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Y-graft and proximal LIMA flow adaptability: the surgical wisdom of iatrogenics

Y-graft and proximal LIMA flow adaptability: the surgical wisdom of iatrogenics European Journal of Cardio-thoracic Surgery 30 (2006) 566—570 www.elsevier.com/locate/ejcts Letters to the Editor Letter to the Editor collateral pump could be an explanation to the poor outcome carried by. Y-graft and proximal LIMA flow adaptability: the surgical As an added level of complexity, one should integrate the wisdom of iatrogenics coronary dominance with the above quoted considerations. A left-dominant coronary system should be though seen as providing the most amount of systolic LAD perfusion through Faranak Kargar, Mathias Aazami Shahid Rejaei Heart Hospital, Melat Park, a single system inflow, left coronary ostium; a pattern that Tehran, Iran can be deemed as singly double-LAD inflow while the right dominant or co-dominant coronary systems can potentially Received 31 March 2006; accepted 1 June 2006; Available online feed LAD by two separate inflow (right and left coronary 20 July 2006 ostia), doubly double-LAD inflow. A more potentially Keywords: Myocardial revascularisation; Left internal thoracic artery; restrictive flow offered by singly double-LAD inflow com- Composite arterial grafts pared with doubly double-LAD inflow pattern can, therefore, support the higher clinical incidence of angina in patients Through their recent article, Lemma et al. [1] reported presenting with aortic stenosis, normal epicardial arteries, and left-dominant coronary system. gratifying adaptability to the flow of proximal LIMA when Provided that surgical revascularisation results in resum- using Y-graft revascularisation, corroborating previous inves- tigation in this field [2], and on which the authors should be ing normal physiological coronary flow, coronary bypass congratulated. grafting should be considered as an opportunity to offer Although the authors concluded that the distal flow of LIMA patients to be provided with a doubly double-LAD inflow is similar between Y-graft and single graft groups, exclusive Y- pattern, even in the case of patient’s left-dominant coronary graft revascularisation may raise concerns over attendant system, and not to transform routinely a native doubly physiological disturbances afflicted to the integrated perfu- double-LAD inflow into a potentially restrictive singly double- sion of coronary systems and their interplay. Apart from LAD inflow by exclusive T- or Y-grafting [2], even though the successfully measuring the relative flow and demonstrating proximal LIMA flow displays some amount of adaptability. technical feasibility, the exclusive T- or Y-graft nonetheless results in a perfusion pattern similar to a left-dominant References coronary system. [1] Lemma M, Innorta A, Pettinari M, Mangini A, Gelpi G, Piccaluga M, Danna P, It is well documented that the systolic antegrade flow Antona C. Flow dynamics and wall shear stress in the left internal thoracic of LAD is composed by antegrade flow from left Valsalva artery: composite arterial graft versus single graft. Eur J Cardiothorac Surg sinus and systolic retrograde given way by its collaterals 2006;29:473—8. such as septal and diagonal arteries [3]. Although being [2] Sakaguchi G, Tadamura E, Ohnaka M, Tambara K, Nishimura K, Komeda M. Composite arterial Y graft has less coronary flow reserve than independent slighted in routine practice, the functional role of the latter grafts. Ann Thorac Surg 2002;74:493—6. is crucial. When occluding LAD with balloon, the amount [3] Spann JAE, Breuls NPW, Laird JD. Forward coronary flow normally seen in of systolic recruitable collateral flow in LAD increases systole is the result of forward and cancealed back flow. Basic Res Cardiol proportional to increasing flow in contralateral artery [4]. 1981;76:582—6. Such a collateral flow that is dependant on myocardium [4] Piek JJ, Koolen JJ, Metting van Rijn AC, Bot H, Hoedemaker G, David GK, Dunning AJ, Spaan JA, Visser CA. Spectral analysis of flow velocity in contractility [5], myocardial collateral pump,gives horizon the contralateral artery during coronary angioplasty: a new method for to new integrated insights in coronary physiology, con- assessing collateral flow. J Am Coll Cardiol 1993;21:1574—82. sequences of which should be taken surgically in good [5] Tron C, Donohue TJ, Bach RG, Wolford T, Caracciolo EA, Aguirre FV, Khoury advantage. A, Kern MJ. Differential characterization of human coronary collateral blood flow velocity. Am Heart J 1996;132:508—15. Therefore, LAD can be seen as having two potential inflows, double-LAD inflow, the importance of which is obvious in clinical practice, such as in the setting of occluded * Corresponding author. Tel.: +98 912 29 74 380. LAD and myocardial hypertrophy where the amount of E-mail address: mathias.aazami@laposte.net (M. Aazami) systolic recruitable flow is increased. Similarly, the loss of contractility by septal infarction that blunt myocardial doi:10.1016/j.ejcts.2006.06.002 1010-7940/$ — see front matter # 2006 Elsevier B.V. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Y-graft and proximal LIMA flow adaptability: the surgical wisdom of iatrogenics

