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Alsagheir A, Koziarz A, Belley-Côté EP, Whitlock RP. Expertise-based design in surgical trials: a narrative review. Can J Surg 2021; 64:E594-E602. [PMID: 34759044 PMCID: PMC8592777 DOI: 10.1503/cjs.008520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 12/29/2022] Open
Abstract
Randomized controlled trials (RCTs) are the most robust study design for evaluating the safety and efficacy of a therapeutic intervention. However, their internal validity are at risk when evaluating surgical interventions. This review summarizes existing expertise- based trials in surgery and related methodological concepts to guide surgeons performing this work. We provide caseloads required to reach the learning curve for various surgical interventions and report criteria for expertise from published and unpublished expertise-based trials. In addition, we review design and implementation concepts of expertise-based trials, including recruitment of surgeons, crossover, ethics, generalizability, sample size and definitions for learning curve. Several RCTs have used an expertise-based design. We found that the majority of definitions used for expertise were vague, heterogeneous, and inconsistent across trials evaluating the same surgical intervention. Statistical methods exist to adjust for the learning curve; however, there is limited guidance. We developed the following criteria for surgical expertise for future trials: 1) decide on the proxy to be used for the learning curve, and 2) assess eligible surgeons by comparing their performance to the previously defined expertise criteria.
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Affiliation(s)
- Ali Alsagheir
- From the Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ont. (Alsagheir, Whitlock); the Faculty of Medicine, University of Toronto, Toronto, Ont. (Kozirarz); the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ont. (Belley-Côté, Whitlock); and the Department of Medicine, McMaster University, Hamilton, Ont. (Belley-Côté)
| | - Alex Koziarz
- From the Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ont. (Alsagheir, Whitlock); the Faculty of Medicine, University of Toronto, Toronto, Ont. (Kozirarz); the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ont. (Belley-Côté, Whitlock); and the Department of Medicine, McMaster University, Hamilton, Ont. (Belley-Côté)
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Oxidative Stress in Patients before and after On-Pump and Off-Pump Coronary Artery Bypass Grafting: Relationship with Syntax Score. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:3315951. [PMID: 34381560 PMCID: PMC8352695 DOI: 10.1155/2021/3315951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/29/2021] [Accepted: 07/19/2021] [Indexed: 12/02/2022]
Abstract
Objective Coronary artery bypass grafting (CABG) represents the significant source of increased oxidative stress (OS). We aimed to follow the OS status parameters (i.e., ischemia-modified albumin (IMA), malondialdehyde (MDA), superoxide anion, prooxidant-antioxidant balance (PAB), total oxidant status (TOS), total antioxidant status (TAS), and superoxide-dismutase (SOD)) change through the predefined study times in two different surgical procedures, i.e., cardiopulmonary bypass (CPB) and off-pump coronary artery bypass grafting (OPCAB). Additionally, we aimed to investigate those OS status parameters in specific study times according to SYNTAX score (SS), an established angiographic score for evaluating the extensity and severity of coronary artery disease. Patients and Methods. A total of 107 patients that were planned to undergo CABG were included (i.e., 47 patients in OPCAB and 60 patients in CPB group). Blood samples were taken at 6 time intervals: before surgery (t1), immediately after intervention (t2), 6 h (t3), 24 h (t4), 48 h (t5), and 96 h after termination of the operation (t6). Results IMA levels were higher in CPB than that in OPCAB baseline and rose in CPB group in t2 point. TOS decreased in both study groups, compared to baseline values, but without statistical significance. Superoxide anion and PAB significantly increased in t3-t6 study times, in both groups. MDA significantly increased only in CPB group in t5 and t6 interval. MDA was significantly higher in CPB group compared to OPCAB in t6 study point. CPB patients had significantly lower TAS compared to OPCAB patients at the beginning and in t2 and t3 study points. They also had significantly lower SOD activities compared to OPCAB, baseline, and in several study points. Moreover, TAS, SOD, and TAS/TOS ratio were significantly lower, whereas PAB and TOS/TAS were significantly higher in patients with high SS compared to corresponding groups. SOD activity, IMA, and TAS level were the best predictors of high SS. Conclusion CPB patients were in more severe ischemia baseline than OPCAB group and IMA rose in CPB patients immediately after the surgery end, but not later. Also, the antioxidant status was significantly lower, whereas the prooxidant status was significantly higher in patients with high SS compared to corresponding groups. SOD activity, IMA, and TAS level were the best predictors of CAD (as determined with SS), showing that SOD and IMA had very good discriminatory capability towards higher SS status.
