirm that regular use of transit time flow measurement (TTFM) does improve the quality of grafting. But even more important is its role in improving the understanding of coronary artery disease and the dynamics of flow in diffusely diseased vessels. Let me mention only two very important points which we learned from regular use of TTFM. Firstly, we discovered that digital palpation of grafts provides no useful information about the quality of flow: a totally shut off graft can have excellent pulsation. Secondly, we learned that hemodynamic instability with or without ST- changes in ECG is almost always associated with poorly functioning graft to an important vessel. In such situations it is pointless to waste time on manipulation of inotropes. Revision of poorly functioning graft, identified on TTFM, improves the hemodynamics immediately.
   
2. Regarding Dr. Iqbal's comment on decision to perform CABG, I must reassure him that grading of coronary arteries has no role in patient selection. Like all surgeons, I accept patients for CABG entirely on two grounds i.e. symptomatic improvement and prognostic advantage. Very frequently, I have to accept patients for surgery with miserable nearly end-stage disease. It is obvious in these patients that the target coronaries are going to be challenging and would require more than just simple anastomoses. Interestingly, in these patients, the angiograms provide no direct information regarding distal run off. The decision of managing such coronaries is neither made nor changed after opening them up. The surgical plan is usually very unconventional and is made much earlier before entering the operating room.
   
3. I do not agree with the comment that the grading would provide another excuse for poor results. The previous studies [2, 3] which incriminated diffuseness of disease for increased mortality used flawed definitions of diffuse disease. I believe diffuseness, if defined properly, has no role in operative mortality. However, it does have impact on short as well as long term patency of grafts. The analysis of my unpublished data supports this belief and I am planning to publish it soon. I hope others will also use this grading system to look at their mortality and morbidity and enlighten us in due course.
   
4. In summary, the sole objective of proposing a grading system is to provide a common language so that when we say mild, moderate and severe all of us should mean the same thing. This would help us understand the behavior of innovative grafting methods like long patches and endarterectomies in different grades of disease. Probing of vessels would remain a concern for some but I believe modern imaging modalities like CT and MRI may, in the near future, obviate the need of preoperative size estimation.
   

	References

Top References

 

1. Jalal A. An objective method for grading of distal disease in the grafted coronary arteries. Interact CardioVasc Thorac Surg 2007; 6:451–457.[Abstract/Free Full Text]
2. Johnson WD, Brenowitz JB, Kyser KL. Factors influencing long term (10-year to 15-year) survival after successful coronary artery bypass operation. Ann Thorac Surg 1989; 48:19–24.[Abstract]
3. Wright JG, Pifarre R, Sullivan HJ, Montoya A, Bakhos M, Grieco J, Jones R, Foy B, Gunnar RM, Bieniewski CL. Multivariate discriminant analysis of risk factors for operative mortality following isolated coronary artery bypass grafting. Loyola University Medical Center Experience, 1970 to 1984. Chest 1987; 91:394–339.[Medline]

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