Programmatic and Surgeon Specialization Improves Mortality in Isolated Coronary Bypass Grafting

Pathway to cardiothoracic surgery: A primer for aspiring students

Objective

The pathway to cardiothoracic surgery is often obscure for premedical students and aspiring applicants and requires navigating various known and unknown obstacles. Recognizing the challenges encountered on the path to a career in cardiothoracic surgery in the United States, we present this guide for students interested in the field to maximize success in their premedical, preclinical, and preresidency years.

Methods

This is a joint collaboration between the Thoracic Surgery Residents Association and the Thoracic Surgery Medical Student Association. Drawing from firsthand experiences and insights gathered from numerous student applicants and current surgical residents, a comprehensive guide was constructed for students from the point of undergraduate school to advanced training options, including super-fellowship training.

Results

Several intricacies to cardiothoracic surgery career planning were discussed, including differences between traditional and integrated/fast-track pathways, college and medical school selection, networking, performing during clinical rotations, extracurricular and research activities, building mentorship relationships, and pursuing alternate career and advanced training opportunities.

Conclusions

For premedical students and aspiring applicants, the road to cardiothoracic surgery requires meticulous planning, grit, and thoughtful dedication. This document consolidates firsthand insights and advice from numerous aspiring and matched applicants to serve as a comprehensive guide for students seeking a career in cardiovascular and thoracic surgery.

Coronary Artery Bypass Grafting versus Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion

OBJECTIVES

 Mechanisms of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) differ as CABG provides surgical collateralization and may prolong life by preventing future myocardial infarctions (MIs). However, evidence for CABG in patients with chronic total occlusion (CTO) has not been fully elucidated and the impact of PCI is discussed controversially.

METHODS

 We performed a meta-analysis of studies comparing outcomes in patients with/without multivessel disease undergoing CABG or PCI for CTO. The primary outcome was long-term all-cause mortality (≥5 years). Secondary outcomes were MIs, repeat revascularization, cardiac mortality, major adverse cardiovascular events, and stroke, as well as short-term mortality (30 days/in-hospital) and stroke. A pooled Kaplan-Meier survival curve after reconstruction analysis was generated. Random-effects models were used.

RESULTS

 Six studies totaling 12,504 patients were included. In the pooled Kaplan-Meier analysis, PCI showed a significantly higher risk of death in the follow-up compared with CABG (hazard ratio [HR]: 2.12, 95% confidence interval [CI]: 1.88-2.38, p < 0.01). During the observation period, PCI was also associated with higher rates of MI (odds ratio [OR]: 2.86, 95% CI: 1.82-4.48, p < 0.01) and more repeat revascularization (OR: 4.88, 95% CI: 1.99-11.91, p = 0.0005). The other outcomes did not show significant differences.

CONCLUSION

 CABG is associated with superior survival to PCI over time in patients with CTO who are eligible for both PCI and CABG. This survival advantage is associated with fewer events of MI and repeat revascularization.

Effect of Surgical Care Team Consistency During Urologic Procedures on Surgical Efficiency and Perioperative Outcomes

OBJECTIVE

To evaluate the effect of urologic surgical care team consistency on surgical efficiency and patient outcomes.

METHODS

Patients undergoing major urologic surgery (prostatectomy, nephrectomy, or cystectomy) at a single institution from 2010 to 2019 were identified. A surgical care team comprised a certified surgical assistant, certified surgical technologist, and circulating nurse. Primary team member status was assigned on a quarterly basis to team members present for the highest proportion of a surgeon's cases. Surgical efficiency outcomes included time to first incision, procedure duration, and turnover time. Perioperative clinical outcomes included hospital length of stay and 30-day readmission and reoperation rates. Outcomes were compared according to team consistency and assessed via univariate and multivariable analyses.

RESULTS

Overall, 11,213 surgical procedures were included. Time to first incision, procedure duration, and turnover time were significantly lower in procedures performed with high-consistency teams (2-3 primary members) versus low-consistency teams (0-1 primary members) (all P <.001). After adjusting for patient-related variables, high-consistency teams were significantly associated with decreased time to first incision (estimate, -2.04 minutes; 95% CI, -2.68 to -1.41 minutes; P <.001) and turnover time (estimate, -7.23 minutes; 95% CI, -9.8 to -4.66 minutes; P <.001). For minimally invasive nephrectomy, high-consistency teams were associated with significantly decreased odds of prolonged hospitalization (odds ratio, 0.63; 95% CI, 0.47-0.84; P = .001). For robotic prostatectomy, high-consistency teams were associated with decreased procedure duration (estimate, -4.55 minutes; 95% CI, -7.48 to -1.62 minutes; P = .002).

