Professor Taggart's presentation is from the 10th International Coronary Congress (ICC 2024) in London on December 13th 2024. This prestigious event brought together the world’s leading cardiac surgeons, making it the perfect venue to unveil INTUI —a highly appreciated and rare occasion of product innovation for coronary surgery.
Why Ignoring Graft Quality Assessment Is No Longer an Option – Prof. David Taggart Explains Why
If you're still on the fence about routine intraoperative quality control during CABG, Prof. David Taggart’s 8-minute presentation will make you rethink that position. Drawing on his leadership in the REQUEST study and decades of experience in cardiac surgery, he lays out clear, data-backed reasons why TTFM and high-frequency ultrasound are essential tools—not optional extras.
He doesn’t just quote numbers. He shows how quality assessment changes surgical decisions in real time—even in the hands of top surgeons. And he delivers a sobering reminder: two-thirds of perioperative ischemia have their origin in the operating room, according to a referring JTCVS study from 2021, and graft related complications represent the most common cause of perioperative ischemia.
🎥 Prof. Taggart makes the case for TTFM and imaging—clear, compelling, and impossible to ignore. Watch now.
“These were all operations done by fairly highly experienced coronary artery surgeons. And the question would be, what would those numbers be in the hands of less experienced surgeons” - David Taggart
See the complete ICC Symposium session [41 min]
The INTUI Software Platform combines Medistim’s proven TTFM technology with High-Frequency Ultrasound (HFUS) to provide surgeons with unparalleled precision, real-time insights, and a seamless, user-friendly interface. At this symposium, you’ll see firsthand how INTUI empowers surgeons to make more informed decisions, enhancing surgical outcomes and patient safety.
Built on a future-proof software architecture, INTUI sets a new standard for Medistim’s MiraQ™ platform. Its redesigned user interface is engineered to enhance procedural efficiency in surgery, offering simplified navigation, quicker access to critical data, and improved data interpretation—ultimately streamlining workflow and optimizing performance.
[00:00:02] So what I'm going to do is just give a bit of background to quality assessment in the operating room and why it is important. So, this is a paper, a summary by Mario Gaudino: The Use of intraoperative transit time flow measurement for coronary artery bypass surgery. I was one of the co-authors on this. And what we said was, in conclusion, although TTFM use may increase the cost and duration of the procedure and requires a learning curve, its cost benefit ratio seems largely favorable in view of the potential clinical consequences of graft dysfunction.
[00:00:41] These consensus statements will help to standardize the use of TTFM in clinical practice and provide guidance in clinical decision making. So if you look a bit at the background to why is this important. If you look at intraoperative graft failure is very well recognized as a clinical problem. It affects somewhere between 2 to 5% of grafts depending on what series you look at.
[00:01:12] 12% of grafts assessed by angiography in the operating room can have problems. Now this is usually asymptomatic, and the relevance of that is that there are often no changes in ECG, hemodynamics, regional wall motion abnormalities, and so often this can happen in the operating room and you don't know about it until you get a call late at night from the hospital.
[00:01:41] And you know, that call is not to tell you you did a great job today, but it's to tell you you've got a problem with your grafts. So the recommendations for quality assessment informal guidelines have been around for almost a decade, so it's not a new concept. And as Kari explained to us the very different adoption rates of this technology in different countries.
[00:02:07] Been well over 90% in Japan, 70 to 80% in Germany and the Scandinavian countries. In the last five years in the UK, we've increased from about 5%. To 20%. So people are adopting the technology and currently in the USA it's estimated to be about 25%. And the next question you then ask, is it just TTFM you use or do you use the high frequency ultrasound?
[00:02:37] And we assessed this in a prospective study funded by Medistim called the REQUEST study. This was done in seven high volume CABG centers, 4 in Europe, 3 in North America. And we, there were two aspects to it. One was using the TTFM probe, and the second bit was using ultrasound to assess the aorta, the conduits, the native coronary artery, and then to assess the anastomosis on completion.
[00:03:09] And as you know, what we did here was we used ultrasound to assess the aorta to look for obvious disease. We then would assess arterial conduits in the coronary targets, then conduct the TTFM measurements. There are four factors we look at, and then ultrasound assessment of the anastomosis. We published this in JTCVS in 2020.
[00:03:38] And just to summarize this study, it was a prospective study of 1016 patients, 86% male, meaning 66, 40% diabetes, 40% the operations were done off-pump, so that's higher than most individual series, which are about 20%. There was also quite a high use of arterial grafts. BITA in 31%, radial artery 23, multiple arterial grafts in 43%, and total arterial grafts in 26%.
[00:04:16] The key findings were that the use of this technology led to changes in surgical procedures. In terms of the coronary artery target in 23%, in relevant aortic manipulation in 10%, and in conduits in 2.7%. Now notice, in terms of any graft revision, it was almost 8%. 65% of this was because of the findings in TTFM and high frequency ultrasound.
[00:04:48] And that's an important figure because these were all operations done by fairly highly experienced coronary artery surgeons. And the question would be, what would those numbers be in the hands of less experienced surgeons? In terms of hospital mortality, 0.6% stroke, 1% MI, 0.3%. And this is another important slide, just summarizing some of what we saw in this study.
[00:05:17] As I said, 40% of the operations were done off-pump, 60% on-pump, but changes in off-pump, proposed manipulation of the ascending aorta was almost 15%. versus 4.3% in on-pump. In terms of changes to the proposed conduits, respectively 0.2 and 2.8%, and in terms of the coronary targets, 4.1 and 3.5%. Now, the next part, point two, is really quite important. In terms of graft revisions, it was just under 5% for arterial grafts, and 2.5% for vein grafts. And as I said, that was in the hands of really quite experienced coronary surgeons. If you look at what territories underwent revision for the inferior wall, it was highest at 5%, the anterior wall just under 3%, and the same for the lateral wall.
[00:06:20] But why is this all important? This was an invited editorial for JTCVS. Post cardiac surgery, myocardial ischemia. Why, when, and how to intervene. And what we pointed out was the incidence for isolated CABG in large series, which was defined as over 500 patients. The incidence of ischemia was around 4%, varying from 2 to 5% in different studies.
[00:06:51] And we then concluded that 2/3 of these cases of perioperative ischemia had their origin in the operating room. And we wrote graft related complications represent the most common cause of perioperative ischemia, accounting for approximately 2/3 of cases. This broad group includes technical errors, leading to direct graft injury and subsequent thrombosis.
[00:07:19] Graft kinking and anastomotic problems such as stenosis, competitive flow, poor distal runoff, and graft spasm.
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