Objective An increase in the diastolic to systolic flow velocity ratio (D/S) in the proximal left internal thoracic artery (ITA) after coronary artery bypass grafting (CABG) enables noninvasive assessment of graft patency by transthoracic Doppler echocardiography (TTDE). The increase in the D/S can be less pronounced at a site distant from the anastomosis. We postulated that proximal ITA flow patterns differ between the left and right ITAs and that the increase in D/S is less pronounced in the right than in the left proximal ITA. Methods Proximal ITA flow was examined by TTDE in 129 consecutive patients after CABG of the left (75) or right (69) ITA to the left coronary artery. The mean D/S of the ITAs was compared with coronary angiography. Results The D/S was lower in the group with a patent right ITA than in the group with a patent left ITA ( P .05). The D/S of both the left and right ITAs negatively correlated with angiographic stenosis ( r  = 0.56 or 0.67, P .001, respectively). The regression line was significantly shifted downward in the right ITA compared with the left ITA, according to analysis of covariance ( P  = .01). Graft stenosis was predicted by a D/S of Conclusion The patency of both left and right ITA grafts to the left coronary artery can be assessed using TTDE, but different cutoff values of D/S are required to diagnose severe ITA stenosis.

Different flow patterns between left and right internal thoracic artery grafts influence the evaluation of severe graft stenosis by transthoracic Doppler echocardiography.

Minimally invasive surgery for coronary revascularization using the left internal thoracic artery (ITA) has gained increasing interest. For control of graft function the established transcutaneous color-Doppler echocardiography in combination with a stress-test was performed to test the ability of this novel technique. Twenty-one patients having received a single ITA-graft were evaluated early postoperatively at rest and during isometric stress test with a handgrip exercise. Compared to the right internal thoracic artery, the mainly systolic flow is changed to a wide diastolic component when the left ITA is anastomosed to the coronary artery. The peak systolic/peak diastolic velocity ratio changed from 4.5+/-1.9 to 1.4+/-0.47 (P<0.0001). During stress reaction with the isometric handgrip maneuver the grafted ITA showed a significant increase of the mean diastolic flow (29.1+/-13.3 to 44.3+/-14.7 cm/s, P<0.0001) and total blood flow (124.8+/-55.4 ml/min to 176.6+/-71.7 ml/min), which may demonstrate an efficient bypass function. We conclude, that the noninvasive measurement of ITA-graft function with Doppler-ultrasound may be a clinically useful method to assess the functional status after minimally invasive coronary artery bypass grafting. In combination with the hand-grip test it represents a valid new technique with the potential to estimate graft patency.

/pdf/stress-doppler-echocardiography-of-the-internal-thoracic-1rxc63qt1j.pdf

Stress Doppler echocardiography of the internal thoracic artery--a new non-invasive approach for functional assessment after minimally invasive coronary bypass grafting.

Alternative methods to central venous pressure for assessing volume status in critically ill patients.

Exactly 10 years ago, the first issue of Interactive CardioVascular and Thoracic Surgery (ICVTS) appeared in print [1], just in time for the 16th Annual Meeting of the European Association for Cardio-Thoracic Surgery (EACTS) in Monte Carlo, Monaco, 22–25 September 2002. However, its electronic version had already appeared in June 2002, to enable online discussion of papers from the first issue. In fact, the virtual conference concept where the accepted manuscript along with its online discussion is published in the print issue was implemented from the outset. The creation of an additional journal had been in the mind of the founding editor for some time prior to his nomination [2], although translating the thought into reality was not easy. First of all, there was no budget for the project; secondly, the publisher of the European Journal of Cardio-Thoracic Surgery (EJCTS) was not enthusiastic about a competing product; thirdly, some experts in the field felt that the task of getting a second journal off the ground might be too ambitious. Undeterred, we forged ahead. The project was financed initially by extracting a slice from the EJCTS page budget. Publication was web-driven (Fig. 1), with a scope and content categories unlike those used traditionally, and specifically different from EJCTS. Thus, ICVTS was looking for ‘State of the Art’, papers not Reviews; ‘New Ideas’, ‘Work in Progress’, ‘Follow-up papers’ ‘Negative Results’ not original articles, and so forth. As for the sceptics, they were proven wrong. 



Figure 1:

Cover of the first issue of ICVTS 2002 with a web-inspired design.




Since then, ICVTS has made big strides. On top of being freely available and the implementation of the virtual conference concept outlined above, a number of improvements have been introduced, including videos as supplemental files [3]. An extremely popular feature initiated by Dunning et al. was ‘Best BETs’ [4], short structured reviews of the literature on very specific questions [5]. From the beginning, ICVTS attracted a fairly significant amount of interest on the world wide web, of an order of magnitude similar to EJCTS, despite the latter having more content [6]. Several factors have contributed to this phenomenon, including the most obvious ones: 


a global scope with an international editorial board;


the free access concept early-on, at a time when this was somewhat unusual;


the virtual conference concept with online discussion, also published in the printed issue;


the inclusion of meeting abstracts in ICVTS supplements [7, 8];


the promotion of ICVTS as the official journal of the European Board of Cardiovascular Perfusion (www.ebcp.org) with the help of the chairman of the Board, Alexander Wahba, the secretary Frank Merkle and others [9, 10].




However, one of the less obvious reasons driving web traffic was the placing of ICVTS in a very prominent position on CTSNet (www.ctsnet.org) by its then Editor, Tom Ferguson, who deserves thanks for his foresight.

