Ninety-day all-cause emergency room use among coronary artery bypass grafting patients associated with near-infrared fluorescence imaging: a retrospective cohort study.

Reducing emergency room (ER) use may indicate the improved quality of patient care at index hospitalization. The aim of this study is to determine whether the use of near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) during coronary artery bypass grafting (CABG) surgery is associated with a lowered 90-day all-cause ER use. Materials and Methods: This retrospective cohort study included adult patients with inpatient hospitalizations between January 2016 and June 2020 for an isolated CABG procedure at a US hospital. Propensity score matching was used to create matched cohorts to address the differences in patient, payer type, hospital, and clinical characteristics. A multivariable regression analysis was conducted to determine the association of NIRF imaging with ICG on ER use within 90 days of discharge after controlling for patient, payer type, hospital, and clinical covariates. Results: In total, 230 506 adult patients underwent an isolated CABG procedure. Less than 1% (n=1965) were assessed with NIRF imaging using ICG. There were differences in patient demographic and hospital characteristics between the treatment group (i.e. NIRF with ICG) and the comparison group (i.e. no NIRF with ICG). After controlling for covariates, a statistically significant lower 90-day all-cause ER use was documented among the treatment group (adjusted odds ratio=0.84, 95% confidence interval=0.73-0.96, P<0.009). Reasons associated with ER use were similar between the two groups. Conclusion: Routine intraoperative graft patency assessment with NIRF imaging using ICG may help to improve a patient's care experience and reduce subsequent resource utilization. Intraoperative graft patency assessment with NIRF imaging using ICG is associated with a 90-day all-cause ER use reduction among CABG patients. Further studies are needed to compare the ER usage among centers that used this technique versus those that did not to determine if associated reductions in ER use are a center or technique-specific phenomenon.

Consensus Conference Statement on the General Use of Near-infrared Fluorescence Imaging and Indocyanine Green Guided Surgery: Results of a Modified Delphi Study.

BACKGROUND: In recent decades, the use of near-infrared light and fluorescence-guidance during open and laparoscopic surgery has exponentially expanded across various clinical settings. However, tremendous variability exists in how it is performed. OBJECTIVE: In this first published survey of international experts on fluorescence-guided surgery, we sought to identify areas of consensus and nonconsensus across 4 areas of practice: fundamentals; patient selection/preparation; technical aspects; and effectiveness and safety. METHODS: A Delphi survey was conducted among 19 international experts in fluorescence-guided surgery attending a 1-day consensus meeting in Frankfurt, Germany on September 8th, 2019. Using mobile phones, experts were asked to anonymously vote over 2 rounds of voting, with 70% and 80% set as a priori thresholds for consensus and vote robustness, respectively. RESULTS: Experts from 5 continents reached consensus on 41 of 44 statements, including strong consensus that near-infrared fluorescence-guided surgery is both effective and safe across a broad variety of clinical settings, including the localization of critical anatomical structures like vessels, detection of tumors and sentinel nodes, assessment of tissue perfusion and anastomotic leaks, delineation of segmented organs, and localization of parathyroid glands. Although the minimum and maximum safe effective dose of ICG were felt to be 1 to 2 mg and >10 mg, respectively, there was strong consensus that determining the optimum dose, concentration, route and timing of ICG administration should be an ongoing research focus. CONCLUSIONS: Although fluorescence imaging was almost unanimously perceived to be both effective and safe across a broad range of clinical settings, considerable further research remains necessary to optimize its use.

Assessing the development status of intraoperative fluorescence imaging for perfusion assessments, using the IDEAL framework.

OBJECTIVES: Intraoperative fluorescence imaging is currently used in a variety of surgical fields for four main purposes: assessing tissue perfusion; identifying/localizing cancer; mapping lymphatic systems; and visualizing anatomy. To establish evidence-based guidance for research and practice, understanding the state of research on fluorescence imaging in different surgical fields is needed. We evaluated the evidence on fluorescence imaging for perfusion assessments using the Idea, Development, Exploration, Assessment, Long Term Study (IDEAL) framework, which was designed for describing the stages of innovation in surgery and other interventional procedures. DESIGN: Narrative literature review with analysis of IDEAL stage of each field of study. SETTING: All publications on intraoperative fluorescence imaging for perfusion assessments reported in PubMed through 2019 were identified for six surgical procedures: coronary artery bypass grafting (CABG), upper gastrointestinal (GI) surgery, colorectal surgery, solid organ transplantation, reconstructive surgery, and cerebral aneurysm surgery. MAIN OUTCOME MEASURES: The IDEAL stage of research evidence was determined for each specialty field using a previously described approach. RESULTS: 196 articles (15 003 cases) were selected for analysis. Current status of research evidence was determined to be IDEAL Stage 2a for upper GI and transplantation surgery, IDEAL 2b for CABG, colorectal and cerebral aneurysm surgery, and IDEAL Stage 3 for reconstructive surgery. Using the technique resulted in a high (up to 50%) rate of revisions among surgical procedures, but its efficacy improving postoperative outcomes has not yet been demonstrated by randomized controlled trials in any discipline. Only one possible adverse reaction to intravenous indocyanine green was reported. CONCLUSIONS: Using fluorescence imaging intraoperatively to assess perfusion is feasible and appears useful for surgical decision making across a range of disciplines. Identifying the IDEAL stage of current research knowledge aids in planning further studies to establish the potential for patient benefit.