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Kowalewski M, Jasiński M, Staromłyński J, Zembala M, Widenka K, Brykczyński M, Skiba J, Zembala M, Bartuś K, Hirnle T, Dziembowska I, Knapik P, Tobota Z, Maruszewski B, Suwalski P. On-Pump vs Off-Pump coronary artery bypass surgery in atrial fibrillation. Analysis from the polish national registry of cardiac surgery procedures (KROK). PLoS One 2020; 15:e0231950. [PMID: 32320434 PMCID: PMC7176119 DOI: 10.1371/journal.pone.0231950] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 04/03/2020] [Indexed: 12/13/2022] Open
Abstract
Background No single randomized study has ever before addressed the safety of On-Pump coronary artery bypass grafting (CABG) vs Off-Pump CABG in the setting of atrial fibrillation (AF) and data from small observational samples remain inconclusive. Methods and findings Procedural data from KROK (Polish National Registry of Cardiac Surgery Procedures) were retrospectively collected. Of initial 188,972 patients undergoing CABG, 7,913 presented with baseline AF (76.0% men, mean age 69.1±8.2) and underwent CABG without concomitant valve surgery between 2006–2019 in 37 reference centers across Poland. Mean follow-up was 4.7±3.5 years (median 4.3 IQR 1.7–7.4). Cox proportional hazards models were used for computations. Of included patients, 3,681 underwent On-Pump- (46.52%) as compared to 4,232 (53.48%) who underwent Off-Pump CABG. Patients in the latter group less frequently were candidates for complete revascularization (P<0.001). In an unadjusted comparison, On-Pump surgery was associated with significantly worse survival at 30 days: HR: 1.28; 95%CIs: (1.07–1.53); P = 0.007. Along the 13-year study period, the trend shifted in favor of On-Pump CABG: HR: 0.92; 95%CIs: (0.83–0.99); P = 0.005. After rigorous propensity matching, 636 pairs were identified. The direction and magnitude of treatment effects was sustained with HRs of 3.58; (95%CIs: 1.34–9.61); p = 0.001 and 0.74; [95%CIs: 0.56–0.98]; p = 0.036) for 30-day and late mortality respectively. Conclusions Off-Pump CABG offered 30-day survival benefit to patients undergoing CABG surgery and presenting with underlying AF. On-Pump CABG was associated with significantly improved survival at long term.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
- * E-mail:
| | - Marek Jasiński
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Jakub Staromłyński
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marian Zembala
- Department of Cardiac, School of Medicine with the Division of Dentistry in Zabrze, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Zabrze, Poland
- Division of Cardiac Surgery, Heart and Lung Transplantation and Mechanical Circulatory Support, Silesian Center for Heart Disease, Zabrze, Poland
| | - Kazimierz Widenka
- Clinical Department of Cardiac Surgery, District Hospital no. 2, University of Rzeszów, Poland
| | | | - Jacek Skiba
- Department of Cardiac Surgery, 4 Military Clinical Hospital Centre for Heart Diseases, Wroclaw, Poland
| | - Michał Zembala
- Department of Cardiac, School of Medicine with the Division of Dentistry in Zabrze, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Zabrze, Poland
- Division of Cardiac Surgery, Heart and Lung Transplantation and Mechanical Circulatory Support, Silesian Center for Heart Disease, Zabrze, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Tomasz Hirnle
- Department of Cardiosurgery, Medical University of Bialystok, Bialystok, Poland
| | - Inga Dziembowska
- Department of Pathophysiology, Faculty of Pharmacy, Collegium Medicum, Nicolaus Copernicus University, Toruń, Poland
| | - Piotr Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Zdzisław Tobota
- Department of Pediatric Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | - Bohdan Maruszewski
- Department of Pediatric Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
