Transit-time flow predicts outcomes in coronary artery bypass graft patients: a series of 1000 consecutive arterial grafts

Objective: This study was undertaken to evaluate transit-time flow (TTF) as a tool to detect technical errors in arterial bypass grafts intraoperatively and predict outcomes. Methods: TTF's three parameters, pulsatility index (PI, index of resistance), flow (cc min(-1)) and diastolic filling (DF, proportion of diastole with coronary flow), were measured in 990/1000 (99%) of arterial grafts in 336 consecutive patients, prospectively enrolled in a database. Grafts were revised when TTF findings supported the otherwise suspected graft malfunction. If no other signs/suspicion of graft malfunction existed (normal electrocardiogram (EKG), stable haemodynamics and unchanged ventricular function on trans-oesophageal echocardiography (TEE)), and the PI was >5, grafts were not revised. Major adverse cardiac events (MACES: recurrent angina, perioperative myocardial infarction, postoperative angioplasty, re-operation and/or perioperative death) were related to TTF measurements. Results: The average number of grafts per patient was 3.02, of which 99% were arterial. Satisfactory grafts were achieved in 916/990 (93%) of the grafts, with flows from 34 to 61 cc min(-1), PI <= 5 and DF of 62-85%. Fourteen conduits, 20 grafts (2%) suspected to be problematic, were revised. Patients were divided into two groups: 277 (82%) with at least one graft with PI <= 5 and 59 (18%) with a PI>5. MACE occurred in 25(7.4%) patients - 15/277 patients with a PI <= 5 (5.4%) and 10/59 with a PI >5 (17%, p = 0.005). Mortality following non-emergent surgery was significantly higher in patients with a PI >5 (5/54, 9%) than in patients with a PI <= 5 (5/250, 2%, p = 0.02). Flow and DF were not predictive of outcomes. Conclusion: A high PI predicts technically inadequate arterial grafts during surgery - even if all other intra-operative assessments indicate good grafts; it also predicts outcomes, particularly mortality. (C) 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.