1. The aim of the present study was to investigate the effects of exercise and of sublingual glyceryl trinitrate on the pattern of blood flow, as studied by Doppler ultrasound, in internal mammary artery grafts performed to relieve severe stenosis of the left anterior descending coronary artery. The accessibility of the graft to transcutaneous ultrasound examination allows the effects of exercise and nitrate administration on coronary blood flow to be studied non-invasively.

2. Angina-free patients with left internal mammary to left anterior descending coronary artery grafts were studied using transcutaneous duplex ultrasound at rest, after leg exercise and after sublingual administration of 0.5 mg or 1 mg of glyceryl trinitrate.

3. Resting graft blood flow showed a biphasic pattern, with forward flow in both systole and diastole. Exercise caused an increase in time-averaged velocity of graft blood flow from 17.3 (3.3) to 24.0 (7.2) cm/s (P = 0.001), and of calculated volume flow from 44.7 (3.08) to 59.8 (5.89) ml/min (P = 0.002). Diastolic peak velocity increased from 36.1 (9.9) cm/s to 46.8 (16.2) cm/s (P = 0.04), while peak systolic velocity was unchanged. Nitrate administration caused a fall in systolic and diastolic blood pressure and an increase in heart rate; graft flow was maintained [time-averaged velocity 18.3 (6.2) cm/s before and 16.7 (5.7) cm/s after 500 μg of glyceryl trinitrate], but systole was shortened and the proportion of blood flow in diastole increased [systolic/diastolic flow ratio 0.558 (0.139) before and 0.374 (0.156) after 500 μg of glyceryl trinitrate, P = 0.01].

4. Doppler ultrasound examination of internal mammary artery to coronary artery grafts is one of the few ways in which physiological changes in coronary flow can be assessed non-invasively in human subjects. Exercise-induced increases in graft flow involve both increased graft distension in systole and increased run-off in diastole — the elasticity of internal mammary artery grafts may be important in sustaining an exercise-induced increase in graft flow. Limitations of the technique include the difficulty of accurately measuring graft diameter, the possibility of flow through persisting connections between the graft and chest wall vessels and competing flow from the native circulation.

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