CONCLUSION

Highly consistent surgical care teams were associated with improved surgical efficiency and patient outcomes.

A 9-year analysis of medical malpractice litigations in coronary artery bypass grafting in China

BACKGROUND

The coronary artery bypass grafting (CABG) is one of the high-risk litigated medical specialties. Further elucidating the causes behind these malpractice claims can help physicians avoid patient injury. This study analyzed CABG litigations occurred in different level hospitals to outline the basic characteristics, as well as present a analysis on the medical malpractice that result in lawsuits.

METHODS

This study utilized the "China Judgments Online" database to compile litigations from 2012 to 2021 across China. 109 cases related to the CABG were included in the study, and were analyzed for demographic, patient outcomes and verdict characteristics in different levels of hospitals.

RESULTS

The median age of plaintiff patient was 62 years, the median length of stay was 25 days, and the median responsibility ratio of the litigation cases was 30%. The average proportion of responsibility of national, provincial and municipal hospitals were 29.6%, 28.4% and 39.5% respectively, and the median days after surgery to death of that were 15, 9 and 5 separately. The top 5 postoperative complications in dispute cases were: low cardiac output syndrome, postoperative hemorrhage, non-surgical site infections, surgical site infections and arrhythmia.

CONCLUSIONS

The diagnosis and treatment capabilities of coronary artery bypass grafting in different levels of hospitals in China were inconsistent, and the treatment capabilities in prefecture-level hospitals were lower than that in national hospitals. The procedural error, failure to properly monitor the patient and diagnostic errors were common in CABG litigations. Postoperative complications related to surgical injuries and insufficient basic postoperative management lead to a higher responsibility proportion.

The Academic Impact of Advanced Clinical Fellowship Training among General Thoracic Surgeons

OBJECTIVE

Advanced clinical fellowship training has become a popular option for surgical trainees seeking to bolster their clinical training and expertise. However, the long-term academic impact of this additional training following a traditional thoracic surgery fellowship is unknown. This study aimed to delineate the impact of an advanced clinical fellowship on subsequent research productivity and advancement in academic career among general thoracic surgeons.

METHODS

Using an internally constructed database of active, academic general thoracic surgeons who are current faculty at accredited cardiothoracic surgery training programs within the United States, surgeons were dichotomized according to whether an advanced clinical fellowship was completed or not. Academic career metrics measured by research productivity, scholarly impact (H-index), funding by the National Institutes of Health, and academic rank were compared.

RESULTS

Among 285 general thoracic surgeons, 89 (31.2%) underwent an advanced fellowship, whereas 196 (68.8%) did not complete an advanced fellowship. The most commonly pursued advanced fellowship was minimally invasive thoracic surgery (32.0%). There were no differences between the two groups in terms of gender, international medical training, or postgraduate education. Those who completed an advanced clinical fellowship were less likely to have completed a dedicated research fellowship compared to those who had not completed any additional clinical training (58.4% vs. 74.0%, p = 0.0124). Surgeons completing an advanced clinical fellowship demonstrated similar cumulative first-author publications (p = 0.4572), last-author publications (p = 0.7855), H-index (p = 0.9651), National Institutes of Health funding (p = 0.7540), and years needed to advance to associate professor (p = 0.3410) or full rank professor (p = 0.1545) compared to surgeons who did not complete an advanced fellowship. These findings persisted in sub-analyses controlling for surgeons completing a dedicated research fellowship.

CONCLUSIONS

Academic general thoracic surgeons completing an advanced clinical fellowship demonstrate similar research output and ascend the academic ladder at a similar pace as those not pursuing additional training.

The Anaortic Technique with Bilateral Internal Thoracic Artery Grafting - Filling the Gap in Coronary Artery Bypass Surgery

Coronary artery bypass grafting (CABG) has consolidated its role as the most effective procedure for treating patients with advanced atherosclerotic coronary artery disease, reducing the long-term risk of myocardial infarction and death compared to other therapies and relieving angina. Despite the recognized benefits afforded by surgical myocardial revascularization, a subset of higher-risk patients bears a more elevated risk of perioperative stroke. Stroke remains the drawback of conventional CABG and has been strongly linked to aortic manipulation (cannulation, cross-clamping, and side-biting clamping for the performance of proximal aortic anastomoses) and the use of cardiopulmonary bypass. Adoption of off-pump CABG (OPCAB) is demonstrated to lower the risk of perioperative stroke, as well as reducing the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay. However, increased risk persists owing to the need for the tangential ascending aorta clamping to construct the proximal anastomosis. The concept of anaortic (aorta no-touch) OPCAB (anOPCAB) stems from eliminating ascending aorta manipulation, virtually abolishing the risk of embolism caused by aortic wall debris into the brain circulation. The adoption of anOPCAB has been shown to further decrease the risk of postoperative stroke, especially in higher-risk patients, entailing a step forward and a refinement of outcomes provided by the primeval OPCAB technique. Therefore, anOPCAB has been the recommended technique in patients with cerebrovascular disease and/or calcification or atheromatous plaque in the ascending aorta and should be preferred in patients with high-risk factors for neurological damage and stroke.

