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

The Impact of Congenital Cardiac Surgery Fellowship on Training and Practice

BACKGROUND

In 2007, congenital cardiac surgery became a recognized fellowship by the American Council of Graduate Medical Education (ACGME). Beginning in 2023, the fellowship transitioned from a 1-year to a 2-year program. Our objective is to provide current benchmarks by surveying current training programs and assessing characteristics contributing to career success.

METHODS

This was a survey-based study in which tailored questionnaires were distributed to program directors (PDs) and graduates of the ACGME accredited training programs. Data collection included responses to multiple-choice and open-ended questions relevant to didactics, operative training, training center characteristics, mentorship, and employment characteristics. Results were analyzed using summary statistics and subgroup and multivariable analyses.

RESULTS

The survey yielded responses from 13 of 15 PDs (86%) and 41 of 101 graduates (41%) from ACGME accredited programs. Perceptions among PDs and graduates were somewhat discordant, with PDs more optimistic than graduates. Of PDs, 77% (n = 10) believed current training adequately prepares fellows and is successful in securing employment for graduates. The responses from graduates demonstrated 30% (n = 12) were dissatisfied with operative experience and 24% (n = 10) with overall training. Being supported during the first 5 years of practice was significantly associated with retention in congenital cardiac surgery and greater practicing case volumes.

CONCLUSIONS

Dichotomous views exist between graduates and PDs regarding success in training. Mentorship during the early career was associated with increased case volumes, career satisfaction, and retention in the congenital cardiac surgery field. Educational bodies should incorporate these elements during training and after graduation.

Are there differences in cardiothoracic surgery performed by trainees versus fully trained surgeons?

OBJECTIVES

We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons.

METHODS

EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. Eight hundred and ninety-two results were obtained, 27 represented best evidence (2-meta-analyses, 1-RCT, and 24 retrospective cohort studies).

RESULTS

In all 474,160 operative outcomes were assessed for 434,535 coronary artery bypass grafting (CABG) (431,329 on-pump vs. 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital, and 4797 thoracic procedures. In all 398,058 cases were performed by trainees and 75,943 by consultants. One hundred fifty-nine cases were indeterminate. There were no statistically significant differences in the patients' preoperative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function, and reoperation cases that were undertaken by consultants. There were no differences in cardiopulmonary bypass and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the postoperative outcomes including perioperative myocardial infarction, resternotomy for bleeding, stroke, renal failure, intensive therapy unit length of stay, and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or midterm mortality out to 5-years.

DISCUSSION

Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.

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.

Effect of Hospital and Surgeon Procedure Volumes on the Incidence of Intraoperative Conversion During Off-Pump Coronary Artery Bypass Grafting

Intraoperative conversion to cardiopulmonary bypass with its subsequent high mortality is a major concern associated with off-pump coronary artery bypass grafting (OPCAB). The impact of procedure volume on the incidence of intraoperative conversion, however, is poorly defined. This study therefore evaluated the effect of procedure volume on the incidence of conversion in OPCAB using nationwide data. We analyzed 31,361 patients who underwent primary, nonemergent, isolated OPCAB during 2013-2016 reported in the Japan Cardiovascular Surgery Database. Hospitals (n = 548) and surgeons (n = 1315) were divided into tertile categories (low-, medium-, and high volumes) based on the total number of isolated coronary artery bypass grafting (CABG). Hierarchical logistic regression analysis, including 22 preoperative factors and hospital and surgeon CABG volumes, was used to assess the relation between procedure volume and the risk of conversion due to bleeding/hemodynamic instability. There were 797 (2.5%) intraoperative conversions due to bleeding/hemodynamic instability. Risk-adjusted odds ratios for conversion were significantly lower in some combined hospital/surgeon CABG volume categories than in the reference category. Hospital/surgeon volumes and their odds ratio (95% confidence interval) were as follows: low/low 1.00 (reference); medium/low 0.62 (0.39-0.96); high/low 0.47 (0.27-0.81); high/high 0.58 (0.38-0.89). There was a lower risk of conversion in medium- and high-volume than low-volume hospitals, especially among low-volume surgeons. Procedure volume is associated with the incidence of conversion during OPCAB. Among low-volume surgeons, hospital CABG volume significantly reduces conversion in a volume-dependent manner. These findings will be useful for safety training of OPCAB surgeons.

Comparative Outcomes of Resident vs Attending Performed Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine whether outcomes are different when surgery is performed by resident or attending surgeons, and which variables may affect outcomes.

DESIGN

MEDLINE, EMBASE, and the Cochrane Library were searched from inception to May 2014 alongside the bibliographies of all included or relevant studies. Any study comparing outcomes from surgery performed by resident vs attending surgeons was eligible for inclusion. The main outcome measures were surgical complications (classified by Clavien-Dindo grade), death, operative time, and length of stay. Data were extracted independently by 2 authors and analyzed using the random-effects model.

