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Chan J, Dimagli A, Dong T, Fudulu DP, Sinha S, Angelini GD. Trend and early clinical outcomes of off-pump coronary artery bypass grafting in the UK. Eur J Cardiothorac Surg 2023; 64:ezad272. [PMID: 37522886 PMCID: PMC10876163 DOI: 10.1093/ejcts/ezad272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/21/2023] [Accepted: 07/29/2023] [Indexed: 08/01/2023] Open
Abstract
OBJECTIVES The popularity of off-pump coronary artery bypass grafting (CABG) varies across the world, ranging from 20% in Europe and the USA to 56% in Asia. We present the trend and early clinical outcomes in off pump in the UK. METHODS All patients who underwent elective or urgent isolated CABG from 1996 to 2019 were extracted from the National Adult Cardiac Surgery Audit database. The trend in operating surgeons and units volume and training in off pump were analysed. Early clinical outcomes between off- and on-pump CABG were compared using propensity score matching. RESULTS A total of 351 422 patients were included. The overall off-pump rate during the study period was 15.17%, it peaked in 2008 (19.8%), followed by a steady decreased to 2018 (7.63%). Its adoption varied across centres and surgeons, ranging from <1% to 48.36% and <1% to 85.5%, respectively, of total cases performed. After propensity score matching for the period 1996-2019, off pump, when compared to on pump, was associated with a lower in-hospital/30-day mortality (1.2% vs 1.5%, P < 0.001), return to theatre (3.7% vs 4.5%, P < 0.001), cerebrovascular accident (transient ischaemic attack: 0.3% vs 0.6%, stroke: 0.3% vs 0.6%, P < 0.001) and deep sternal wound infection (0.8% vs 1.2%, P ≤ 0.001). In a sub-analysis from the introduction of EuroScore II (2012-2019), there were no differences in-hospital/30-day mortality (1.0% vs 1.0%, P = 0.71). However, on pump, had a higher return to theatre (4.2% vs 2.7%, P < 0.001), cerebrovascular accident (transient ischaemic attack: 0.4% vs 0.2%, stroke: 0.5% vs 0.3%, P = 0.003) and deep sternal wound infection (1.0% vs 0.6%, P = 0.004). CONCLUSIONS Our data show a decreasing trend in the use of off pump in the UK since 2008. This is likely to be multifactorial and raises the question of whether it should be a specialized revascularization technique.
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Affiliation(s)
- Jeremy Chan
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | | | - Tim Dong
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | | | - Shubhra Sinha
- Bristol Heart Institute, University of Bristol, Bristol, UK
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Kenny L, Booth K, Freystaetter K, Wood G, Reynolds G, Rathinam S, Moorjani N. Training cardiothoracic surgeons of the future: The UK experience. J Thorac Cardiovasc Surg 2018; 155:2526-2538.e2. [DOI: 10.1016/j.jtcvs.2018.01.088] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 01/15/2018] [Accepted: 01/26/2018] [Indexed: 12/11/2022]
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Jolbäck P, Rolfson O, Mohaddes M, Nemes S, Kärrholm J, Garellick G, Lindahl H. Does surgeon experience affect patient-reported outcomes 1 year after primary total hip arthroplasty? Acta Orthop 2018; 89:265-271. [PMID: 29508643 PMCID: PMC6055771 DOI: 10.1080/17453674.2018.1444300] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Several studies have reported on the influence of various factors on patient-reported outcomes (PROs) after total hip arthroplasty (THA), but very few have focused on the experience of the surgeon. We investigated any association between surgeons' experience and PROs 1 year after primary THA. Patients and methods - Patient characteristics and surgical data at 10 hospitals in western Sweden were linked with PROs (EQ-5D-3L, Satisfaction Visual Analogue Scale (VAS), Pain VAS). These data were retrieved from the Swedish Hip Arthroplasty Register (SHAR). The surgeon's level of experience was divided into 4 subgroups related to experience: < 8 years, 8-15 years, and >15 years of clinical practice after specialist certificate. If no specialist certificate was obtained the surgery was classified as a trainee surgery. Surgeons with >15 years' experience as an orthopedic specialist were used as reference group in the analyses. Results - 8,158 primary THAs due to osteoarthritis were identified. We identified the surgeons' level of experience in 8,116 THAs. Data from SHAR on pre- and postoperative PROs and satisfaction at 1 year were available for 6,713 THAs. We observed a statistically significant difference among the 4 groups of surgeons regarding mean patient age, ASA classification, Charnley classification, diagnosis, and fixation technique. At 1-year follow-up, there were no statistically significant differences in Pain VAS, EQ-5D index, or EQ VAS among the subgroups of orthopedic specialists. Patients operated on by orthopedic trainees reported less satisfaction with the result of the surgery compared with the reference group. Interpretation - These findings indicate that patients can expect similar health improvements, pain reduction, and satisfaction 1 year after a primary THA operation irrespective of years in practice after specialty certification as an orthopedic surgeon.