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Jayaraman DK, Mehla S, Joshi S, Rajasekaran D, Goddeau RP. Update in the Evaluation and Management of Perioperative Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:76. [DOI: 10.1007/s11936-019-0779-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Zhu P, Chen A, Wang Z, Ye X, Zhou M, Liu J, Zhao Q. Long-term outcomes of multiple and single arterial off-pump coronary artery bypass grafting. J Thorac Dis 2019; 11:909-919. [PMID: 31019780 PMCID: PMC6462725 DOI: 10.21037/jtd.2019.01.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 01/17/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND To compare the clinical outcomes between multiple arterial (MA) and single arterial (SA) off-pump coronary artery bypass grafting (OPCAB) when applied to left main coronary disease or three-vessel disease. METHODS A total of 537 patients with left main coronary disease or three-vessel disease underwent MA OPCAB (n=114) or SA OPCAB (n=423) in our center from January 2006 to December 2008. The propensity score matching (PSM) was used to obtain the risk-adjusted outcome. Both the perioperative and long-term results were analyzed. RESULTS The median follow-up time was 117 months (interquartile range, 110 to 128 months). There was no statistical difference in postoperative mortality and the volume of drainage. The intensive care unit (ICU) length of stay (LOS) of the MA group was shorter than that of the SA group {1 [1-2] vs. 2 [1-3], P=0.001). In the long term, the mortality (5.7% vs. 17.5%, P=0.006), cardiac mortality (1.0% vs. 8.8%, P=0.008), fatal myocardial infarction (MI) rate (0.0% vs. 6.1%, P=0.015) and incidence of readmission for heart failure (19.8% vs. 37.7%, P=0.003) were lower in the MA group than in the SA group. The distributions of NYHA class (P<0.001) and CCS class (P<0.001) were better in the MA group than in the SA group. There was no significant difference in other outcomes. These results were consistent with the K-M curves of freedom from the adverse events. CONCLUSIONS MA OPCAB was as safe as SA OPCAB, providing better perioperative recovery and better long-term clinical outcomes in the treatment of left main coronary disease or three-vessel disease.
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Affiliation(s)
- Pengxiong Zhu
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Anqing Chen
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhe Wang
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xiaofeng Ye
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Mi Zhou
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jun Liu
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Qiang Zhao
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Calafiore AM, Di Mauro M. On-pump or off-pump? Right debate, but wrong question! J Thorac Cardiovasc Surg 2018; 156:984-985. [DOI: 10.1016/j.jtcvs.2018.03.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 03/23/2018] [Indexed: 01/05/2023]
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Gaudino M, Angelini GD, Antoniades C, Bakaeen F, Benedetto U, Calafiore AM, Di Franco A, Di Mauro M, Fremes SE, Girardi LN, Glineur D, Grau J, He G, Patrono C, Puskas JD, Ruel M, Schwann TA, Tam DY, Tatoulis J, Tranbaugh R, Vallely M, Zenati MA, Mack M, Taggart DP. Off-Pump Coronary Artery Bypass Grafting: 30 Years of Debate. J Am Heart Assoc 2018; 7:e009934. [PMID: 30369328 PMCID: PMC6201399 DOI: 10.1161/jaha.118.009934] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
| | | | | | | | | | | | - Antonino Di Franco
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
| | | | - Stephen E. Fremes
- Schulich Heart CentreSunnybrook Health ScienceUniversity of TorontoCanada
| | - Leonard N. Girardi
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
| | - David Glineur
- Division of Cardiac SurgeryOttawa Heart InstituteOttawaCanada
| | - Juan Grau
- Division of Cardiac SurgeryOttawa Heart InstituteOttawaCanada
| | - Guo‐Wei He
- TEDA International Cardiovascular HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeTianjinChina
| | - Carlo Patrono
- Department of PharmacologyCatholic University School of MedicineRomeItaly
| | - John D. Puskas
- Department of Cardiovascular SurgeryIcahn School of Medicine at Mount SinaiNew York CityNY
| | - Marc Ruel
- University of Ottawa Heart InstituteOttawaCanada
| | | | - Derrick Y. Tam
- Schulich Heart CentreSunnybrook Health ScienceUniversity of TorontoCanada
| | - James Tatoulis
- Department of SurgeryUniversity of MelbourneParkvilleAustralia
| | - Robert Tranbaugh
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York CityNY
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