Cardiac Surgery mproving the Quality of Coronary ypass Surgery With Intraoperative Angiography alidation of a New Technique

OBJECTIVES We report a comprehensive assessment and validation of a new intraoperative angiography technique. BACKGROUND Technical problems at the site of the distal anastomosis compromise an underappreciated proportion of coronary bypass grafts. The absence of a systematic, validated technique to verify graft patency in the operating room represents a significant breach in quality assurance. METHODS Fluorescent indocyanine green (ICG) dye is excited with dispersed laser light to create an angiographic depiction of the graft, native vessel, and anastomosis. One-hundred twenty patients underwent ICG angiography. Angiograms were reviewed for reliability and validity studies. RESULTS A total of 348 coronary bypass grafts were studied. Each ICG angiogram took 2.2 1.1 min to perform. The ICG angiography found 4.2% of patients had significant graft problems requiring major revision. Quality of visualization was rated according to a seven-point Likert scale (1 worst, 7 best). Among conduits, saphenous veins were best visualized (mean score standard deviation), 6.4 1.5 versus 5.5 1.9 for internal mammary arteries and 4.4 2.3 for radial arteries (p 0.02). Location of distal anastomosis did not influence quality of visualization. There was high inter-rater reliability for graft revision (kappa 1.0) and graft patency (kappa 0.97) between surgeons. Sensitivity and specificity of the ICG angiograms for graft stenosis 50% was 100% among 22 grafts also studied with X-ray angiography. CONCLUSIONS Information from ICG angiograms led to graft revisions for technical problems in 4.2% of patients that would have otherwise gone unrecognized. Intraoperative angiography is an emerging tool for improving the quality of coronary bypass surgery. (J Am Coll Cardiol ublished by Elsevier Inc. doi:10.1016/j.jacc.2005.05.081