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Affiliation(s)
- Per Jolbäck
- Swedish Hip Arthroplasty Register, Gothenburg,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg,Department of Orthopaedics, Skaraborgs Hospital, Lidköping, Sweden,Correspondence:
| | - Ola Rolfson
- Swedish Hip Arthroplasty Register, Gothenburg,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg
| | - Maziar Mohaddes
- Swedish Hip Arthroplasty Register, Gothenburg,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg
| | | | - Johan Kärrholm
- Swedish Hip Arthroplasty Register, Gothenburg,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg
| | - Göran Garellick
- Swedish Hip Arthroplasty Register, Gothenburg,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg
| | - Hans Lindahl
- Swedish Hip Arthroplasty Register, Gothenburg,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg,Department of Orthopaedics, Skaraborgs Hospital, Lidköping, Sweden
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Almassi GH, Carr BM, Bishawi M, Shroyer AL, Quin JA, Hattler B, Wagner TH, Collins JF, Ravichandran P, Cleveland JC, Grover FL, Bakaeen FG. Resident versus attending surgeon graft patency and clinical outcomes in on- versus off-pump coronary artery bypass surgery. J Thorac Cardiovasc Surg 2015; 150:1428-35, 1437.e1; discussion 1435-7. [DOI: 10.1016/j.jtcvs.2015.08.124] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 08/06/2015] [Accepted: 08/26/2015] [Indexed: 10/23/2022]
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Smith TA, Asimakopoulos G. How safe is it to train residents to perform off-pump coronary artery bypass surgery? Interact Cardiovasc Thorac Surg 2015; 20:658-61. [PMID: 25662959 DOI: 10.1093/icvts/ivu447] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 12/19/2014] [Indexed: 11/12/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, in [patients undergoing off-pump CABG] are [postoperative mortality and morbidity outcomes] acceptable when performed by [trainees]? Altogether more than 597 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. Six retrospective cohort studies directly compared the performance of trainees and experienced surgeons in off-pump coronary artery bypass graft surgery. Of the remaining papers, one recorded the performance of trainees in on- and off-pump operations and finally one paper evaluated a single trainee's performance in off-pump coronary artery bypass graft surgery, both supervised and unsupervised, over a 1-year period. It is important to note that the two respective cohort studies included in our analysis compared similar cohorts of patients. However, both studies were included in our paper as they provide additional information regarding trainee performance. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Although a heterogeneous range of postoperative complications were recorded in the identified studies, we were able to determine that, overall, there was no significant difference in the 30-day mortality seen in operations performed by trainees or experienced surgeons. The incidence of myocardial infarction and stroke were also similar among cases performed by both groups. However, senior surgeons were more likely to operate on patients with more complex or severe disease, or those requiring more urgent operations. Therefore, it was not possible to directly compare outcomes between trainees and experienced surgeons in operations of similar complexity. However, we conclude that despite the absence of randomized controlled trials comparing the performance of trainees and experienced surgeons in off-pump coronary artery bypass (OPCAB) surgery, the evidence provided in this paper supports the involvement of trainees in performing off-pump coronary artery bypass graft surgery as a reliable and safe alternative to on-pump coronary artery bypass graft surgery in selected cases.
