ICC 2024 Gianluca Torregrossa, MD: "New Developments in Surgical Quality Assessment"

Complete Transcript:

[00:00:02] Good morning, everyone. Good afternoon. Actually it's after lunch. Now we are at the peak of your glycemia. Your glycemia is very low. The sandwich is gone. Your glucose is around 74.

[00:00:13] Right now I have to wake you up because everybody's getting warm in their seat. This is my disclosure in about this this speech and this talk. I'm a avid proponent, and again, sometimes I, we want to have a conversation with you why we have this low adoption rate of a technology that improves safety for our patients.

[00:00:35] Why we cannot adopt more. We will go from there. These are two pictures and I think that these two picture tell a lot about what INTUI is. Left and right. Probably on your right side you have something that most of you are familiar with and in that case it was a robotic, but it can be easily like a sternotomy with the previous technology on the right you have, what is the new system?

[00:01:01] We have evidence. We have publication. Publication that goes back through years. And we have a chart that try to tell you how to do, what to do, how to deal with cases in which your graft goes down. But yet, despite we can provide you with education, flowcharts, paper recommendation the best names of the coronary intelligenza of the world who writes paper in support of TTFM.

[00:01:31] Yet we struggle to have more teams, more centers to do and to adopt this technology. And I think that we need to find new ways to engage, and engagement start with our generation, the future generation, the people that are now under training. This is a beautiful paper and I ask you please just take a picture and read it.

[00:01:51] Not tonight, but maybe before you're going home. This is why surgeons don't change the way in which they change. They should. And this is a great paper written by general surgery about the adoption of new technology in surgeon and what are the limit of adopting new technology. And the reality is that we don't use TTFM, I'm telling you the 3 major reasons.

[00:02:14] First is that, God forbid, you are telling me that my bypass doesn't work. That's what my chief would have said, years ago. My bypass are always perfect. Number 2, if the flow is not good? Now what? I have to redo it. And that open a huge question mark about what should I do if I don't have the minimum skills of an off-pump, redoing a LIMA to LAD for a large majority of surgeon means I have to recross-clamp, redid cardioplegia, open that coronary and find a solution for a problem.

[00:02:49] That is the right thing to do for that individual patient, but a lot of surgeons unfortunately don't think in this way. And we need to change this culture. And finally, I think that we need to integrate a lot of more imaging with the flow. And I think that the first step and the first information you should go home in this moment of lowered down peak of glycemia, just go home with one information from my talk and it is:

[00:03:16] If your flow is not good or if your flow is in that gray zone, just of your LIMA to the LAD. Your next step is the following. You take an off-pump stabilizer, the octopus, you put it around your LIMA to the LAD. You take an imaging probe, you put tons of gel and you put the probe on top of your graft.

[00:03:38] Start to do it with good graft. Start to do it from Monday when you go home and start to develop your own eye skills on how to take picture and imaging of your LITA to the LAD. Forget about PDA or OM they will come later. Just go home and start to use imaging and start to see how your graft look like, how much cobra head you have, how much the flow and the colors goes.

[00:04:03] That's the first thing, because the first thing you should do when your flow is in the gray zone is take the imaging probe and check with the imaging probe. And if you are confident in your ability to take good pictures, it requires a little bit of training as everything of what we do, you will go home and that night you feel comfortable to go to sleep without being worried that a phone call will come at 2 o'clock in the morning.

[00:04:27] If we want to improve what we offer to our patients. And we are thinking about multi-arterial complex grafts We are thinking about robotics. We need this technology and this technology is the exactly point of connection is the cornerstone. Of the 3 major elements that are part of the present and future of coronary.

[00:04:53] If you want to train the next generation of surgeons if you want to advance your techniques towards more minimal invasive, and if you want to improve the safety of what we do for our patients. We need TTFM. So when people tell me, Oh, I want to learn robotic. Can I come in? And my first question are always, do you have TTFM in your institution?

[00:05:16] And if you tell me no, I will not let you come and try to take down a mammary robotically. Start to do the basics, start to check that your flows are good and start to advance your first skills. From there you can build up second arterial, multi-arterial, off-pump, robotic, TECAB or whatever you want, but you need that and you need that for my training, for the training of our next generation together with Amanda, we sitting here and she's my surgical partner.

[00:05:43] She's my surgical boss. I actually, I, during the time in which we are training a fellow, like the fellow is doing the anastomosis, a man is helping and I'm in the third, second assistant position with my blower from distance. Checking with my eyes every stitch that he passes, and I know that I can do that because I can check that flow after the fellow has finished to perform a LIMA to the LAD off-pump.