Yet, the increasing volume of web traffic rapidly brought about some problems with a publisher, who was unable and/or unwilling to support the required development of the ICVTS website, which obviously went beyond simple maintenance [11]. Consequently, it was decided that EACTS would self-publish ICVTS, backed by the experienced editorial team of Ian Beecroft, Rita Brightwell and Judy Gaillard, with the collaboration of Morgan Lyons (Compuscript), not forgetting Margaret Tolland's invaluable help in the compilation and editing of the conference abstract supplements. The self-publishing venture was successful. L. Henry Edmunds, Editor-in-Chief of the Annals of Thoracic Surgery has dubbed ICVTS a ‘stalking horse’, considering the fact that EACTS was tied to a publisher for EJCTS, but ICVTS ran ‘without strings’. The resulting know-how acquired in-house facilitated a smoother acquisition of the rights to EJCTS by the EACTS Council, as well as the subsequent competition to publish the EACTS journal portfolio, by then augmented by the Multimedia Manual of Cardio-Thoracic Surgery (MMCTS), edited by Marko Turina (www.mmcts.org).

With Friedhelm Beyersdorf at the helm, supported by the new editorial team (Judy Gaillard, Franziska Luder, Jia-Lin Muller and Melanie Kunzie), as of 2012, EJCTS, ICVTS (Fig. 2) and MMCTS are now published by Oxford University Press [12]. Recent statistics on ICVTS web traffic show a monthly full-text download number between 47 000 and >50 000 for the first half of 2012 (with the exception of January, when the change of publisher may have affected the numbers; Fig. 3). More interesting than the sheer numbers is the type of articles downloaded. All categories contributed to the overall ICVTS web traffic, well-demonstrated by the most frequent downloads in the first half of 2012 extracted from the statistics summarized in Fig. 3. All papers with >200/month (arbitrary definition for practical reasons) full-text downloads are listed in Table 1 [13–25]. Interestingly enough, the papers most frequently downloaded in the first half of 2012 have been those published during the entire 10-year span of ICVTS; they cover all categories, not only Institutional Reports (now renamed Original Articles), but also Best BETs, Negative Results, Protocols and even Case Reports. This is somewhat contrary to conventional editorial wisdom that only original articles and reviews are ranked highly because they supposedly contribute most to the Impact Factor. Table 1 also demonstrates that interesting articles have a much longer citation life than that implied by the Impact Factor, which is derived from the most frequently cited articles in the previous 2 years. 



Table 1:

List of most frequent full-text downloads from ICVTS (search criterion = n > 200): interestingly enough the papers most frequently downloaded in the first half of 2012 have been published during the entire 10 years ...





Figure 2:

Refreshed cover of the first issue of ICVTS 2012 published by Oxford University Press.





Figure 3:

Full-text downloads from ICVTS during the first half of 2012 (data provided by Oxford University Press): numbers vary between 26 700 and >50 000 downloads per month.



ICVTS was initially established as an experimental publication with a greater degree of freedom than the traditional, Impact Factor-driven journals. After 10 years of growth, this concept has demonstrated that further development is merited. Currently, the potential inclusion of, for example, social media, new article types, and educational commentaries, is being evaluated. In addition, an application is underway for an Impact Factor for the journal.

Check out more at www.icvts.org

Ten years of Interactive CardioVascular and Thoracic Surgery.

OBJECTIVES Arterial revascularization with the internal thoracic artery (ITA) has shown exceptional long-term results, even though early hypoperfusion can occur and can cause ischemia and contractile dysfunction. Therefore, it is still controversial as to whether the bypass vessel can guarantee the required demand for blood flow during the early postoperative (EPO) phase or whether this is only possible a long time after the operation. This question is important particular in the early postoperative phase to manage afterload and reduce left ventricular oxygen demand. Therefore, stress Doppler echocardiography was performed to assess EPO and late postoperative (LPO) flow capacity after minimal-invasive coronary artery bypass grafting (MIDCAB) in subjects with single vessel disease. METHODS Doppler echocardiography was performed after MIDCAB in 15 patients (mean age 65 years+/-12 standard deviation) in the EPO (15 days) and LPO (266 days) at rest and under stress. RESULTS The mean diastolic velocity (MDV) as a measure for the coronary perfusion in the bypass-graft was comparable (30.9+/-14.5 EPO to 30.8+/-13.9 cm/s LPO, P>0.05) for both settings (early vs. late). In both tests, the stress reactions by means of handgrip maneuver lead to comparable increases in blood flow: MDV 65.0+/-54.4% (EPO) to 62.5+/-53.7% n.s. (LPO). The flow increase in the bypass graft was just as similar [48.2+/-46.2% (EPO) to 51.1+/-41.6% n.s. (LPO)]. CONCLUSION The stress echocardiography revealed for the first time that the ITA-graft after MIDCAB-operation is able to produce the same flow reserve through the EPO phase as well as the LPO phase. Restrictions to a maximum early flow adaptation are not justified. Thus, particularly a patient with severe comorbidities or higher age should be mobilized in the EPO phase to minimize the postoperative complications without risk of myocardial ischemia caused by impaired early blood flow through recent implanted ITA. This method for assessment of ITA blood flow allows for long-time observations and can detect disturbances in perfusion at an early stage.

/pdf/evaluation-of-early-and-late-postoperative-flow-capacity-of-5go7pu6iyr.pdf

Evaluation of early and late postoperative flow capacity of internal thoracic artery bypass by means of stress Doppler echocardiography

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Stress Doppler echocardiography of the internal thoracic artery--a new non-invasive approach for functional assessment after minimally invasive coronary bypass grafting.