Excellent short- and long-term outcomes after concomitant aortic valve replacement and coronary artery bypass grafting performed by surgeons in training

Teaching hospitals and their influence on survival after valve replacement procedures: A retrospective cohort study using inverse probability of treatment weighting (IPTW)

BACKGROUND

The effect of teaching hospital status on cardiovascular surgery has been of common interest in recent decades, yet its magnitude on heart valve replacement is still a matter of debate. Given the ethical and practical unfeasibility of randomly assigning a patient to such an exposure, we use the inverse probability of treatment weighting (IPTW) to assess this marginal effect on the survival of Colombian patients who underwent a first heart valve replacement between 2016 and 2019.

METHODS

A retrospective cohort study was conducted based on administrative records. The time-to-death event and cumulative incidences of death, readmission, and reoperation are presented as outcomes. An artificial sample is configured through IPTW, adjusting for sociodemographic variables, comorbidities, technique, and intervention weight.

RESULTS

Of a sample of 3,517 patients, 1,051 (29.9%) were operated on in a teaching hospital. The median age was 65.0 (18.1-91.5), 38.5% of patients were ≤60, and 6.9% were ≥80. The cumulative incidences of death at 30, 90 days, and one year were 5.9%, 8%, and 10.9%, respectively. Furthermore, 23.5% of the patients were readmitted within 90 days and 3.6% underwent reintervention within one year. The odds of 30-day mortality are lower for patients operated in a teaching hospital (OR 0.51; 95% CI 0.29-0.92); however, no effect on survival was identified in terms of time-to-event of death (HR 1.07; 95%CI 0.78-1.46).

CONCLUSIONS

After IPTW, the odds of 30-day mortality are lower for patients operated in a teaching hospital. There was no effect on survival, 90-day or one-year mortality, 90-day readmission, or one-year reintervention. Together, we offer an opening for investigating an exposure that has yet to be explored in Latin America with potential value to understand teaching hospitals as the essential nature of reality of an academic-clinical synergy.

Is It Reasonable to Perform Isolated SAVR by Residents in the TAVI Era?

BACKGROUND

The role of conventional surgical aortic valve replacement (SAVR) is increasingly questioned since the indication for transcatheter aortic valve implantations (TAVIs) is currently extended. While the number of patients referred to SAVR decreases, it is unclear if SAVR should be performed by junior resident surgeons in the course of a heart surgeons training.

METHODS

Patients with isolated aortic valve replacement (AVR) were analyzed with respect to the surgeon's qualification. AVR performed by resident surgeons was compared with AVR by senior surgeons. The collective was analyzed with respect to clinical short-term outcomes comparing full sternotomy (FS) with minimally invasive surgery and ministernotomy (MS) with right anterior thoracotomy (RAT) after a 1:1 propensity score matching.

RESULTS

The 30-day all-cause mortality was 2.3 and 3.4% for resident versus senior AVR groups, cerebrovascular event rates were 1.1 versus 2.6%, and no cases of significant paravalvular leak were detected. Clinical short-term outcomes between FS and minimally invasive access, as well after MS and RAT were comparable.

CONCLUSION

Our current data show feasibility and safety of conventional SAVR procedure performed by resident surgeons in the era of TAVI. Minimally invasive surgery should be trained and performed in higher volumes early in the educational process as it is a safe treatment option.

Outcomes of cardiac surgical procedures performed by trainees versus consultants: A systematic review with meta-analysis

OBJECTIVES

Cardiac surgery is highly demanding and the ideal teaching method to reach competency is widely debated. Some studies have shown that surgical trainees can safely perform full operations with equivocal outcomes compared with their consultant colleagues while under supervision. We aimed to compare outcomes after cardiac surgery with supervised trainee involvement versus consultant-led procedures.

