Angiography During Cardiovascular Surgery

  • Derek Muehrcke


Intraoperative fluorescence imaging (IFI) is currently indicated as a tool to determine the patency of coronary artery bypass grafts. Graft patency is the major determinant of survival and freedom from repeat intervention after coronary artery bypass grafting (CABG) (Desai et al. J Am Coll Cardiol 46;1521–1525, 2005). Unfortunately, early graft failure after coronary artery bypass grafting is common. The PREVENT IV study revealed that at 1 year up to 26% of coronary bypass grafts will be closed (PREVENT IV Investigators. JAMA 294:2446–2454, 2005). Interestingly, the 30-day mortality outcomes were excellent in the trial (PREVENT IV Investigators. JAMA 294:2446–2454, 2005). However, the subgroup with graft failure had twice the rate of perioperative myocardial infarction (MI) and four times the risk of death, MI, and need for revascularization at 1 year. Significant advances in medical therapy including early postoperative aspirin administration, statin use, and increased use of arterial grafting have improved early and late graft patency (Taggart DP. J Thorac Cardiovasc Surg 120:651–659, 2000; Yusuf et al. Lancet 344;563–570, 1994; Lytle et al. J Thorac Cardiovasc Surg 117:855, 1999; Taggart et al. Lancet 358:870–875, 2001). However, technical errors in bypass graft construction by the operating surgeon are primarily responsible for the majority of these early failures (Puskas et al. JAMA 291:1841–1849, 2004; Khan et al. N Engl J Med 350:21–28, 2004). With the exception of coronary artery bypass surgery, virtually all other interventions on the heart, including cardiac valve repair/replacement and coronary stenting, are accompanied by completion diagnostic imaging to ensure an adequate technical result. Despite tremendous improvements in the quality of processes of care in cardiac surgery over the past decade, there are still no well-accepted or broadly used techniques to assess the quality of the bypass graft itself. Recent angiographic trials by Puskas et al. (JAMA 291:1841–1849, 2004) and Khan et al. (N Engl J Med 350:21–28, 2004) have shown significant clustering of the technical results of off-pump surgery at the level of the individual surgeon, highlighting the need for intraoperative quality assurance. Since graft patency is the predominant predictor of long-term survival after coronary surgery, a well-validated method to assess graft patency in coronary surgery remains an important opportunity for improving quality assurance (Lytle et al. J Thorac Cardiovasc Surg 103(5):831–840, 1992; Halabi et al. Am J Cardiol 96:1254–1259, 2005). We will discuss the use of intraoperative fluorescence imaging as a method of assessing real-time coronary artery bypass grafts as well as the quantification of improved myocardial blood flow. We will also discuss the other currently available methods of assessing early graft patency and compare them to intraoperative fluorescence imaging.


Intraoperative imaging Coronary bypass Fluorescence imaging Bypass patency CABG outcomes 

Supplementary material

Video 7.1

(00:01) Intraoperative fluorescent imaging of coronary artery bypass grafts. This video demonstrates the intraoperative use of fluorescent imaging during open heart surgery and coronary artery bypass grafting. (00:49) We image all of our proximal and distal bypass graft anastomoses. This is done to ensure the patency of the bypass grafts at the time of surgery as graft patency is the most important predictor of long-term survival after coronary artery bypass grafting. (1:13) This video demonstrates the actual time required to perform fluorescent imaging of distal venous bypass grafts. This is very quick and adds little extra time that the heart is arrested. (1:41) This segment is a venous bypass graft to the circumflex coronary artery. This video demonstrates the three different phases of fluorescent imaging, which includes the arterial phase where the contrast goes through the artery, the blush phase where the myocardium is illuminated, and the venous phase where the contrast leaves the study area through the veins. (2:14) This is a video of a diagonal artery being bypass graft with a vein. This is the first of two arterial bypass distal anastomoses using the same vein graft. The three phases of imaging can be distinctly seen. (2:48) This is the second or sequential arterial bypass graft to a ramus intermedius artery which is visualized separate from the diagonal artery. (3:10) This is a video of the internal mammary artery (IMA) to the left anterior descending coronary artery (LAD) anastomosis which is performed by injecting ICG contrast into the heart lung machine. The only blood supply to the heart, while the cross-clamp is on the aorta, is through the IMA graft to the LAD. This video reveals an unexpected problem with the anastomosis. There is no flow of contrast beyond the anastomosis, representing a major problem. (3:54) Here is the revised IMA to LAD anastomosis. The video demonstrates how the intraoperative imaging allows us to revise problematic anastomoses immediately if a problem is found. (4:23) Here are the proximal anastomoses imaging. The contrast material ICG is administered via central line, while the aortic cross-clamp is off and the patient is off bypass. This allows the blood flow through the proximal vein graft anastomoses to be visualized. This technology allows us to ensure that the blood supply to the heart is intact at the end of the procedure (MP4 601079 kb)


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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Derek Muehrcke
    • 1
  1. 1.Department of Cardiothoracic SurgeryFlagler HospitalSaint AugustineUSA

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