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ICVTS on-line discussion C1 Author's reply to the comments of Ibrahim and Refaat

King Khalid University Hospital, Riyadh 11472, Saudi Arabia

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

eResponse: I was delighted to read the comments of Ibrahim et al. I appreciate the hard work put in by him for reading the paper and especially for counterchecking the mathematical calculations [1]. I would reply to his observations point by point:

• I have failed to understand the rationale of the comment regarding the number of distal lesions versus uniform narrowing of coronary arteries. Both situations have similar if not the same outcomes in terms of tissue perfusion and graft survival. The understanding of basic fluid dynamics would reveal that flow across each successive lesion results in dissipation of energy and hence results in lesser pressure distal to it. Therefore, both the size and the number of lesions have impact on graft survival and relief of angina. I do not find any problem with the measurement of size in multiple lesions. The probe would obviously measure the smallest diameter negotiable and hence the tightest lesion would determine the degree of disease, which is exactly what is desired from grading system.
  
• This comment is based on a wrong assumption. Table-2 shows that there were 57 grafts to the severely diseased vessels. Therefore, the analysis of flows and pulsitility indices does include data of severely diseased vessels. Why I chose to do simple grafting without special techniques like on-lay patches or endarterectomies in these 57 grafts is a complex question. Surgeons who perform CABG on a significantly large number of diffusely diseased coronaries can easily appreciate that there are many coronaries where we have to ignore the suboptimal long term results and resort to palliation of angina. For example, sometimes we like to graft only that segment of LAD which supplies a large septal branch and leave the remaining diffusely diseased vessel unattended.
  
• I am glad that some other surgeons from Saudi Arabia have commented on the high prevalence of Diabetes Mellitus in Saudi patients undergoing CABG. For surgeons working elsewhere this incidence is too high to believe.
  
• In my previous post, ‘Reply to the comments of Aboul-Azm and Iqbal’, I have elaborated my point of view regarding concerns about the role of grading in patient selection, sizing of vessels, and severity of disease as a risk of mortality.
  
• The comment regarding the choice between conventional CABG, OPCAB and OBCAB has nothing to do with the theme of this paper. The choice of these methods depends on patient's co-morbid factors, ventricular function, timing of surgery, anatomy of coronary arteries, standard of anaesthetic support and of course, the surgeon's subjective assessment of the individual patient.
  
• The percentage of LIMA grafts (70%) mentioned by Ibrahim et al. is not a true figure for the whole population of patients. Many LIMA grafts were excluded from the analysis as explained in the next paragraph. Nevertheless, the patients who did not receive LIMA were those who arrived in the operating room in hemodynamically unstable condition or had more than one reason of relatively lesser benefit of LIMA like very old age, poor flow in LIMA, intra-operative damage to LIMA and severe COPD etc.
  
• The observation regarding number of grafts and the extent of 3-vessel disease is very interesting but erroneous. It appears from the text that 186 patients had a total of 486 grafts and hence average of 2.52 i.e. 468/186. Ibrahim et al. have drawn similar impressions by looking at the grafts to the individual vessels. This confusion results from overlooking the detailed description of exclusion criteria mentioned in Patients and Methods. The fact is that the exclusion criteria were applied in two steps. In step one, as mentioned in the paper, all patients who had any procedure other than isolated CABG were removed from the study leaving 186 patients who had 553 grafts i.e. average of 2.97 (553/186). The data of demographic factors, risk factor and outcome were summarized from these 186 patients. In the second stage all grafts which were done after endarterectomies, on-lay patches, or with missing/unreliable data were removed from further analysis hence leaving 468 grafts from the same 186 patients. It is wrong to make any assumptions about the completeness of revascularization from just the number of grafts included in the study.
  
• The last remark is very controversial. If we agree with the comment of Ibrahim et al. then we cannot claim that small Asian ladies have worse coronary artery disease than others.
  

	Reference

Top Reference

 

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]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anjum Jalal Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Jalal, A. Search for Related Content PubMed Articles by Jalal, A. Related Collections Related Article