Calcium phosphate cements improve bone density when used in osteoporotic sternums.

PURPOSE: Calcium phosphate cements control bleeding and are safe to use in osteoporotic sternums during open heart surgery. We looked at the clinical and radiographic effects of this agent on bone healing. DESCRIPTION: Since March 2006, 18 patients had calcium phosphate cement inserted in their sternal tables at heart surgery. They were followed-up by office visits and chest computed tomographic (CT) scans. All preoperative and postoperative CT chest scans were evaluated for cement absorption, bone replacement, and bone density. EVALUATION: Five preoperative and 41 postoperative CT chest scans were available for evaluation. Median interval from surgery to CT scan was 531 days (range, 3 to 966 days). At follow-up there were neither clinical dehiscences nor nonunions of the sternums. Calcium phosphate cement appears to reabsorb quickly, but not completely. Five patients with pre-surgical CT chest scans demonstrated an average, improved bone density of 281.66 Hounsfield units at follow-up (p = 0.006). CONCLUSIONS: In each patient, cement was replaced by new bone, and there is evidence that more bone is present as a result of cement use.

Calcium phosphate cements to control bleeding in osteoporotic sternums.

PURPOSE: A new method to control bleeding from fragile, severely osteoporotic sternums in patients undergoing open heart surgery. DESCRIPTION: From January 2006 and January 2007, we used orthopedic calcium phosphate cement in 11 patients to control sternal table bleeding. Each patient had greater than 35% of their sternal table surface missing and had associated bleeding after open heart surgery. The cement was packed into the deficient sternal table surface at the conclusion of surgery, just prior to closure. EVALUATION: All patients had immediate cessation of bleeding from their sternums, despite large superficial sternal deficits, after the cement was applied. All patients made uneventful recoveries and none required exploration for bleeding after surgery. There were no instances of superficial or deep sternal wound infections. At follow-up all sternums were well healed and firm. Seven patients had computed tomographic scans performed at 6 months revealing excellent complete sternal healing. CONCLUSIONS: Calcium phosphate cement can be used safely to control bleeding in patients with osteoporotic sternums and seems to be safe to use in the sternum.

Transmyocardial laser therapy: a strategic approach.

BACKGROUND: Coronary artery bypass and percutaneous intervention have become the established methods of coronary revascularization in treating angina pectoris. Subsets of angina patients, however, are not amenable to either of these procedures. Transmyocardial laser revascularization (TMR) has been developed as a potential treatment to address such patients, and clinical research to date illustrates the success of TMR for this patient group. STRATEGIC PLAN SUMMARY: Although the symptoms of ischemic heart disease manifest themselves in a variety of ways, the best results with TMR are seen in patients with severe angina rather than in patients with silent ischemia or congestive heart failure. Potential TMR patients receive diagnostic tests to determine if and where the therapy should be applied. A recent cardiac catheterization is required to document the status of and the coronary-system suitability for the planned intervention. It is not appropriate to assume that a patient with nonbypassable, noninterventional coronary artery disease has to be relegated to medical therapy only. Additionally, echocardiography demonstrates the status of cardiac valves and segmental wall motion activity. This knowledge allows the surgeon to determine the sequence of surgery and if abnormalities are present. Once the decision to use TMR use has been made, there are 2 approaches--sole therapy or adjunctive therapy. TMR is not to be substituted for a feasible bypass graft, but the best time to make this decision may well be during the surgery itself, because grafts that appear surgically feasible on an angiogram may be less feasible after the chest has been opened. The decision to perform sole-therapy TMR in the absence of bypassable vessels clearly must be made before opening the chest. Whether to use cardiopulmonary bypass (CPB) and the sequence in which to perform TMR and bypass grafts are based on surgeon preference. The advantage of performing TMR on CPB is that channels can quickly be lased without pause. A potential advantage of performing TMR before bypass grafts is that "channel leak" (bleeding) can be minimized by the conclusion of the surgery. Complete revascularization has become technically more difficult because of the increasing use of percutaneous approaches and because patients are being referred for coronary artery bypass grafting much later in the course of their coronary disease progression than before. TMR may well be a viable alternative to bypassing a heavily diseased, previously intervened, small-diameter coronary artery. Thus, a model in which myocardial perfusion is considered within the context of the natural circulation can be conceived as an alternative to a model in which circulation is altered by interventional, surgical, and/or transmyocardial methods. TMR has been shown to be effective in accomplishing a complete revascularization when the restoration of circulation to ischemic territories with interventional therapy, bypass surgery, or a combination of both has been ineffective. We recommend that interested users follow this "complete revascularization strategy" algorithm for all ischemic vessels being considered for interventional or surgical treatment. Running each diseased vessel through this thought process will ensure that available treatment options are considered in the optimization of a patient's outcome. CONCLUSION: The use of TMR for angina relief has evolved into a clinically proven technology that has enabled physicians to address difficult revascularization cases with a therapy that is safe and effective.