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Eur J Cardiothorac Surg 2009;35:556-557. doi:10.1016/j.ejcts.2008.12.004
Copyright © 2009, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Letters to the Editor

Reply to Maros

Masashi Kawamura, Hiroyuki Nakajima*, Junjiro Kobayashi

Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan

Received 1 December 2008; accepted 1 December 2008.

* Corresponding author. Tel.: +81 6 6833 5012; fax: +81 6 6872 7486. (Email: hnakajim{at}hsp.ncvc.go.jp).

Key Words: Coronary artery bypass strategy • Competitive flow • Fractional flow reserve

We thank Dr Maros [1] for his meaningful comments, and agree with the importance of fractional flow reserve (FFR) in coronary revascularization strategy. FFR is calculated as the ratio of blood pressure in the proximal and distal sites of the coronary stenosis after induced hyperemia [2], and has been generally accepted as a reliable method for detecting myocardial ischemia and assessing functional severity of coronary stenosis. Particularly, FFR is considered useful for decision making of bypass grafting to the intermediate stenosis lesion to avoid creating non-functioning bypass, which will be occluded in association with flow insufficiency [2].

One of the major issues regarding selecting graft material is that the situations, which truly necessitate the saphenous vein graft, have not been fully delineated. The venous graft as the aorto-coronary bypass has higher intraluminal pressure and lower resistance of the conduit itself than the in-situ internal thoracic artery (ITA) graft [3]. It is widely considered that ITA grafting can give rise to hypoperfusion syndrome and residual myocardial ischemia in spite of graft patency when its flow capacity is insufficient for huge flow demand of the myocardium. We, therefore, believe that assessment of peripheral vascular resistance and flow demands in the myocardium would be valuable for appropriate usage of the venous graft.

Most of previous studies about FFR focused on management of the intermediate stenosis, not on predicting shortage of flow capacity of the ITA graft, nor necessity of the venous graft. In addition, we suggested complicated mechanism of competitive flow, which was found in the ITA to left anterior descending artery graft and caused by the venous graft to the circumflex branch [4]. As Botman and colleagues mentioned previously [5], we consider that usefulness of FFR in selection of graft materials, including in patients with left main trunk or proximal left coronary artery disease, has not been proved, and may be the next concern in the future.

References

  1. Maros T. Fractional flow reserve: a reliable tool in bypass strategy. Eur J Cardiothorac Surg 2009;35:556.[Free Full Text]
  2. Pijls NH, Van Gelder B, Van der Voort P, Peels K, Bracke FA, Bonnier HJ, el Gamal MI. Fractional flow reserve. A useful index to evaluate the influence of an epicardial coronary stenosis on myocardial blood flow. Circulation 1995;92:3183-3193.[Abstract/Free Full Text]
  3. Glineur D, Poncelet A, El Khoury G, D’hoore W, Astarci P, Zech F, Noirhomme P, Hanet C. Fractional flow reserve of pedicled internal thoracic artery and saphenous vein grafts 6 months after bypass surgery. Eur J Cardiothorac Surg 2007;31:376-381.[Abstract/Free Full Text]
  4. Kawamura M, Nakajima H, Kobayashi J, Funatsu T, Otsuka Y, Yagihara T, Kitamura S. Patency rate of the internal thoracic artery to the left anterior descending artery bypass is reduced by competitive flow from the concomitant saphenous vein graft in the left coronary artery. Eur J Cardiothorac Surg 2008;34:833-838.[Abstract/Free Full Text]
  5. Botman CJ, Schonberger J, Koolen S, Penn O, Botman H, Dib N, Eeckhout E, Pijls N. Does stenosis severity of native vessels influence bypass graft patency? A prospective fractional flow reserve-guided study. Ann Thorac Surg 2007;83:2093-2097.[Abstract/Free Full Text]




This Article
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Hiroyuki Nakajima
Junjiro Kobayashi
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