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

Assessing the benefits of anaortic off-pump coronary artery bypass grafting

Introduction

The procedure called the "aorta no-touch" (NT) or anaortic technique in off-pump coronary artery bypass grafting (OPCAB) is designed to reduce the perioperative risk of stroke. We have observed an increased frequency of anaortic OPCAB procedures at our institution. The main purpose of the present study is to investigate the effectiveness of anaortic OPCAB in reducing the perioperative risk of stroke.

Methods

From April 2011 to July 2023, a total of 2,236 patients underwent isolated OPCAB at our single center. The patients were divided into the anaortic group (NT, n = 762) and the aortic group (A, n = 1,474). The NT group was propensity score-matched (PSM) with the A group at a 1:1 ratio (NT n = 640; A n = 640), and matching was performed based on 26 covariates with preoperative clinical characteristics.

Results

In both the unmatched and matched cohorts of the NT and A groups, there were no significant differences observed in new stroke rates (NT vs. A; unmatched, 1.0% vs. 1.2%, p = 0.624; matched, 0.9% vs. 1.3%, p = 0.789). The univariable logistic analysis did not identify the anaortic technique as an independent factor negatively associated with new stroke events (OR = 0.81, 95% CI = 0.35-1.86, p = 0.624).

Conclusion

The present study did not find the anaortic technique to reduce the perioperative risk of stroke in OPCAB. Hence, further large studies are needed to identify patient cohorts in which anaortic OPCAB is significantly beneficial.

Experience, exposure, and attitudes regarding off-pump coronary artery bypass grafting techniques in US cardiothoracic surgical residents: Results of a survey

Background

We sought to determine the current level of exposure to and interest in off-pump coronary artery bypass and beating heart surgery techniques regarding cardiothoracic surgical residents in the United States.

Methods

An email survey consisting of 6 questions was sent to all cardiothoracic surgery residents of approved cardiothoracic training programs in the United States. The survey was emailed using the Qualtrics XM cloud-based survey platform. When the email responses were received, the answers to the survey questions were tabulated by the Qualtrics software and the resident's institution and year of graduation from their residency was noted.

Results

Of 400 surveys sent, we received 99 responses for a response rate of 25%. A total of 78% of cardiothoracic surgery residents reported that they are at programs that do off-pump coronary artery bypass or beating heart surgery infrequently, noting that these cases are done in less than 5% of the coronary artery bypass graftings to which they are exposed. A total of 51% responded that they do not feel comfortable with off-pump coronary artery bypass grafting under any circumstances. A total of 49% reported some comfort with the technique with most of these respondents noting that they would do off-pump coronary artery bypass or beating heart surgery on a selective basis if the clinical situation arose and 4% plan to do off-pump coronary artery bypass routinely. Exposure to off-pump coronary artery bypass and beating heart surgery significantly correlated with future adoption of the technique by the cardiothoracic surgery residents. Cardiothoracic surgery residents in the lowest, middle, and highest terciles of exposure to off-pump coronary artery bypass and beating heart surgery plan to use these techniques 31%, 86%, and 75%, respectively, in selective cases when they are in independent practice.

Conclusions

Over half of graduating cardiothoracic surgery residents do not feel comfortable with off-pump coronary artery bypass or beating heart surgery techniques. Exposure to these techniques in training correlates with comfort level and plans to use them in independent practice.

Implementation of a beating heart system for training in off-pump and minimally invasive coronary artery bypass

Background

Several training devices have been developed to train anastomotic skills in off-pump coronary artery bypass grafting (OPCAB). However, assessment of trainees’ improvement remains challenging. The goal of this study was to develop a new practical scoring chart and investigate its reliability and utility for anastomotic skills in OPCAB and minimally invasive direct coronary artery bypass (MIDCAB).

Methods

A training device was used, which included a beating heart model installed in a dedicated box. A soft plastic tube was used as the left anterior descending artery, and a porcine ureter was used as the left internal mammary artery. Five cardiac surgery fellows (Fellows, > 5 year of surgical experience) and five residents or medical students (Residents, ≤ 5 year of surgical experience) were enrolled for this study. Before and after training, skills were evaluated using a scoring chart that took into account anastomotic time, leakage, shape, flow measurement, and self-estimation.

