Cardiothoracic surgery training in Israel: A critical look at the past, aiming for a better future

The impact of surgical training on early and long-term outcomes after isolated aortic valve surgery

 

OBJECTIVES

Patients presenting with more comorbidities, requiring more complex cardiac surgical procedures and an increase in public scrutiny are impacting on training programme because of the perceived risk of worse outcomes. Hence, we aimed to provide evidence that trainees as the first operator can achieve comparable results to consultants when performing isolated surgical aortic valve replacement.

METHODS

From 1996 to 2017, 2919 patients underwent surgical aortic valve replacement at the Bristol Heart Institute, operated on by either a consultant (n = 2220) or a trainee (n = 870) as the first operator. Propensity score matching was used to adjust for imbalance in the baseline characteristics of the 2 groups.

RESULTS

Over a 21-year period, the proportion of trainee cases dropped from 41.5% to 25.9%. No differences in the rates and risk of in-hospital mortality, new cerebrovascular accidents, re-exploration for bleeding, deep sternal wound infection and length of stay were found between patients operated on in the 2 groups. Also, there was a comparable risk of late death between the 2 groups (HR 0.88; 95% CI 0.73–1.06; P = 0.27) and this was present regardless of trainees career level and patients surgical risk based on the EuroSCORE. Finally, we showed an increase in patients risk profile in the latest year but, this was not associated with the worst outcomes when trainees performed the operation.

CONCLUSIONS

Surgical aortic valve replacement is a safe and reproducible technique and regardless of the patient’s risk profile, and no differences in the outcomes between trainees and consultant cases were found.

Global perspectives on cardiothoracic, cardiovascular, and cardiac surgical training

OBJECTIVE

Various methods for cardiothoracic, cardiovascular, and cardiac surgical training exist across the globe, with the common goal of producing safe, independent surgeons. A comparative analysis of international training paradigms has not been undertaken, and our goal in doing so was to offer insights into how to best prepare future trainees and ensure the health of our specialty.

METHODS

We performed a comparative analysis of available publications offering detailed descriptions of various cardiothoracic, cardiovascular, and cardiac surgical training paradigms. Corresponding authors from previous publications and other international collaborators were also reached directly for further data acquisition.

RESULTS

We report various approaches to common challenges surrounding (1) selection of trainees and plans for the future surgical workforce; (2) trainee assessments and certification of competency before independent practice; and (3) challenges related to a changing practice landscape.

CONCLUSIONS

Cardiothoracic surgery remains a dynamic and rewarding specialty. Current and future trainees face several challenges that transcend national borders. To foster collaboration and adoption of best practices, we highlight international strengths and weaknesses of various nations in terms of workforce selection, trainee operative experience and assessment, board certification, and preparation for future changes anticipated in cardiothoracic surgery.

Cardiothoracic surgery training in South Korea: Challenges and new hopes

In this era when multiple challenges are surrounding the cardiothoracic surgery specialty, including an increase in procedural complexity and institutionalization of public reporting, it is rather paradoxical to have an unprecedentedly unfavorable condition for quality education while the level of proficiency and competency to be achieved during the course of training became more demanding. Cardiothoracic surgery in South Korea is also facing several challenges across multiple levels that includes a persistent low filling rate of residency positions, severe therapeutic deviation toward percutaneous transcatheter intervention in coronary artery disease, a social climate reluctant to cardiovascular surgery and consequent underestimation of surgical volume, and skewed health insurance reimbursement system. Meanwhile, some hopeful signs have been observed in our specialty because of ongoing efforts of our leaderships of the Society, including recent financial initiative and several educational platforms such as boot camp. We introduce our system internationally to share our experience for the purpose of promoting further discussions and encouraging persistent efforts toward education.

Training of Residents in Cardiac Surgery-Does It Have Impact on the Outcome?

OBJECTIVES

In many centers, training in cardiac surgery is considered to increase perioperative risk. This study aims to test whether a resident working as the main operator is a genuine risk factor.

METHODS

We analyzed patients who underwent elective isolated aortic valve replacement, elective isolated coronary artery bypass grafting, or both, in our institution, from 2008 to 2016. Redo- and off-pump surgery, ejection fraction < 30%, and other concomitant procedures were the exclusion criteria. After this selection, we included 3,077 patients in our study. Within this group, 357 (11.6%) had been operated by residents and 2,720 (88.4%) by senior surgeons. We performed propensity score matching using the nearest neighbor method with a ratio of 1:2, considering the most important preoperative conditions. In this way, the 357 patients operated by residents were matched with the 714 patients who were operated by senior surgeons. The standardized mean differences were highly reduced after matching, so both groups had similar risk profiles. We compared surgical data, postoperative adverse events, and the 30-day mortality between the two groups.

RESULTS

The times of surgery, cardiopulmonary bypass, and cross-clamp were longer if residents operated (p < 0.001). There were no differences regarding postoperative adverse events, time of mechanical ventilation, and the intensive care unit length of stay. The 30-day mortality rates of the two groups were very similar (p = 0.75, power = 0.8).

CONCLUSION

Training in cardiac surgery is safe, and carefully selected patients can be operated by residents without increased risk of perioperative mortality and complications.