[00:06:10] If I didn't have any opportunity to check, I will not let him do a LITA to the LAD those are the 10 and 15 years mortality of that single individual. And I can tell you a story like that happened just 2 weeks ago. You finish a perfect anastomosis. We I saw every stitches and the flow was not good. I take it down and I redo that myself.

[00:06:31] And it was a much better flow. Not exactly sure what happened, but in the picture, I think that there was, I took a picture and I saw a little like flap and I think that flap was probably a deeper stitch or something, or one of the stitches create tension on the end and create a local dissection.

[00:06:47] I reopened the mammary, clean the mammary up and remove up the rest of the LITA to attach to the LAD. This is where we can learn off-pump. Off-pump has failed because it was in an era in which we didn't have technology to support it and we didn't have technology to test our graft before leaving the operating room.

[00:07:07] Let me guide you through INTUI and then we go for some questions. Here, this is the system, integration of imaging, and this is how you start. You start. This is how the system, I let you press the button start of the system. This is the new technology. You press the start. This is, I have to say thanks to Massimo Baudo is my research fellow in a cardiac surgeon that is doing all of these videos here.

[00:07:35] You see you hook up all of the probe down here. You have the three major buttons you can flow, you can switch between Imaging and flow up there, you have in the imaging the opportunity to decide where you're taking picture of and where you can, where are you measuring pre protamin or post protamin your own flow.

[00:07:57] So you go in flow and then you press that inflow target, as you see, and you can build up your composition. In this case, let's start with something simple, LITA to the LAD. And you do LITA, inflow LITA to the LAD and come up as that one. Then we do something more complicated.

[00:08:14] For example, this is a RITA extended radial. Ok, and look, you do radial extended RITA, so your conduit is the radial, you are extending from the RITA, and you go to the PDA, and you sequentialize PDA and OM. So you build up a graphics. And immediately you have all of the graphics around and you can even change at this point.

[00:08:40] Let's say that you end up doing also the diagonal with another piece of LITA with a diagonal. So you can add before you tested the graft, you can add an extra conduit that you do it. Here's some pictures and videos taken. You see this is the way in which it looks. You can have that probe, that Q2, that blue probe, you can put it in different points.

[00:09:02] As we were hearing from the previous presentation, important to define, particularly in sequential, where you are, at which point you are of your anastomosis, which flow are you recording. Everything looks like a car. I can tell that there is some car aficionado. And if you know me well, I'm a big car petrolhead myself.

[00:09:22] I love this concept of these gears that looks like the Ferrari I don't have and I wish to have. And you move the probe in different part, so now we are moving the probe. For example, that is a radial, I think it's an SVG to the OM. And from the aorta, and then you put the probe to the SVG to the OM.

[00:09:42] And if you have a sequential, you can decide at which point of your sequential or your Y you are taking the pictures of. And then you generate the report and the report gives you a complete graphics of everything that you have done with all of the flow in each area. And this is valuable material you give back to the patients, even the patient is proud.

[00:10:04] I remember David Adams, when I trained him at Mount Sinai, he was giving to all of the patients a picture of their mitral. He was taking a picture of the mitral inside the operating room and everyone was going home proud with their mitral after the repair. And this is the picture. You see the LITA up.

[00:10:20] This is the LAD down there was an intramuscular. I move a little bit. I move towards the anastomosis and that the anastomosis will come up. Right now you see the midst of the LITA with the flow of the, and goes in both direction. So I'm happy in, in, in seeing, and you see the graphics that will build up, you can see in both directions going in the two ways.

[00:10:45] This one is the way in which you see the flow works. I always pace at 80 when I'm measuring my flow at the end. I love to put a temporary pacing. I think that the algorithm also of study by Medistim is for optimized for 80 beats per minute. It always works better. So take a temporary pacing, pace at 80 and measure your flow with 80 beats per minute.

[00:11:11] Temporarily paced. That is the best set-up for, for check all of your graft. And then you go around and you do your SVG, you do your. This case is a radial to the obtuse marginal and you move around checking around making sure. Look in this case, for example, I cannot have a good application. The radial has fat and fascia around it.

[00:11:32] And once you put it on, you can really check properly the flow. In general, and I want to have some discussion without showing too much, the concept here is we have a new technology as a cardiac surgeon involving coronaries. We should be happy because nobody gives a new technology to the coronary surgeons.

[00:11:50] So we want to thank Medistim after years. We needed something new and these new comes with a lot of tech culture and the most important elements are 1: Possibility to educate immediately. 2: Better understanding with facility to drawing what type of surgery you have planned for your patients and taking different grafts and different flow in different points Number 3: Generating a report that gives the opportunity to spread the news, gives back to your patients, to the referring physician. Number 4: Imaging with a complete new self-dedicated images. Video that helps even more your usage of the video. Thank you so much.