Results

Mean total score of all trainees was 15.4 ± 4.0 at pre-training and 18.5 ± 2.4 at post-training (P = 0.05). Before training, there was a significant difference in the total score between Fellows and Residents (18.6 ± 2.2 vs 12.2 ± 2.4 points, P = 0.002), which disappeared after training (19.4 ± 2.5 vs 17.6 ± 2.2 points, P = 0.262). Residents benefitted from training with improvements in their time, total score, score for time, score for flow and subtraction score; however, these effects were not seen in Fellows. The most evident training effect was improvement of self-estimation, which was also seen in Fellows.

Conclusions

Residents were most likely to derive benefit from these training models with regard to both efficiency and quality. Training models seem to have an important role in making surgeons feel more comfortable with the procedure.

Establishing the Safety of Training in Off-Pump Coronary Artery Bypass Surgery: A Retrospective Comparison of Outcomes between Trainees and a Consultant Surgeon

BACKGROUND

The safety of training in off-pump coronary artery bypass (OPCAB) surgery and the stage at which trainees should be exposed to this technique remain controversial. This single-center retrospective study aimed to compare outcomes of OPCAB surgery in consultant and trainee cases.

METHODS

Between 2014 and 2018, all isolated OPCAB operations performed under the care of a consultant surgeon (G.A.) were analyzed. Cases where a surgeon below consultant grade performed at least 70% of the distal anastomoses were designated as "trainee cases" with the remaining cases designated as "consultant cases." The baseline characteristics of patients, perioperative data, and short-term outcomes were prospectively collated and analyzed.

RESULTS

During the study period, 245 OPCAB cases were identified: 142 (58%) consultant and 103 (42%) trainee cases. The trainee cases were performed exclusively by trainees in the final 2 years of the UK National Cardiothoracic Training Program. Both trainee and consultant groups had low mortality with two perioperative deaths occurring in either group. The rates of serious postoperative complications including stroke (n = 1 vs. 2, p = 0.759), resternotomy for bleeding (n = 3 vs. 7, p = 0.431), and mediastinal infection (n = 2 vs. 3, p = 0.926) were low and not significantly different between the two groups. Patients operated on by trainees had a slightly longer hospital stay than those operated on by the consultant surgeon, although this did not reach statistical significance (9.9 vs. 7.9 days).

CONCLUSIONS

These results demonstrate comparable outcomes in OPCAB surgery between a consultant surgeon and trainees. This study supports the conclusion that training surgeons in OPCAB is appropriate for trainees in the final years of cardiac surgery training.

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.

Is There a Difference in the Outcome of Mid-Urethral Sling Operations Performed by Urogynecologists Compared with Supervised Residents?

STUDY OBJECTIVE

To compare the operative results of midurethral sling (MUS) surgeries for stress urinary incontinence (SUI) performed by residents under the guidance of an attending specialist in urogynecology and those performed by attendings.

DESIGN

Retrospective chart review (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

A retrospective analysis of all MUS surgeries performed at a single public tertiary medical center between January 2009 and December 2013 was carried out. A total of 257 patients underwent transobturator tape (TOT) placement during the study period, including 136 (52.9%) placed by an attending specialist in urogynecology (group A) and 121 (47.1%) placed by a resident, under the guidance of an attending (group B).

MEASUREMENTS

The efficacy of treatment was evaluated in terms of early postoperative course, reoperation, and symptom improvement, as based on the Pelvic Floor Distress Inventory short form (PFDI-20) questionnaire. The primary outcome was patient-reported symptoms of SUI, as assessed with the PFDI-20 questionnaire, as well as absence of surgical retreatment for SUI.

RESULTS

Immediate postoperative complications were comparable in the 2 groups, as were subjective failure and self-reported SUI. The primary outcome-moderate and severe symptoms of SUI-were reported by 23.7% of the patients in group A and 23.6% of those in group B (p = .91). At a mean follow-up of 40 months in both groups, symptoms, as assessed using the urinary scale and prolapse scale of the PFDI-20, were also similar in the 2 groups. The rate of reoperation with repeated sling for SUI was 5% in both groups.

CONCLUSION

The operative results of TOT surgery for SUI performed by residents under the guidance of an attending specialist in urogynecology did not differ significantly from those performed by the attendings themselves.