Transit time flow measurement of coronary bypass grafts before and after protamine administration

Dror B Leviner, Miriam von Mücke Similon, Carlo Maria Rosati, Andrea Amabile, Daniel J F M Thuijs, Gabriele Di Giammarco, Daniel Wendt, Gregory D Trachiotis, Teresa M Kieser, A Pieter Kappetein, Stuart J Head, David P Taggart, John D Puskas, Dror B Leviner, Miriam von Mücke Similon, Carlo Maria Rosati, Andrea Amabile, Daniel J F M Thuijs, Gabriele Di Giammarco, Daniel Wendt, Gregory D Trachiotis, Teresa M Kieser, A Pieter Kappetein, Stuart J Head, David P Taggart, John D Puskas

Abstract

Background: Intraoperative graft assessment with tools like Transit Time Flow Measurement (TTFM) is imperative for quality control in coronary surgery. We investigated the variation of TTFM parameters before and after protamine administration to identify new benchmark parameters for graft quality assessment.

Methods: The database of the REQUEST ("REgistry for QUality AssESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery") study was retrospectively reviewed. A per graft analysis was performed. Only single grafts (i.e., no sequential nor composite grafts) where both pre- and post-protamine TTFM values were recorded with an acoustical coupling index > 30% were included. Grafts with incomplete data and mixed grafts (arterio-venous) were excluded. A second analysis was performed including single grafts only in the same MAP range pre- and post- protamine administration.

Results: After adjusting for MAP, we found a small increase in MGF (29 mL/min to 30 mL/min, p = 0.009) and decrease in PI (2.3 to 2.2, p < 0.001) were observed after the administration of protamine. These changes were especially notable for venous conduits and for CABG procedures performed on-pump.

Conclusion: The small changes in TTFM parameters observed before and after protamine administration seem to be clinically irrelevant, despite being statistically significant in aggregate. Our data do not support a need to perform TTFM measurements both before and after protamine administration. A single TTFM measurement taken either before or after protamine may suffice to achieve reliable data on each graft's performance. Depending on the specific clinical situation and intraoperative changes, more measurements may be informative.

Trial registration: Clinical Trials Number: NCT02385344 , registered February 17th, 2015.

Keywords: Coronary artery bypass grafting; Intraoperative graft flow measurement; Quality control.

Conflict of interest statement

DBL – None, MvMS – None, CR – None, AA – None, DJT - Medistim. Travelling support/speaking fees, GDG - Medistim. Travelling support/speaking fees, DW - Medistim. Travelling support/speaking fees, GDT – None, TMK - Medistim. Travelling support/speaking fees, APK - Medistim. Travelling support/speaking fees. Medtronic Employment, SJH - Medistim. Travelling support/speaking fees. Medtronic Employment, DPT - Medistim. Research funding, speaking and travelling honoraria, consultant, JDP - Medistim. Travelling support/speaking fees.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Patient and graft inclusion and exclusion flow chart. ACI = acoustic coupling index; MAP = mean arterial pressure; REQUEST = Registry for Quality Assessment with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery; TTFM = transit-time flowmetry
Fig. 2
Fig. 2
Mean graft flows (A) and pulsatility indices (B) pre- and post-protamine: single grafts with pre- and post-protamine TTFM with ACI > 30 (both pre- and post-protamine) and same MAP range (for each graft). Data reported as medians. Boxes represent the 1st to 3rd (IQR) quartile while the whiskers are from the min to the max values and are truncated to no longer than 1.5 times the IQR. ACI = acoustic coupling index; MAP = mean arterial pressure; MGF = mean graft flow; PI = pulsatility index; TTFM = transit-time flowmetry

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