Advice
Expert comments
Expert comments
Comments on this technology were invited from clinical experts working in the field and relevant patient organisations. The comments received are individual opinions and do not represent NICE's view.
Two out of 3 experts were familiar with or had used this technology before.
Level of innovation
Two clinical experts commented that the technology has been around for some time, about 20 years. One expert said that other modalities offer the same information but at no extra cost and 1 expert said that MiraQ cardiac is the most user-friendly form that this technology has been presented in. The other expert said that MiraQ cardiac is a useful tool for quality control of anastomotic issues. Two experts described the standard care used in clinical practice, which includes assessment of graft adequacy and flow by: changes in electrocardiogram measurements and haemodynamic parameters, infusing cardioplegia through a conduit during the procedure and palpation of the conduit. Two of the clinical experts stated that the technology would be used in addition to standard care and 1 said that it has the potential to replace standard care.
Potential patient impact
Two experts said that the primary benefit of the technology for patients is providing surgeons with detailed objective information about the graft condition and graft flow. This information can be used to make necessary changes to improve blood flow in the graft and potentially reduce long-term graft failure. One expert also highlighted the ability of the technology to detect the position of deep lying arteries, which prevents the surgeon from making unnecessary dissections during the procedure. This may reduce the risk of bleeding and intraoperative complications. Based on this aspect of detection, 1 expert said that the technology is most appropriate for use in people with known peripheral vascular disease and another expert said that it would provide more benefit in people with calcified vessels or small vessels with a high syntax score.
Potential system impact
One expert said that the technology has the potential to standardise the methods used in practice, which are currently subjective and not evidence-based. This expert added that the potential to reduce future cardiac events would mean fewer hospital visits, which would free up resource. All of the experts agreed that the technology will initially cost significantly more than standard care. This is because of the cost of purchasing the technology and disposables, training theatre nursing staff and surgeons, and the extra time required to perform flow measurements and ultrasound assessment. One expert felt that the long-term cost impact would be equal to or less than standard care.
General comments
All 3 experts agreed that the technology would not require any specific changes to facilities and infrastructure, though 2 experts noted that storage space within the operating theatre would be needed. They also agreed that training would be required to achieve competency with the device. One of the experts highlighted that the technology does not automatically record blood pressure during the flow measurement and that this would be useful for retrospective analyses of outcomes. They also said that a small portion of the left internal mammary artery must be prepared for placing the flow probe around the vessel. If this step is not done before the procedure and instead done at the end, this could cause damage to the mammary artery and cause bleeding. All 3 experts suggested that larger studies are needed to determine both the clinical and cost effectiveness of the technology, including in different patient groups. Two experts said that the technology would be needed for all coronary artery bypass graft (CABG) procedures done in the NHS, which is approximately 15,000 a year.