METHODS

We systematically reviewed databases (PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar) and reference lists of relevant articles for studies that compared outcomes of cardiac surgery performed by trainees versus consultants. Primary end points included: operative mortality, coronary events, neurological/renal complications, reoperation, permanent pacemaker implantation, and sternal complications. Secondary outcomes included cardiopulmonary bypass and aortic cross-clamp times and intensive care/in-hospital length of stay. Random effects meta-analysis was performed.

RESULTS

Thirty-three observational studies that reported on a total of 81,616 patients (trainee: 20,154; consultant: 61,462) were included. There was a difference favoring trainees in terms of operative mortality in the main analysis and in an analysis restricted to propensity score-matched samples, whereas other outcomes were not consistently different in both analyses. Overall cardiopulmonary bypass and aortic cross-clamp times were longer in the trainee group but did not translate in longer intensive care unit or hospital stay.

CONCLUSIONS

In the right conditions, good outcomes are possible in cardiac surgery with trainee involvement. Carefully designed training programs ensuring graduated hands-on operative exposure as primary operator with appropriate supervision is fundamental to maintain high-quality training in the development of excellent cardiac surgeons.

Medium-term outcomes of 78,808 patients after heart valve surgery in a middle-income country: a nationwide population-based study

BACKGROUND

Heart valve surgery outcomes are unknown in middle-income countries and thus cannot be used in health system decision making processes. This study estimated in-hospital mortality and medium and long-term survival.

METHODS

This was a retrospective study of 78,806 patients who underwent heart valve surgery between 2001 and 2007 in Brazil. Two national databases were used, the Hospital Information System and the Mortality Information System. Kaplan-Meier survival analysis and log-rank tests were performed. Maximum and median follow-up was 7.7 and 2.8 years, respectively (0.002-7.707).

RESULTS

Valve replacement accounted for 69.1% of procedures performed. Mitral stenosis, the most common valve injury, represented 38.9% of the total. In 94.7% of mitral stenosis patients, aetiology was rheumatic heart disease. In-hospital mortality was 7.6% and was higher for women, for patients who had undergone concomitant coronary artery bypass grafting (CABG) and for the elderly. Overall survival was 69.9% at the end of follow-up. Survival was worst among elderly, male and concomitant CABG patients (P<0.001).

CONCLUSIONS

Rheumatic heart disease is still a major public health problem in Brazil. In-hospital mortality and global survival rates of patients who have undergone heart valve surgery were less satisfactory than those reported in high-income countries. The findings of this study can contribute to guiding decision making processes in middle-income countries similar to Brazil and others concerned with improving the quality of care.

Trainees can learn minimally invasive aortic valve replacement without compromising safety

OBJECTIVES

Minimally invasive aortic valve replacement (Mini-AVR) is a technically advanced procedure. However, it results in equivalent operative mortality, less bleeding and reduced intensive care/hospital stay when compared with conventional AVR. Our aim was to assess the impact of trainee performance on short-term outcomes of patients undergoing elective and urgent Mini-AVR where a significant proportion were performed by trainees.

METHODS

All patients undergoing non-emergency, elective and urgent, isolated Mini-AVR between September 2005 and December 2012 were studied. Operative details and short-term outcomes, with particular attention to trainee performance, were analysed.

RESULTS

During the study period, there were 205 Mini-AVR with a median age of 67 years (range 29-86); 74 (36%) operations were performed by trainees. The overall median cross-clamp and bypass times were 42 (range 33-63) and 59 min (range 59-94) for the attending surgeon and 52 (range 42-63) and 71 min (range 59-94) for the trainee (P = 0.03). Five Mini-AVR patients (2.4%) required conversion to full sternotomy for ascending aortic replacement, right ventricular bleeding, coronary artery bypass graft surgery and failure to cardiovert. None of these cases were performed by trainees. Median lengths of intensive care and hospital stay were 1 and 5 days and were not different for attending surgeon and trainee. Only 1 (0.5%) patient died in hospital.

CONCLUSIONS

Mini-AVR can be performed with a low conversion rate and hospital stay and taught to trainees without compromising safety.