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Intraoperative Fluorescence Imaging System for On-Site Assessment of Off-Pump Coronary Artery Bypass Graft

Katsuhisa Waseda, MD, PhD^_*, Junya Ako, MD, PhD^_*, Takao Hasegawa, MD^_*, Yoshihisa Shimada, MD, PhD^_*, Fumiaki Ikeno, MD^_*, Toshihiro Ishikawa, MD, PhD, Yoshitaka Demura, MD, Kazuyoshi Hatada, MD, Paul G. Yock, MD^_*, Yasuhiro Honda, MD^_*, Peter J. Fitzgerald, MD, PhD^_*,_*, Masao Takahashi, MD, PhD

^_* Stanford University Medical Center, Stanford, California
Department of Cardiovascular Surgery, Hiratsuka Kyosai Hospital, Hiratsuka, Japan

^_* Reprint requests and correspondence: Dr. Peter J. Fitzgerald, Professor of Medicine (Cardiology), Co-Director, Center for Research in Cardiovascular Interventions, Director, Cardiovascular Core Analysis Laboratory, Stanford University Medical Center, 300 Pasteur Drive, Room H3554, Stanford, California 94305 (Email: crci-cvmed{at}stanford.edu).

Objectives: The aim of this study was to evaluate the intraoperative fluorescence imaging (IFI) system in the real-time assessment of graft patency during off-pump coronary artery bypass graft.

Background: Intraoperative fluorescence imaging is an intraoperative angiography-like imaging modality using fluorescent indocyanine green excited with laser light. Recently, assessment of graft patency using the IFI system was introduced into clinical use. The feasibility and efficacy of IFI technology in off-pump coronary artery bypass graft has not been systematically compared with other conventional diagnostic modalities.

Methods: Patients undergoing off-pump coronary artery bypass graft received IFI analysis, intraoperative transit time flowmetry, and postoperative X-ray angiography. In off-line IFI analysis, the graft washout was classified based on the number of heartbeats required for indocyanine green washout: fast washout (15 beats) and slow washout (>15 beats).

Results: A total of 507 grafts in 137 patients received IFI analysis. Of all the IFI analyses, 379 (75%) grafts were visualized clearly up to the distal anastomosis. With regard to anastomosis location, anterior location was associated with a higher percentage of fully analyzable images (90%). More than 80% of images were analyzable, irrespective of graft type. Six grafts with acceptable transit time flowmetry results were diagnosed with graft failure by IFI, which required on-site graft revision. All revised grafts' patency was confirmed by post-operative X-ray angiography. Conversely, 21 grafts with unsatisfactory transit time flowmetry results demonstrated acceptable patency with IFI. Graft revision was considered unnecessary in these grafts, and 20 grafts (95%) were patent by post-operative X-ray angiography. Compared with slow washout, fast washout was associated with a higher preoperative ejection fraction, use of internal mammary artery grafts, and anterior anastomosis location.

Conclusions: The IFI system enables on-site assessment of graft patency, providing both morphologic and functional information. This technique may help reduce procedure-related, early graft failures in off-pump bypass patients.

Key Words: surgery • coronary artery bypass graft • fluorescence

Abbreviations and Acronyms   CABG = coronary artery bypass graft   ICG = indocyanine green   IFI = intraoperative fluorescence imaging   MGF = mean graft flow   MID-CABG = minimally invasive direct coronary artery bypass graft   PI = pulsatility index   TTFM = transit time flowmetry

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