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2018 European Guidelines Stress Quality Measures

Posted by Susan Eymann, MS on Feb 26, 2020

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The European Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery

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(EACTS), with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI), developed the The 2018 ESC/EACTS Guidelines on Myocardial Revascularization to provide a comprehensive roadmap to assist physicians in selecting the best management strategies for an individual patient with a given condition.

The guidelines integrate the most recent research (780 citations) with educational tools and implementation programs for its recommendations.

Graft flow during coronary artery bypass grafting (CABG) surgery is a major determinant in postoperative surgical success. Since 2010, The European Guidelines for Myocardial Revascularization have recommended its use. In the latest 2018 update of the Guidelines, routine intraoperative graft flow measurement is addressed in Section 15.1.7. It states:

“Besides continuous ECG monitoring and transoesophageal echocardiography immediately after revascularization, intraoperative quality control may also include graft flow measurement to confirm or exclude a technical graft problem.2 Transit-time flow measurement is the most frequently used technique for graft assessment and has been able to detect that 2-4% of grafts require revision. 2,3 In observational studies, the use of intraoperative graft assessment has been shown to reduce the rate of adverse events and graft failure, although interpretation can be challenging in sequential and T-graft configurations.2,4-6

Some studies even suggest that quality measures during coronary artery bypass grafting (CABG), such as graft flow verification with transit-time ultrasound, are more important than simply the volume of surgeries performed by a center.7,8 “When quality indicators in hospitals strongly predicted mortality, irrespective of surgeon or hospital case volumes.”9

1. Neumann F‐J, Sousa‐Uva M, Ahlsson A, et al. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2019; 40(2):87‐165.
2. Kieser TM et al., “Transit-time flow predicts outcomes in coronary artery bypass graft patients: A series of 1000 consecutive arterial grafts. Eur J Cardiothorac Surg. 2010;38:155-162.
3. Mujanovic E et al., “Transit time flowmetry in coronary surgery-an important tool in graft verification,” Bosn J Basic Med Sci. 2007;7:275-8.
4. Jokinen JJ et al., “Clinical value of intra-operative transit-time flow measurement for coronary artery bypass grafting: A prospective angiography-controlled study,” Eur J Cardiothorac Surg. 2011;39: 918-923.
5. Lehnert P et al., “Transit-time flow measurement as a predictor of coronary bypass graft failure,” J Card Surg. 2015;30:47-52.
6. Niclauss L. “Techniques and standards in intraoperative graft verification by transit time flow measurement after coronary artery bypass graft surgery: A critical review,” Eur J Cardiothorac Surg. 2017;51:26-33.
7. Zacharias A, et al., “Is hospital procedure volume a reliable marker of quality for coronary artery bypass surgery? A comparison of risk and propensity adjusted operative and midterm outcomes,” Ann Thorac Surg. 2005;79:1961-199.
8. Kurlansky PA et al., “Quality, not volume, determines outcome of coronary artery bypass surgery in a university-based community hospital network,” J Thorac Cardiovasc Surg. 2012;143:287-293.
9. Auerbach AD et al., “Shop for quality or volume? Volume, quality, and outcomes of coronary artery bypass surgery.” Ann Intern Med. 2009;150:696-704.

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