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Publisher
Oxford University Press
Copyright
© 2006 Elsevier B.V. All rights reserved.
Subject
Letters to the Editor
ISSN
1010-7940
eISSN
1873-734X
DOI
10.1016/j.ejcts.2006.06.002
pmid
16857369
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Abstract

European Journal of Cardio-thoracic Surgery 30 (2006) 566—570 www.elsevier.com/locate/ejcts Letters to the Editor Letter to the Editor collateral pump could be an explanation to the poor outcome carried by. Y-graft and proximal LIMA flow adaptability: the surgical As an added level of complexity, one should integrate the wisdom of iatrogenics coronary dominance with the above quoted considerations. A left-dominant coronary system should be though seen as providing the most amount of systolic LAD perfusion through Faranak Kargar, Mathias Aazami Shahid Rejaei Heart Hospital, Melat Park, a single system inflow, left coronary ostium; a pattern that Tehran, Iran can be deemed as singly double-LAD inflow while the right dominant or co-dominant coronary systems can potentially Received 31 March 2006; accepted 1 June 2006; Available online feed LAD by two separate inflow (right and left coronary 20 July 2006 ostia), doubly double-LAD inflow. A more potentially Keywords: Myocardial revascularisation; Left internal thoracic artery; restrictive flow offered by singly double-LAD inflow com- Composite arterial grafts pared with doubly double-LAD inflow pattern can, therefore, support the higher clinical incidence of angina in patients Through their recent article, Lemma et al. [1] reported presenting with aortic stenosis, normal epicardial arteries, and left-dominant coronary system. gratifying adaptability to the flow of proximal LIMA when Provided that surgical revascularisation results in resum- using Y-graft revascularisation, corroborating previous inves- tigation in this field [2], and on which the authors should be ing normal physiological coronary flow, coronary bypass congratulated. grafting should be considered as an opportunity to offer Although the authors concluded that the distal flow of LIMA patients to be provided with a doubly double-LAD inflow is similar between Y-graft and single graft groups, exclusive Y- pattern, even in the case of patient’s left-dominant coronary graft revascularisation may raise concerns over attendant system, and not to transform routinely a native doubly physiological disturbances afflicted to the integrated perfu- double-LAD inflow into a potentially restrictive singly double- sion of coronary systems and their interplay. Apart from LAD inflow by exclusive T- or Y-grafting [2], even though the successfully measuring the relative flow and demonstrating proximal LIMA flow displays some amount of adaptability. technical feasibility, the exclusive T- or Y-graft nonetheless results in a perfusion pattern similar to a left-dominant References coronary system. [1] Lemma M, Innorta A, Pettinari M, Mangini A, Gelpi G, Piccaluga M, Danna P, It is well documented that the systolic antegrade flow Antona C. Flow dynamics and wall shear stress in the left internal thoracic of LAD is composed by antegrade flow from left Valsalva artery: composite arterial graft versus single graft. Eur J Cardiothorac Surg sinus and systolic retrograde given way by its collaterals 2006;29:473—8. such as septal and diagonal arteries [3]. Although being [2] Sakaguchi G, Tadamura E, Ohnaka M, Tambara K, Nishimura K, Komeda M. Composite arterial Y graft has less coronary flow reserve than independent slighted in routine practice, the functional role of the latter grafts. Ann Thorac Surg 2002;74:493—6. is crucial. When occluding LAD with balloon, the amount [3] Spann JAE, Breuls NPW, Laird JD. Forward coronary flow normally seen in of systolic recruitable collateral flow in LAD increases systole is the result of forward and cancealed back flow. Basic Res Cardiol proportional to increasing flow in contralateral artery [4]. 1981;76:582—6. Such a collateral flow that is dependant on myocardium [4] Piek JJ, Koolen JJ, Metting van Rijn AC, Bot H, Hoedemaker G, David GK, Dunning AJ, Spaan JA, Visser CA. Spectral analysis of flow velocity in contractility [5], myocardial collateral pump,gives horizon the contralateral artery during coronary angioplasty: a new method for to new integrated insights in coronary physiology, con- assessing collateral flow. J Am Coll Cardiol 1993;21:1574—82. sequences of which should be taken surgically in good [5] Tron C, Donohue TJ, Bach RG, Wolford T, Caracciolo EA, Aguirre FV, Khoury advantage. A, Kern MJ. Differential characterization of human coronary collateral blood flow velocity. Am Heart J 1996;132:508—15. Therefore, LAD can be seen as having two potential inflows, double-LAD inflow, the importance of which is obvious in clinical practice, such as in the setting of occluded * Corresponding author. Tel.: +98 912 29 74 380. LAD and myocardial hypertrophy where the amount of E-mail address: mathias.aazami@laposte.net (M. Aazami) systolic recruitable flow is increased. Similarly, the loss of contractility by septal infarction that blunt myocardial doi:10.1016/j.ejcts.2006.06.002 1010-7940/$ — see front matter # 2006 Elsevier B.V. All rights reserved.

Journal

European Journal of Cardio-Thoracic Surgery – Oxford University Press

Published: Sep 1, 2006

Keywords: Keywords Myocardial revascularisation Left internal thoracic artery Composite arterial grafts

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