RESULTS

The final analysis included 182 eligible studies that enrolled 141 555 patients. Resident performed surgery took longer by 10.2 minutes (95% confidence interval (CI): 8.38-11.95), and had more Clavien-Dindo grade 1 (rate ratio = 1.14, 95% CI: 1.02-1.29) and grade 3a complications (rate ratio = 1.22, 95% CI: 1.04-1.44). Resident performed surgery resulted in fewer deaths (risk ratio = 0.83, 95% CI: 0.70-0.999) with a shorter length of stay of -0.49 days (95% CI: -0.77 to -0.21). Significant heterogeneity was present in 7 of 10 outcomes, which persisted during multiple subgroup analyses.

CONCLUSIONS

Resident performed surgery appears to be safe in carefully selected patients. The significant amount of heterogeneity present in the study outcomes prevents generalizability of these results to specific clinical contexts.

Anaortic, total-arterial, off-pump coronary artery bypass surgery: why bother?

Coronary artery bypass grafting (CABG) remains the standard of care for multi-vessel coronary disease. However, the increased rate of peri-operative stroke reported after surgery compared to percutaneous coronary intervention (PCI) remains of concern. Anaortic, total-arterial, off-pump coronary artery bypass (OPCAB) grafting is a technique that offers the main advantages of surgical revascularisation with a rate of stroke that is equivalent to that of PCI. Some recent trials comparing conventional on-pump CABG with OPCAB have questioned the efficacy of the off-pump technique - these are most often performed with manipulation of the ascending aorta. We review the potential benefits of the anaortic, total-arterial OPCAB technique to explain why it is being employed by an increasing number of surgeons.

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.

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.

The trainer, the trainee and the surgeons' assistant: clinical outcomes following total hip replacement

Balancing service provision and surgical training is a challenging issue that affects all healthcare systems. A multicentre prospective study of 1501 total hip replacements was undertaken to investigate whether there is an association between surgical outcome and the grade of the operating surgeon, and whether there is any difference in outcome if surgeons' assistants assist with the operation, rather than orthopaedic trainees. The primary outcome measure was the change in the Oxford hip score (OHS) at five years. Secondary outcomes included the rate of revision and dislocation, operating time, and length of hospital stay. There was no significant difference in DeltaOHS or complication rates between operations undertaken by trainers and trainees, or those at which surgeons' assistants and trainees were the assistant. However, there was a significant difference in the duration of surgery, with a mean reduction of 28 minutes in those in which a surgeons' assistant was the assistant. This study provides evidence that total hip replacements can be performed safely and effectively by appropriately trained surgeons in training, and that there are potential benefits of using surgeons' assistants in orthopaedic surgery.

Orthopaedic trauma surgery performed by unsupervised and supervised trainees: complication rates compared

PURPOSE

To compare the complication rates associated with orthopaedic trauma surgery performed by unsupervised and supervised trainees.

METHODS

In our hospital, 6361 orthopaedic trauma operations were performed between 1 January 1998 and 31 December 2002. Data pertinent to the surgeon's supervision and postoperative complications were collected. Elective operations were excluded, as consultants were almost always present. Complication rates ensuing in unsupervised and supervised groups were compared using the Chi squared test.

RESULTS

Of 6361 orthopaedic trauma operations performed, 3754 (59%) were by unsupervised trainees of varying experience, whereas 2494 (39%) were by supervised trainees or consultants. In 113 (2%) of the operations, the supervision status was not recorded. The complication rate was significantly higher in the supervised than unsupervised group (5.3 vs 3.3%, Chi squared=15, df=1, p=0.0001).

CONCLUSION

The complication rate was not higher for operations performed by unsupervised trainees than those performed in the presence of a consultant.

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.

Off-pump coronary artery bypass grafting through sternotomy: for whom?

PURPOSE OF REVIEW

Off-pump coronary artery bypass grafting hopes to avoid morbidity associated with cardiopulmonary bypass, improving clinical outcomes. Yet its technical difficulty and unfamiliarity raise concern that adoption of off-pump coronary artery bypass might be associated with poorer outcomes. Both surgeon-specific and patient-related factors are believed to play roles in the success of off-pump coronary artery bypass. This review sought to elucidate these factors.

RECENT FINDINGS

Current prospective data suggest that both techniques have similar rates of mortality but off-pump coronary artery bypass does provide patients with a lower morbidity. Multiple prospective studies suggest a decrease in stroke rates for off-pump coronary artery bypass grafting. There is a consensus that certain patients will have better outcomes if done off-pump. Surgeon experience with the procedure does impact patient outcome.

SUMMARY

Though every patient must be dealt with on an individual basis, it would appear that almost any patient is a candidate for off-pump coronary artery bypass and that, given time and an appropriate desire, most any surgeon can perform the procedure.

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.

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.