Factors That Contribute to Cost Differences Based on ICU of Admission in Neonates Undergoing Congenital Heart Surgery: A Novel Decomposition Analysis

OBJECTIVES

We leveraged decomposition analysis, commonly used in labor economics, to understand determinants of cost differences related to location of admission in children undergoing neonatal congenital heart surgery.

DESIGN

A retrospective cohort study.

SETTING

Pediatric Health Information Systems database.

PATIENTS

Neonates (<30 d old) undergoing their index congenital heart surgery between 2004 and 2013.

MEASUREMENTS AND MAIN RESULTS

A decomposition analysis with bootstrapping determined characteristic (explainable by differing covariate levels) and structural effects (if covariates are held constant) related to cost differences. Covariates included center volume, age at admission, prematurity, sex, race, genetic or major noncardiac abnormality, Risk Adjustment for Congenital Heart Surgery-1 score, payor, admission year, cardiac arrest, infection, and delayed sternal closure.Of 19,984 infants included (10,491 [52%] to cardiac ICU/PICU and 9,493 [48%] to neonatal ICU), admission to the neonatal ICU had overall higher average costs ($24,959 ± $3,260; p < 0.001) versus cardiac ICU/PICU admission. Characteristic effects accounted for higher costs in the neonatal ICU ($28,958 ± $2,044; p < 0.001). Differing levels of prematurity, genetic syndromes, hospital volume, age at admission, and infection contributed to higher neonatal ICU costs, with infection rate providing the most significant contribution ($13,581; p < 0.001). Aggregate structural effects were not associated with cost differences for those admitted to the neonatal ICU versus cardiac ICU/PICU (p = 0.1). Individually, prematurity and age at admission were associated with higher costs due to structural effects for infants admitted to the neonatal ICU versus cardiac ICU/PICU.

CONCLUSIONS

The difference in cost between neonatal ICU and cardiac ICU/PICU admissions is largely driven by differing prevalence of risk factors between these units. Infection rate was a modifiable factor that accounted for the largest difference in costs between admitting units.

Impact of advanced clinical fellowship training on future research productivity and career advancement in adult cardiac surgery

BACKGROUND

Advanced clinical fellowships are important for training surgeons with a niche expertise. Whether this additional training impacts future academic achievement, however, remains unknown. Here, we investigated the impact of advanced fellowship training on research productivity and career advancement among active, academic cardiac surgeons. We hypothesized that advanced fellowships do not significantly boost future academic achievement.

METHODS

Using online sources (eg, department webpages, CTSNet, Scopus, Grantome), we studied adult cardiac surgeons who are current faculty at accredited United States cardiothoracic surgery training programs, and who have practiced only at United States academic centers since 1986 (n = 227). Publicly available data regarding career advancement, research productivity, and grant funding were collected. Data are expressed as counts or medians.

RESULTS

In our study, 78 (34.4%) surgeons completed an advanced clinical fellowship, and 149 (65.6%) did not. Surgeons who pursued an advanced fellowship spent more time focused on surgical training (P < .0001), and those who did not were more likely to have completed a dedicated research fellowship (P = .0482). Both groups exhibited similar cumulative total publications (P = .6862), H-index (P = .6232), frequency of National Institutes of Health grant funding (P = .8708), and time to achieve full professor rank (P = .7099). After stratification by current academic rank, or by whether surgeons pursued a dedicated research fellowship, completion of an advanced clinical fellowship was not associated with increased research productivity or accelerated career advancement.

CONCLUSION

Academic adult cardiac surgeons who pursue advanced clinical fellowships exhibit similar research productivity and similar career advancement as those who do not pursue additional clinical training.

Quality metrics in coronary artery bypass grafting

Studies on the association between care quality, case volume, and outcomes in coronary artery bypass grafting (CABG) have concluded that consistent adherence to quality measures improves mortality rates and outcomes. However, the quality metrics are not well-defined, and their significance to surgeons and healthcare providers remains uncertain. We review the concept of "quality and quality metrics" and discuss their importance in the context of CABG.