Fractional flow reserve–guided coronary artery bypass grafting: Can intraoperative physiologic imaging guide decision making? T. Bruce Ferguson, MD,

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Presentation transcript:

Fractional flow reserve–guided coronary artery bypass grafting: Can intraoperative physiologic imaging guide decision making? T. Bruce Ferguson, MD, Cheng Chen, PhD, Joseph D. Babb, MD, Jimmy T. Efird, PhD, Ramesh Daggubati, MD, John M. Cahill, MD The Journal of Thoracic and Cardiovascular Surgery Volume 146, Issue 4, Pages 824-835.e1 (October 2013) DOI: 10.1016/j.jtcvs.2013.06.026 Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Physiologic imaging of angiography and perfusion with near-infrared fluorescence complex angiography and perfusion analysis. A, A single frame at near-peak fluorescence from the 1020 frames captured in each 34-second video sequence with near-infrared fluorescence angiography of an in situ internal mammary artery to the left anterior coronary artery graft. The raw data are presented as a 1 to 255 grey scale because the near-infrared spectrum is outside the visible spectrum. This grey scale best illustrates the angiographic component of the dynamic image data. B, The same single frame at near-peak fluorescence. These data are presented to highlight perfusion rather than angiography. This color scheme presents alternative warm and cold colors to facilitate the visual differentiation between levels of fluorescence, which represent differences in levels of perfusion. Note that no manipulation of the raw image metadata is required to generate these displays. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 824-835.e1DOI: (10.1016/j.jtcvs.2013.06.026) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 The complex angiography and perfusion analysis platform presentation construct, with representative patient analyses. Dynamic video and relative perfusion comparisons are displayed. Unique synchronization of the postgrafting (lower right) versus pregrafting (lower left) image sequences allowed for nonquantitative, but visual, comparison of these data. The complex angiography and perfusion analysis platform analyzes the underlying video metadata for the quantitative comparison of the postgrafting versus pregrafting regional myocardial perfusion in the regional territory supplied (at least in part) by the grafted target vessel epicardial coronary artery. This relative comparison is presented using 2 methods in this scheme. Upper right, The blue line represents perfusion before grafting, with only the native target vessel epicardial coronary artery supplying the myocardial region; the red line represents perfusion after grafting, with both the target vessel epicardial coronary artery and graft supplying the myocardial region; and the green line is the calculated difference in myocardial perfusion, if any, as a result of bypass grafting. Upper middle, The bar graph normalizes the pregraft perfusion to 1 and illustrates this relative comparison as a ratio against this normalized value. A and B, Analysis from 2 different patients undergoing in situ internal mammary artery grafting to the left anterior descending coronary artery. A, A significant increase occurred in regional myocardial perfusion in the anterior wall. B, No increase occurred in regional myocardial perfusion, despite widely patent bypass grafts beyond ∼75% stenoses according to the near-infrared fluorescence complex angiography and perfusion analysis evaluation. The patient whose data are shown in Figure A had a preoperative left anterior descending coronary artery fractional flow reserve of 0.73, and the patient whose data are shown in part B had a preoperative fractional flow reserve of 0.81. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 824-835.e1DOI: (10.1016/j.jtcvs.2013.06.026) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Diagram illustrating the clinical and imaging flow of the study. CABG, Coronary artery bypass grafting; OPCAB, off-pump CABG; ICF, image-described competitive flow; IMA, internal mammary artery; RA, radial artery; SVG, saphenous vein graft; RMP, regional myocardial perfusion, as assessed using near-infrared fluorescence complex angiography and perfusion analysis. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 824-835.e1DOI: (10.1016/j.jtcvs.2013.06.026) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 The individual regional myocardial perfusion data for 2 patients who had undergone multivessel off-pump coronary artery bypass grafting were aggregated into a 2-dimensional representation of the global change in perfusion in the heart as a result of bypass grafting. In case 1, only the inferior wall region had an increase in myocardial perfusion with grafting. In case 2, however, a significant change in perfusion occurred in all 3 areas as a result of revascularization. In both cases, all grafts were widely angiographically patent as documented by the near-infrared fluorescence angiographic evaluation. The difference between these 2 patients' physiologic outcomes with bypass grafting highlight the importance of a new knowledge opportunity inherent in intraoperative physiologic evaluation of both angiography and perfusion at bypass grafting. CX, Circumflex region; LAD, left anterior descending region; LIMA-LAD, left internal mammary artery to left anterior descending; RCA, right coronary artery region; RA-PDA, right coronary-posterior descending artery; SVG-CX, saphenous vein graft to circumflex marginal; SVG-RCA, saphenous vein graft to right coronary artery. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 824-835.e1DOI: (10.1016/j.jtcvs.2013.06.026) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Histogram plot of the percentage of grafts with a categorized magnitude of change in regional myocardial perfusion (RMP) as a result of bypass grafting. Black bars indicate in situ internal mammary artery (IMA) grafts; hashed bars, aortocoronary (saphenous vein graft [SVG]/radial artery [RA]) grafts. The straight lines represent the log exponential decay curves for the IMA (solid black line) and aortocoronary grafts (dashed line). The slopes of the 2 lines differed by 25% (P < .05). More clustering of smaller increases (10% to 75%, <2.0) was found in the aortocoronary grafts, and the IMA grafts (92% to the left anterior descending coronary artery) had a broader range of RMP increases. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 824-835.e1DOI: (10.1016/j.jtcvs.2013.06.026) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions