Off-pump coronary operations can be safely taught to cardiothoracic trainees

Successful introduction of off-pump coronary artery bypass grafting in southeastern Asian countries: A single Center's experience in Thailand

Background

Off-pump coronary artery bypass grafting has not been standardized in Southeastern Asian countries because it is technically demanding. However, this method could be suitable for economically disadvantaged institutions because it saves cost on the heart–lung machine. We summarized our results to assess the validity of our early introduction of this method.

Methods

We reviewed the data from 750 patients who underwent off-pump coronary artery bypass grafting at our institution. Before the introduction of off-pump coronary artery bypass grafting, experts from Japan were enlisted to teach our surgeons technicalities of the procedure. The primary outcome was in-hospital mortality, and secondary outcomes included any major adverse cardiac or cerebrovascular event.

Results

The in-hospital mortality rate was 1.5%. The rates of survival and freedom from major adverse cardiac or cerebrovascular event 3 years after the operation were 92.5% ± 1.8% and 90.7% ± 2.2%, respectively. In the multivariable analysis, the independent risk factors for major adverse cardiac or cerebrovascular event were chronic obstructive pulmonary disease (adjusted hazard ratio = 2.35, 95% confidence interval = 1.35–4.10, P = .003) and renal insufficiency (adjusted hazard ratio = 2.70, 95% confidence interval = 1.52–4.80, P = .001), whereas risk factors for in-hospital death were pump conversion (relative risk = 17.4, 95% confidence interval = 1.63–4.41, P < .001).

Conclusion

Successful introduction of off-pump coronary artery bypass grafting provided a favorable outcome almost equal to that in high-volume centers in developed countries.

Is It Safe to Let Trainees Operate on High Risk Cardiac Surgery Cases?

Increasing complexity in cardiac operations has raised the discussion on trainee autonomy and the number of cases required to achieve competency. This study compares outcomes among cases done by trainees vs consultants for high risk patients. 696 (trainee=158 vs consultant=438) major high risk cardiac operations (Euroscore >10) were reviewed at a single center. Observations were propensity matched to consultant or trainee based on several baseline characteristics. Euroscore was: Trainee; 12.3 ± 1.6 versus Consultant; 12.8 ± 2.2, p=.036. Multivariable analysis did not identify trainee as a risk factor for worse in-hospital mortality (OR; 0.95, CI; 0.4-2.2, p=.914) or composite outcome of length of stay >30 days, deep sternal infection, new hemodialysis, new stroke or transient ischemic attack, in-hospital death or reoperation (OR; 0.64, CI; 0.39-1.03, p=.069). NYHA class, diabetes and emergency/salvage surgery were predictors of worse composite outcome. After propensity matching (130 pairs), there was no difference in reoperation rates (3.1% versus 4.6%, p=.727), inhospital death (5.4% versus 7.7%, p=.607) or composite outcome (20.8% versus 29.2%, p=.152). There was no statistical difference in cross clamp times (Trainee; 74.0 ± 32.7 min vs Consultant; 82.6 ± 51.1, p=.229) and bypass times (Trainee; 116.3 ± 52.8 min versus Consultant 135.3 ± 72.6 min, p=.055). The length of stay was similar (18.2 ± 13.2 days versus 19.9 ± 15.6 days, p=.302). It is possible for trainees to perform high risk cardiac surgery without compromising the quality of patient care.

Training the novice to become cardiac surgeon: does the "early learning curve" training compromise surgical outcomes?

OBJECTIVE

It is unclear whether novice trainees can be taught safely to perform adult cardiac surgery without any impact on early or late outcomes.

METHODS

All patients (n = 1305) data were obtained from an externally validated, mandatory institutional database (2003-2010). 'Novice' is defined as a trainee who required substantial assistance or supervision to perform part or whole of the specified procedure (Intercollegiate Surgical Curriculum Programme UK, Competency Level ≤2). Outcome measures were in-hospital mortality, composite score of in-hospital mortality-morbidities, mid-term survival and revascularisation rate after CABG. Follow-up up to 7 years (median 3.2 years) was determined.

RESULTS

Some 39 % (n = 510) of the cases involved novice (28 %-part, 11 %-whole procedure), 12 % (n = 157) competent trainees and 49 % (n = 638) consultant. Median EuroSCORE was higher in consultant group (p < 0.001). Without risk adjustment, composite outcome score and mid-term mortality were higher in consultant group (p = 0.03). With adjustment using EuroSCORE and propensity scores, EuroSCORE was significantly predictive of in-hospital mortality [odd ratio (OR) 1.38, 95 %CI 1.20-1.57, p < 0.001], composite outcome (OR 1.26, 95 %CI 1.15-1.37, p < 0.001) and mid-term mortality (HR 1.24, 95 %CI 1.18-1.31, p < 0.001) but not the operator categories. Further analysis of subcohort undergoing first-time, isolated CABG (n = 1070) showed that EuroSCORE remained predictive of adjusted in-hospital mortality (OR 1.39, 95 %CI 1.13-1.71, p = 0.002), composite outcome (OR 1.33, 95 %CI 1.19-1.49, p < 0.001) and mid-term mortality (HR 1.22, 95 %CI 1.10-1.35, p < 0.001). The operator categories were not associated with adjusted outcome measures including revascularisation rate after CABG.

CONCLUSION

Supervised training in adult cardiac surgery can be achieved safely at the early learning curve phase without compromising both early and mid-term clinical outcomes.

Off-pump coronary revascularization: A potential benefit for female patients?

Coronary artery disease is one of the leading causes of illness for both men and women. However, women are 3 times more likely to die for coronary artery disease as they are of breast cancer. There are an increasing prevalence of coronary artery disease in women and thus facing the need for surgical revascularization. It has long being accepted that women carry a high risk of coronary surgery than men. Many investigators have suggested that female itself is predictive of poor outcome after on pump coronary surgery. We thought to search the litlature to investigate whether women who undergo off-pump surgery receive any benefits compared with women undergoing on-pump surgery.

Safety of training and assessment in operating theatres--a systematic review and meta-analysis

OBJECTIVE

Procedural outcomes can be used to assess the performance of specialists and trainees. This article establishes a systematic evidence base for the safety of training in the operating theatre. It also explores the possibility of using early, intermediate and late procedural outcomes of cardiac surgical operations to evaluate the performance of the clinicians and the healthcare system.

METHODS

Medline, EMBASE and PsycINFO databases were searched. Comparative studies evaluating quality indicators of cardiac surgical procedures (coronary artery bypass grafting (CABG) and valve surgery) were included. guidelines from the preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used.

RESULTS

Fourteen studies met the inclusion criteria. For CABG, meta-analysis of outcomes did not show any significant differences between the technical and non-technical skills of trainees versus specialists apart from bypass time (less for specialists) and intensive care unit (ICU) length of stay (less for trainees). Studies reporting outcomes on valve surgery also did not report any statistically significant differences amongst the outcomes.

CONCLUSION

This systematic review did not discern any significant differences between the procedural outcomes of trainees and specialists, which indicates that trainees are safe to operate under senior supervision. In addition, this article recommends that various procedural outcomes can be used to evaluate the performance of clinicians and healthcare systems. Prospective studies need to be performed, taking into account the specific contribution of trainees and specialists during the procedure. This will give a clearer indication of safety and performance of trainees and specialists in the operating theatre.

Elective minimally invasive coronary artery bypass: shunt or tournique occlusion? Assessment of a protective role of perioperative left anterior descending shunting on myocardial damage. A prospective randomized study

Background

To determine impact of intraluminal-left anterior descending shunt to prevent myocardial damage in minimally invasive coronary artery bypass.

Methods

38 patients were randomly assigned to external tournique occlusion (n = 19) or intraluminal-left anterior descending shunt group (n = 19). Blood samples for cardiac troponin T were collected at 30 minutes prior to, 6 and 24 hours after surgery.

Results

One patient in external tournique occlusion and two patients in intraluminal-left anterior descending shunt group were excluded from futher analysis due to preoperative cardiac troponin T level above the 99th-percentile. Postoperatively, each six patients in external tournique occlusion (33.3%) and intraluminal-left anterior descending shunt (35.3%) group were above the 99th-percentile. Two patients from each group (external tournique occlusion group 11.1% vs. intraluminal-left anterior descending shunt group 11.8%) had peak values above 10-% coeficient of variation cutoff (p = 1). There were no significant differences in between both groups at all studied timepoints.

Conclusion

There was no protective effect of intraluminal shunting on myocardial damage compared to short-term tournique occlusion. It is upon the surgeon's discretion which method may preferrably be used to achieve a bloodless field in grafting of the non-occluded left anterior descending in minimally invasive coronary artery bypass.

Teaching off-pump coronary artery bypass surgery

Off-pump coronary artery revascularization requires a unique skill set and a different conduct of operation compared with on-pump coronary artery bypass. Not only must the surgeon perform anastomoses on the beating heart, but he/she must understand the hemodynamic consequences of cardiac positioning and stabilization, the effects of regional ischemia on hemodynamic function, contractility, and arrhythmias, and the importance of anesthesia and grafting sequence given variants of anatomy and clinical conditions. Given these differences, the ability to teach off-pump coronary artery bypass to residents and surgeons places unique demands on the teaching surgeon. In this article, we review the available literature about the safety and efficacy of teaching off-pump coronary artery bypass to residents, discuss the fundamentals for training residents, and review the future of simulation and new training paradigms and the impact this will have on current training methods.

Index laparoscopic cholecystectomy for acute admissions with cholelithiasis provides excellent training opportunities in emergency general surgery

BACKGROUND

There is minimal data on the outcome of early laparoscopic cholecystectomy (LC) for acute gallbladder disease when performed by trainees. This study assesses the outcomes of a policy of same admission LC incorporated into a surgical training programme in a major teaching hospital.

METHODS

447 index LCs performed over a 3-year period were reviewed retrospectively. The indications, operating surgeon, operating time, use of IOC, conversion rates, reasons for conversion and post-operative stay were analysed. Multivariate analysis of reasons for conversion was performed.

RESULTS

150 LCs were performed by consultants and 297 by registrars; 67 were performed by year 1-3 specialist registrars (SpR) and 230 by year 4-6 SpRs. The indications were biliary colic (n=7), acute cholecystitis (n=180), chronic cholecystitis (n=260), carcinoma (n=1). No difference was found in demographics, operating time (105 min Vs 115 min), use of IOC (34% Vs 29%; P=0.2) and post-operative stay (2 days Vs 1 day) between consultants and registrars. The conversion rates were higher for consultants compared to registrars (29 (19%) Vs 28 (9%), P=0.004). The overall conversion rate was 11%. There were no bile duct injuries. Predictors for conversion were CRP>50 at admission and acute cholecystitis.

CONCLUSION

In a teaching hospital setting most acute admission LCs (66%) were performed by trainees. A step wise training programme with active consultant supervision of all index LCs results in low morbidity, low conversion rates, and a short post-operative stay for acute gallbladder disease. This model of same admission cholecystectomy provides a good training opportunity in emergency general surgery.

Short- and midterm outcomes of coronary artery bypass surgery performed by surgeons in training

OBJECTIVE

The effect of training on outcomes in cardiac surgery is poorly studied. We aimed to study the results of coronary artery bypass grafting procedures performed by surgeons in training across our state with respect to short- and midterm postoperative outcomes.

METHODS

All coronary artery bypass grafting surgeries performed by trainee surgeons between July 2001 and December 2006 were compared with those performed by consultant surgeons using mandatory prospectively collected statewide data. Early mortality; prolonged ventilation or intensive care unit stay; return to operating theater for bleeding, stroke, myocardial infarction, or renal failure; and 5-year survival were compared using propensity score analysis.

RESULTS

A total of 7745 surgeries were included in this study. Trainees performed 983 (13%) surgeries. Trainee surgeries had longer perfusion and crossclamp times. Crude early postoperative outcomes were similar between trainee and consultant surgeries. After propensity score adjustment, early outcomes remained similar, with the exception of myocardial infarction (0.8% in trainee surgeries vs 0.4% in consultant surgeries, P = .046). Adjusted 1-, 3-, and 5-year survivals were similar between trainee and consultant surgeries: 95.3% versus 95.5%, 90.8% versus 92.0%, and 86.3% versus 87.1%, respectively.

CONCLUSION

Coronary artery bypass grafting performed by trainee surgeons within a supervised program is safe with acceptable short- and midterm outcomes.

Impact of residency status on perfusion times and outcomes for coronary artery bypass graft surgery

BACKGROUND

A price of training residents in cardiothoracic surgery is often perceived to be a loss in intraoperative efficiencies, leading to prolonged cardiopulmonary bypass and perfusion time. Because these indicators are also thought to adversely affect operative outcome, we investigated the association between residency training status, perfusion times, and outcomes.

METHODS

Using the Society of Thoracic Surgeons (STS) National Cardiac Database, we studied 369,906 CABG patients undergoing isolated coronary artery bypass graft (CABG) procedures during January 2002 through June 2005. Participating institutions were stratified by residency versus nonresidency status and by perfusion time categories and analyzed for association with clinical outcomes.

RESULTS

Overall, 57 (10%) of 594 STS participants had a residency training program. Residency programs had longer mean cross-clamp and perfusion times than nonresidency programs, 73.10 versus 67.44 minutes and 104.75 versus 98.00 minutes, respectively (p < 0.0001 for both. Longer perfusion time was significantly associated with higher operative mortality at the patient level. Unadjusted mortality rates were, however, similar for patients at residency and nonresidency programs (2.30% versus 2.27%), with an adjusted odds ratio of 0.96 (95% confidence interval, 0.84 to 1.09). Although perfusion times have not changed significantly over time between residency and nonresidency programs, mortality rates have significantly improved over time at each.

CONCLUSIONS

Residency programs have longer CABG perfusion times than nonresidency cardiothoracic surgery programs, but these differences are minor. Adjusted procedural outcomes at residency training programs are similar to those at nonresidency centers; thus, patients do not appear to be adversely impacted by the time costs of surgical training.

Acquiring proficiency in off-pump surgery: traversing the learning curve, reproducibility, and quality control

As the risk profile of patients considered for surgical revascularization worsens, the cumulative benefit of off-pump coronary artery bypass (OPCAB) over conventional coronary artery bypass grafting, in terms of lower morbidity and reduced healthcare costs, may increase. There is still resistance to the introduction of OPCAB surgery however, its practice is variable and surgical residents are rarely trained in these techniques. This article considers how the learning curve in OPCAB may be negotiated and prospectively monitored to ensure quality control. The evidence suggests that situations in which suitable senior expertise exists, OPCAB surgery can be introduced into surgical practice and safely taught to trainees without detriment to patients. This is achieved by a progressive increase in the complexity of the case mix and careful early supervision. The introduction of OPCAB has coincided with the increasing use of control charts as quality control tools. Performance monitoring provides reassurance that patients are not being put at risk during the introduction of OPCAB; control chart methods can be used prospectively for real time performance monitoring by consultant surgeons and residents alike. These techniques may ultimately be used to determine proficiency and accreditation. Increasing use of parallel training techniques, the development of structured training programs that encompass OPCAB and other new technologies in cardiac surgery, coupled with objective performance monitoring are warranted to meet the needs of a changing patient population.

Controversies in the Use of Intraluminal Shunts During Off-Pump Coronary Artery Bypass Grafting Surgery

Technical advances have made the performance of multivessel off-pump coronary artery bypass feasible. Snaring and intraluminal shunts are the techniques used for vascular control. Snaring provides a bloodless surgical field, is usually well tolerated by the patient, and is supported by years of clinical experience. Intraluminal shunts aim to achieve hemostasis at the arteriotomy site and to allow antegrade flow to provide myocardial protection. There are unresolved issues regarding whether shunts have a clinical benefit, do provide adequate flow to provide myocardial protection, and whether they cause significant endothelial damage. In this article, we have reviewed the literature to lend perspective to these issues.

How safe is it to train residents to perform off-pump coronary artery bypass surgery?

BACKGROUND

The technique of off-pump coronary artery bypass graft (OPCABG) surgery differs considerably from on-pump CABG. This study investigates the impact of surgical training on clinical outcome in patients undergoing OPCABG.

METHODS

All 251 OPCABG cases performed by one service over an 18-month period were analyzed. The 83 operations (33%) performed by two trainees under supervision were compared with the 168 operations (67%) performed by an experienced consultant surgeon. Patient and disease characteristics, intraoperative and postoperative data, morbidity and mortality were analyzed using univariate and multivariate analysis. Data were extracted from a prospective database.

RESULTS

Patients operated on by the consultant were more likely to have had unstable angina (p = 0.003, odds ratio [OR] = 3.5), impaired left ventricular function (ejection fraction < 0.3; p = 0.005, OR = 2.4), or previous cardiac surgery (p = 0.03). They were more likely to receive three or more grafts (p = 0.017, OR = 2.0). Operative mortality was 2.4% (consultant) and 0% (trainees; p = 0.31). Postoperative morbidity, such as reoperation for bleeding (consultant 3% versus trainees 1.2%), stroke (0.6% versus 1.2%), and hemofiltration (3.6% versus 0%) was similar between the two patient groups. Stay in the intensive care unit was not significantly different in the two groups.

CONCLUSIONS

In our experience, trainee surgeons are less likely to operate on patients with unstable angina or cardiac dysfunction. Operative morbidity and mortality are, however, similar in patients operated on by either an experienced consultant surgeon or trainees. We believe OPCABG can be taught safely to trainees under supervision.

Effect of training in mitral valve repair surgery on the early and late outcome

BACKGROUND

Preservation of the native mitral valve provides important advantages over valve replacement. The aim of this study was to evaluate the effect of training for mitral valve repair on the outcome.

METHODS

Between 1997 and 2004, 471 patients underwent mitral valve repair procedures in a single firm. Of these procedures, 300 (64%) were performed by a consultant (TJS) (consultant group) and 171 (36%) by trainees supervised by the same consultant (trainees group).

RESULTS

Atrial fibrillation was more prevalent in the consultant group (p = 0.02) but there were no significant differences in the demographics, etiology of mitral regurgitation, and other comorbidity between the groups. Posterior leaflet prolapse was more prevalent in the trainees group (p < 0.0001) and anterior leaflet prolapse (p < 0.0001), bileaflet prolapse (p = 0.003), and Barlow's syndrome (p = 0.0003) in the consultant group. The consultant performed a higher proportion of concomitant coronary artery bypass grafting (p = 0.04), aortic valve replacement (p = 0.02), procedures, and nonelective cases (p = 0.03) with shorter bypass (p = 0.01) and ischemic times (p = 0.0004) than trainees. The complication rate was similar in the two groups (26% vs 22%), but the consultant had a higher operative mortality than the trainees (5% vs 0.6%) (p = 0.01). A similar proportion in the two groups exhibited recurrent mitral regurgitation (8% vs 9%). Kaplan-Meier five-year freedom from reoperation (95.6 +/- 1.6 vs 95.7 +/- 2.2%) (p = 0.7) and survival (82 +/- 4% vs 88 +/- 4%) (p = 0.09) were similar in the two groups.

CONCLUSIONS

With appropriate patient selection, cardiothoracic trainees can be taught mitral valve repair surgery without a negative effect on the early or late outcome.

L'enseignement de la chirurgie influence-t-il les résultats des cures de hernies de l'aine ?

AIMS

To evaluate influence of surgical experience on inguinal hernia repair.

PATIENTS

From 1997 to 2003, 380 patients (mean age 55 years old) with primary unilateral inguinal hernia were treated by Lichtenstein technique.

METHODS

In this retrospective study, surgeons were classified in three groups: group 1: hernia repair was performed by an experimented surgeon (consultant or senior registrar) and a young surgical trainee (resident) (161 cases); group 2: surgery was performed by a junior surgeon (resident) under the control of an experimented surgeon (135 cases) and in the group 3 (84 cases), Lichtenstein technique was performed by two residents, alone, supervised by an experimented surgeon, in the operative room. Evaluation criterion were operative time, hospital stay, morbidity, time to return to normal and professional activities, recurrences and chronic pain with a follow up of, at least, 2 years.

RESULTS

The three groups were comparable in term of socio economic data, hernia and follow up. The only significant (P=0.01) difference concern operative time which increased from 20% for group 2 and 3 (residents) compared to the group 1. There was also no difference between junior and senior resident.

CONCLUSION

Lichtenstein hernia repair should be performed by young surgeon in training alone in condition of precise teaching organization and experimented surgeon supervision. For patient, in this condition, there is no trouble in term of surgical results.

Monitoring the performance of residents during training in off-pump coronary surgery

OBJECTIVE

Control charts (eg, cumulative sum charts) plot changes in performance with time and can alert a surgeon to suboptimal performance. They were used to compare performance of off-pump coronary artery bypass surgery between a consultant and four resident surgeons and to compare performance of off-pump coronary artery bypass surgery and conventional coronary artery bypass grafting within surgeons.

METHODS

Data were analyzed for consecutive patients undergoing coronary artery bypass grafting who were operated on by one consultant or one of four residents. Conversions were analyzed by intention to treat. Perioperative death or one or more of 10 adverse events constituted failure. Predicted risks of failure for individual patients were derived from the study population. Variable life-adjusted displays and risk-adjusted sequential probability ratio test charts were plotted.

RESULTS

Data for 1372 patients were analyzed; 769 of the procedures were off-pump coronary artery bypass operations (56.0%). The consultant operated on 382 patients (293 off-pump, 76.7%), and the residents operated on 990 (474 off-pump, 47.9%). Patients operated on by residents tended to be older, more obese, more likely to require an urgent operation, and more likely to need a circumflex artery graft but less likely to have triple-vessel disease. There were 7 conversions (consultant 5, residents 2). The overall failure rate was 8.5% (9.2% for consultant's operations and 8.2% for residents' operations), including 10 deaths (0.7%). Predicted and observed risks of failure were similar for all five surgeons. After 100 off-pump coronary artery bypass operations, performance was the same or better for the residents as for the consultant. For all surgeons, performance was the same or better for off-pump as for conventional coronary artery bypass grafting.

CONCLUSIONS

Off-pump coronary artery bypass surgery can be safely taught to cardiothoracic residents. Implementation of continuous performance monitoring for residents is practicable.

Training Residents in Mitral Valve Surgery

BACKGROUND

The safety of training residents in complex procedures has not been elucidated. In particular, the impact of resident-performed mitral valve surgery on patient outcomes is unknown.

METHODS

All mitral valve procedures performed by residents between 1998 and 2003 were compared with those performed by staff surgeons. Operative mortality and a composite morbidity (reoperation for bleeding, myocardial infarction, infection, stroke, or ventilation > 24 hours) were compared using multivariate analysis. Individual outcomes were compared with the use of propensity scores.

RESULTS

There were 1020 cardiac surgeries performed by residents, including 165 mitral valve procedures (86 replacements, 79 repairs). In the same period, the staff surgeons performed 261 mitral procedures. Crude operative mortality for isolated mitral procedures was 5.4% and 4.7% (resident and staff, respectively, p = 1.00). Mitral valve repair including combined procedures had an operative mortality of 3.8% and 4.3% (resident and staff, respectively, p = 1.00). The composite morbidity outcome was 29.7% and 35.3% for resident and staff-performed cases, respectively (p = 0.24). In multivariate analysis, resident was not associated with the adverse outcomes examined (OR 0.80, 95% CI, 0.47, 1.37). The incidence of major adverse outcomes for propensity score-matched mitral valve cases, including combined procedures, were similar between residents and staff, respectively: mortality, 7.4% versus 8.7% (p = 0.67), stroke, 4.0% versus 6.7% (p = 0.30), and reoperation for bleeding, 4.7% versus 9.4% (p = 0.11).

CONCLUSIONS

There were no significant differences in morbidity and mortality in patients undergoing mitral valve surgery between resident and staff surgeons. It is possible to train residents to perform complex cardiac cases without adversely affecting outcomes.

Trainees operating on high-risk patients without cardiopulmonary bypass: a high-risk strategy?

BACKGROUND

The safety of teaching off-pump coronary artery bypass grafting to trainees is best tested in high-risk patients, who are more likely to experience significant morbidity after surgery. This study compared outcomes of off-pump coronary artery bypass grafting operations performed by consultants and trainees in high-risk patients.

METHODS

Data for consecutive patients undergoing off-pump coronary artery bypass grafting were collected prospectively. Patients satisfying at least one of the following criteria were classified as high-risk: age older than 75 years, ejection fraction less than 0.30, myocardial infarction in the previous month, current congestive heart failure, previous cerebrovascular accident, creatinine greater than 150 micromol/L, respiratory impairment, peripheral vascular disease, previous cardiac surgery, and left main stem stenosis greater than 50%. Early morbidity, 30-day mortality, and late survival were compared.

RESULTS

From April 1996 to December 2002, 686 high-risk patients underwent off-pump coronary artery bypass grafting revascularization. Operations by five consultants (416; 61%) and four trainees (239; 35%) were the focus of subsequent analyses. Nine visiting or research fellows performed the other 31 operations. Prognostic factors were more favorable in trainee-led operations. On average, consultants and trainees grafted the same number of vessels. There were 18 (4.3%) and 5 (1.9%) deaths within 30 days, and 14 (3.4%) and 5 (1.9%) myocardial infarctions in consultant and trainee groups, respectively. After adjusting for imbalances in prognostic factors, odd ratios for almost all adverse outcomes implied no increased risk with trainee operators, although patients operated on by trainees had longer postoperative stays and were more likely to have a red blood cell transfusion. Kaplan-Meier cumulative mortality estimates at 24-month follow-up were 10.5% (95% confidence interval, 7.7% to 14.2%) and 6.4% (95% confidence interval, 3.8% to 10.9%) in consultant and trainee groups, respectively (hazard ratio = 0.60 [95% confidence interval, 0.37 to 0.99]; p = 0.05).

CONCLUSIONS

Off-pump coronary artery bypass grafting surgery in high-risk patients can be safely performed by trainees.

A simple technique of introducing intracoronary shunts for off-pump coronary artery bypass surgery

We describe a simple technique of introducing intracoronary shunts for off-pump coronary artery bypass. This technique, with an aid of micro-bulldog clamp, provides both a test clamp with ischemic preconditioning effect, and a quick and easy introduction of intracoronary shunt, giving a clear visualization of coronary anastomosis site and distal coronary artery perfusion. We recommend this technique as another effective modality in off-pump coronary artery bypass surgery.

Effects of training and supervision on recurrence rate after inguinal hernia repair

Background

There is little information about the effects of operative experience and supervision of trainees on outcome in inguinal hernia surgery, one of the cornerstone operations of basic surgical training.

Methods

All primary inguinal hernia repairs carried out between 1994 and 2001 were registered prospectively in the Lothian Surgical Audit database. Subsequent problems that required re-referral were identified from this database. Patients who required reoperation for recurrence a median of 3 (range 1–7) years after surgery were identified.

Results

Some 4406 repairs, including 90 recurrences (2·0 per cent), were identified. Open mesh, open sutured and laparoscopic techniques were employed. Senior trainees (registrars and senior registrars) had similar recurrence rates to consultants; supervision did not affect outcome. Junior trainees (senior house officers) had similar recurrence rates to consultants as long as they were supervised by either a senior trainee or a consultant. Unsupervised junior trainees had unacceptably high recurrence rates (open mesh: relative risk (RR) 21·0 (95 per cent confidence interval (c.i.) 7·3 to 59·9), P &lt; 0·001; open sutured: RR 16·5 (95 per cent c.i. 7·2 to 37·8), P &lt; 0·001).

Conclusion

Senior trainees may operate independently and supervise junior trainees, with recurrence rates equal to those of consultant surgeons. Junior trainees should be encouraged and given more practice in inguinal hernia repair with appropriate supervision.

Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting

BACKGROUND

Uncertainty continues to surround the relative benefits and harms of conventional coronary artery bypass grafting (CABG) and off-pump coronary artery bypass grafting (OPCABG). Possible reasons are that high-quality studies have not comprehensively examined relevant patient outcomes and have enrolled a limited range of patients. Some studies may have been too small to detect clinically important differences in patient outcomes. The present study addresses these issues using meta-analysis.

METHODS

We comprehensively retrieved randomized and nonrandomized controlled studies according to predetermined criteria. We performed meta-analyses for each outcome and empirically determined whether potential biases that might result from differences in study design or patient characteristics actually biased a study's results. We also conducted sensitivity analyses and tested for publication bias.

RESULTS

Rates of perioperative myocardial infarction, stroke, reoperation for bleeding, renal failure, and mortality were lower after OPCABG than after CABG. Reductions in length of hospital stay, atrial fibrillation, and wound infection were also associated with OPCABG, but statistically significant differences among study results for these outcomes could not be explained by available information. Midterm (3 to 25 months) angina recurrence did not appear to differ between treatments; a trend was noticed toward lower reintervention rates with CABG, and a trend toward lower overall mortality with OPCABG, at least when performed at experienced centers. These midterm outcome results require confirmation.

CONCLUSIONS

Off-pump coronary artery bypass grafting appears to reduce length of hospital stay, operative morbidity, and operative mortality relative to on-pump CABG. More studies are required before firm conclusions can be drawn concerning the effect of OPCABG on midterm mortality, angina recurrence, and repeat intervention.

Multivessel off-pump coronary artery bypass grafting can be taught to trainee surgeons

BACKGROUND

Although Off-Pump Coronary Artery Bypass (OPCAB) surgery is being increasingly explored and practised in many cardiac units worldwide, there have been only few reports documenting the training of surgeons in this new technique. The purpose of this study was to address the reproducibility of the OPCAB in a unit where this technique is used extensively.

METHODS

Registry data, notes, and charts of 64 patients who were operated on by four trainee cardiac surgeons over a period of thirteen months at Harefield Hospital, were reviewed retrospectively. These trainees were part of an accredited training program for cardiothoracic training and were trained by a single consultant trainer in a cardiac unit after it had an established recent experience in performing nonselective OPCAB for all in-coming patients. Five (7.8%) patients (with 17 distal anastomoses) consented and underwent early postoperative angiography to check the quality of the grafts and anastomoses.

RESULTS

The mean age of the study patients was 65.6 and the mean Parsonnet score was 9.4. There was a mean of 2.9 grafts per patient and circumflex territory anastomoses were performed in 48 (75%) patients. No operation required conversion to Cardiopulmonary Bypass (CPB). Angiography of the five patients revealed 17 satisfactory (100%) distal anastomoses.

CONCLUSION

With appropriate training, it is possible for trainees to learn OPCAB and perform multivessel revascularization in relatively high-risk patients with good results.

Off pump coronary surgery in Argentina

Benetti and Buffolo repopularized off pump surgery (OPCAB), developing the technique and using it in all arteries of the heart with veins and arteries in the different clinical situations inclusive in patients with acute myocardial infarction. Despite my personal experience with more than 2500 cases of off pump conducted in my country and different places of the world during the teaching and education process. In 1997, we started a new approach (xiphoid) to perform the ambulatory off pump surgery (ie, discharging the patient after 24 hours of the operation). Between October 1997 and December 2001, 78 patients were operated on through the xiphoid (lower sternotomy approach). The mean age of the patients was 64.2 years (range 45-78), there were 70% males, and all were class 3-4 according to the Canadian Association. The mortality of the 78 patients was 1% (1 patient), conversion to complete sternotomy was 1% (1 patient), and perioperative infarction was 1% (1 patient). From the 16 patients restudied immediately the patency rate was 100% G A anastomosis. Six patients from this group were discharged during the next 24 hours after the operation. The mortality was 0% and perioperative infarction 0%. With the xiphoid (lower sternotomy approach) we had good initial experience in discharging the patients during the first day. Using the technology that already exists, it is possible to perform multiple arterial grafts with this approach and in the future expand the concept of ambulatory coronary surgery in multiple vessels.

The evolution of training in off-pump coronary surgery in a single institution

BACKGROUND

This study analyses the development of off-pump coronary artery bypass (OPCAB) surgery training at a single institution, and compares the early and midterm clinical outcomes of OPCAB and conventional coronary artery bypass grafting (CABG) procedures performed by trainees with or without direct consultant cardiothoracic surgeon supervision.

METHODS

Analysis was undertaken on data prospectively recorded on a computer database (Patient Analysis and Tracking System). Of the 2,422 CABG operations performed between January 1999 and December 2001, 969 (40%) were carried out by trainees either off pump (422) or on pump (547).

RESULTS

Although the total number of CABG operations performed by trainees remained constant, there was a significant increase in the number of OPCAB operations during the study period compared with conventional CABG, as well as an increase in the average number of grafts per patient in the OPCAB group (both p < 0.05). Furthermore, a significant trend towards using two or more arterial conduits in the OPCAB group was observed in the study period. The number of OPCAB operations performed by trainees as independent operators without direct consultant supervision also increased significantly (p < 0.05). Early and midterm clinical outcomes were similar between patients operated by trainees on pump or off pump as independent operators versus under direct consultant supervision.

CONCLUSIONS

The significant increase in OPCAB operations performed by trainees as independent operators or under direct consultant supervision, as well as the increase in the number of grafts per patient and arterial conduits used for myocardial revascularization, demonstrate a progression of training in beating heart surgery for cardiothoracic trainees. Improvements in the techniques have made it safe to teach trainees off-pump multivessel coronary artery revascularization.

Is it safe to train residents to perform cardiac surgery?

BACKGROUND

The impact of surgical training on patient outcomes in cardiac surgery is unknown.

METHODS

All cases performed by residents from 1998 to 2001 were compared to staff surgeon cases using prospectively collected data. Operative mortality and a composite morbidity of: reoperation for bleeding perioperative myocardial infarction, infection, stroke, or ventilation more than 24 hours were compared using multivariate analysis.

RESULTS

Four residents performed 584 cases. The cases were as follows: coronary artery bypass grafting (CABG), 366 cases; aortic valve replacement (AVR) with or without CABG (AVR +/- CABG), 86 cases; mitral valve replacement, 31 cases; mitral valve repair, 25 cases; thoracic aneurysm/dissection, 22 cases; aortic root, 20 cases; transplantations, 14 cases; and adult congenital defect repairs, 20 cases. There were 2,638 CABGs and 363 AVR +/- CABG performed by the staff during the same period. Crude operative mortality in CABG patients was 2.5% (resident) and 2.9% (staff) (p = 0.62). In multivariate analysis, resident was not associated with operative mortality odds ratio (OR) of 0.59 (p = 0.19). Resident cases had a higher incidence of the composite morbidity outcome for CABG cases (19.4% vs 13.6% for staff; p = 0.003). However, in multivariate analysis, resident was not associated with increased morbidity (OR = 1.23, p = 0.16). The AVR +/- CABG crude mortality was 3.6% (resident) and 2.8% (staff) (p = 0.69). Because of the small number of cases (n = 447), operative mortality was combined with the composite morbidity outcome for the AVR +/- CABG model. In all, 16.7% of resident cases and 19.8% of staff cases had the composite outcome or died (p = 0.51). In multivariate analysis resident was not associated with this outcome (OR = 0.74, p = 0.35).

CONCLUSIONS

In this analysis of our experience with residency training, the operative morbidity and mortality in CABG and AVR patients was similar for residents and staff. Training residents to perform cardiac surgery appears to be safe.

Intracoronary shunts reduce transient intraoperative myocardial dysfunction during off-pump coronary operations

BACKGROUND

This study investigated the hemodynamic changes in patients undergoing multiple vessel beating heart coronary revascularization in the presence or absence of an intracoronary shunt.

METHODS

Forty patients were randomized to off-pump with a shunt (n = 20) or with the proximal coronary artery occluded by a soft snare (n = 20). Hemodynamic measurements were recorded at base line, during construction, and after completion of each distal anastomosis.

RESULTS

Grafting of the left anterior descending coronary artery anastomosis was associated with a significant decrease in stroke volume, cardiac index, and mean arterial pressure, and an increase in pulmonary capillary wedge pressure and systemic vascular resistance in the snare but not in the shunt group. During grafting of the posterior descending coronary artery there was a marked decrease in stroke volume and cardiac index, and an increase in central venous pressure in both groups, and an increase in heart rate, mean pulmonary arterial pressure, pulmonary capillary wedge pressure, and systemic vascular resistance only in the snare group. The most extensive changes were observed during the circumflex coronary artery anastomosis with a reduction in stroke volume, cardiac index, and mean arterial pressure, and an increase in central venous pressure, pulmonary capillary wedge pressure, pulmonary arterial pressure, and systemic vascular resistance in both groups. In all settings, these changes were transient and recovered after the heart was returned to its anatomical position in the shunt group, whereas stroke volume and cardiac index remained reduced, and systemic vascular resistance was elevated in all settings in the snare group.

CONCLUSIONS

Stabilization of the left anterior descending coronary artery to perform the anastomosis resulted in temporary hemodynamic changes, which are prevented by the use of an intracoronary shunt. The hemodynamic deterioration during the construction of the posterior descending coronary artery and circumflex coronary artery anastomoses is transient in the shunt group, whereas the snaring technique is associated with an impairment of early functional recovery.

Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials

BACKGROUND

Although no randomised controlled trial has assessed the midterm effects of coronary-artery bypass surgery on the beating heart, this technique is being used in more and more patients. We did two randomised trials to compare the short-term morbidity associated with off-pump and on-pump myocardial revascularisation. Our aim was to pool the results to assess midterm outcomes.

METHODS

From March, 1997, to November, 1999, we randomly allocated 200 patients to off-pump and 201 to on-pump coronary surgery. In Beating Heart Against Cardioplegic Arrest Study (BHACAS) 1, we excluded patients who had had myocardial infarction in the past month or who required grafting of the circumflex artery distal to the first obtuse marginal branch. In BHACAS 2, we included such patients. Primary outcomes were all-cause mortality and cardiac-related events at midterm follow-up (1-3 years). Analysis was by intention to treat.

FINDINGS

Analyses of combined data from both trials showed the following risk differences with off-pump compared with on-pump surgery: atrial fibrillation -25% (95% CI -33% to -16%); chest infection -12% (-19% to -5%); inotropic requirement -18% (-25% to -10%); transfusion of red blood cells -31% (-41 to -21); and hospital stay longer than 7 days -13% (-21 to -5). Mean follow-up was 25 0 months (SD 9.1) for BHACAS 1 and 13.7 months (5 5) for BHACAS 2. Four (2%) of 200 patients in the off-pump groups died from any cause, compared with seven (3%) of 201 in the on-pump group (hazard ratio 0.57, 95% CI 0.17-1.96). 33 (17%) of 200 patients in the off-pump group died or had a cardiac-related event, compared with 42 (21%) of 201 in the on-pump group (0.78, 0 49-1.22).

INTERPRETATION

Off-pump coronary surgery significantly lowers in-hospital morbidity without compromising outcome in the first 1-3 years after surgery compared with conventional on-pump coronary surgery.