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J Thorac Cardiovasc Surg 2005;129:1195-1196
© 2005 The American Association for Thoracic Surgery

Letters to the Editor

The answer is an intra-aortic balloon pump

Yoshiyuki Takami, MD, Hiroshi Masumoto, MD

Division of Cardiovascular Surgery, Kasugai Municipal Hospital, 1-1-1 Takagi-cho, Kasugai City, 486-8510 Japan

To the Editor:

We have presented an article1 in the Journal with a case of wrong anastomosis of the left internal thoracic artery (LITA) with the cardiac vein that could not be detected with transit flow measurement. The LITA graft anastomosed with the cardiac vein demonstrated biphasic and diastolic-dominant flow, forming a trapezoid-shaped waveform, which was quite similar to the flow of the patent LITA graft to the left coronary artery.

Readers may not be able to understand why the arteriovenous flow pattern was similar to the arterioarterial flow pattern in this patient, because we did not discuss the mechanism that caused this similarity. In addition, readers may think that this similarity in flow pattern between the arteriovenous graft and the arterioarterial graft supports the idea of selective arterialization of the coronary venous system for patients with severe diffuse coronary artery disease.2–4 More recently, this idea has been expanded to the concept of percutaneous in situ coronary venous arterialization.5

The answer for this is the use of the intra-aortic balloon pump (IABP) in our patient. We have been applying prophylactic and preincision IABP aggressively to patients undergoing coronary artery bypass grafting. The IABP-induced diastolic flow augmentation of the incorrect LITA graft may result in the trapezoid-shaped waveform in transit flow measurement. Unfortunately, we did not record the waveform of the graft without IABP counterpulsation in this patient. We need further investigation of the flow pattern of the graft to the coronary vein without IABP counterpulsation.

Our article1 does not support the idea of coronary venous arterialization. We did not ligate the cardiac vein distally to isolate the arterialized venous system from the rest of the venous anatomy and to prevent steal through the coronary sinus to the right atrium, as is performed in surgical or percutaneous arterialization of the coronary venous system. However, even in the presence of the steal to the right atrium, the flow pattern of the arteriovenous graft we demonstrated may give the readers some suggestions regarding the physiology of the arterialized coronary venous system.

To be exact, the main finding of our article1 is that it is impossible to detect incorrect grafting of the LITA to the coronary vein by flow waveform analysis with the transit time flow measurement under IABP counterpulsation.

References

  1. Takami Y, Masumoto H. Transit time flow measurement cannot detect wrong anastomosis with the cardiac vein in coronary artery surgery. J Thorac Cardiovasc Surg. 2004;128:629-631.[Free Full Text]
  2. Arealis EG, Volder JGR, Kolff WJ. Arterialization of the coronary vein coming from an ischemic area. Chest. 1973;63:462-463.[Abstract/Free Full Text]
  3. Benedict JS, Buhl TL, Henney RP. Cardiac vein myocardial revascularization. An experimental study and report of 3 clinical cases. Ann Thorac Surg. 1975;20:550-557.[Abstract]
  4. Sadaba JR, Nair UR. Selective arterialization of the coronary venous system. Ann Thorac Surg. 2004;78:1458-1460.[Abstract/Free Full Text]
  5. Oesterle SN, Reifart N, Hauptmann E, Hayase M, Yeung AC. Percutaneous in situ coronary venous arterialization. Circulation 2001;103:253-260.[Abstract/Free Full Text]




This Article
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Right arrow Cardiac - physiology
Right arrow Coronary disease

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