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Murzi M, Miceli A, Cerillo AG, Di Stefano G, Kallushi E, Farneti P, Solinas M, Glauber M. Training surgeons in minimally invasive mitral valve repair: a single institution experience. Ann Thorac Surg 2014; 98:884-9. [PMID: 25087930 DOI: 10.1016/j.athoracsur.2014.05.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 05/13/2014] [Accepted: 05/14/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND We aimed to study the results of minimally invasive mitral valve repair performed by 5 young surgeons who were trained in mitral valve repair directly through a minimally invasive approach, and a senior surgeon who introduced the technique at our institution and was responsible for the training program. METHODS This was a retrospective, observational cohort study of prospectively collected data from 595 consecutive patients who underwent minimally invasive mitral repair performed by 5 trainees (n = 240, 40.3%) and by our lead consultant (n = 355, 59.7%) between 2007 and 2013. Treatment selection bias was controlled by constructing a propensity score from core patient characteristics and it was included along with the comparison variable in the multivariable analyses of outcome. RESULTS Patients operated on by trainees were more likely to be female (p = 0.04), older (p = 0.001), and with history of atrial fibrillation (p = 0.001). Trainees required a significant longer cardiopulmonary bypass (137 ± 56 vs 123 ± 52 minutes; p = 0.003) and aortic clamp time (97 ± 41 vs 83 ± 40 minutes; p = 0.001). I-hospital mortalities were 1.3% in the trainees group and 0.8% in the senior surgeon group (p = 0.6). The incidence of stroke (1.7% vs 2.5%; p = 0.5), conversion to sternotomy (2.6% vs 3.5%; p = 0.5), and conversion to mitral valve replacement (12.5% vs 10.9%; p = 0.6) were similar between groups. No differences were found regarding other complications. Five-year survival (88.9% vs 89.5%; p = 0.4) and freedom from reoperation (94.5% vs 95.1; p = 0.6) were similar between groups. CONCLUSIONS Minimally invasive mitral valve repair is a safe and reproducible surgical technique that can be taught successfully to cardiac trainees.
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Affiliation(s)
- Michele Murzi
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Antonio Miceli
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Alfredo G Cerillo
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Gioia Di Stefano
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Enkel Kallushi
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Pierandrea Farneti
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Marco Solinas
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Mattia Glauber
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy.
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Training the novice to become cardiac surgeon: does the "early learning curve" training compromise surgical outcomes? Gen Thorac Cardiovasc Surg 2013; 62:149-56. [PMID: 24078280 DOI: 10.1007/s11748-013-0321-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 09/09/2013] [Indexed: 01/15/2023]
Abstract
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.
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Excellent short- and long-term outcomes after concomitant aortic valve replacement and coronary artery bypass grafting performed by surgeons in training. J Thorac Cardiovasc Surg 2013; 145:334-40. [DOI: 10.1016/j.jtcvs.2012.09.073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 08/14/2012] [Accepted: 09/27/2012] [Indexed: 11/21/2022]
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9
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Wong THI, Guy G, Babidge W, Maddern GJ. Impact of consultant operative supervision and surgical mortality in Australia. ANZ J Surg 2012; 82:895-901. [DOI: 10.1111/j.1445-2197.2012.06310.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Teresa Hoi Ian Wong
- Discipline of Surgery; University of Adelaide and The Queen Elizabeth Hospital; Adelaide; South Australia; Australia
| | - Gordon Guy
- Australian Safety and Efficacy Register of New Interventional Procedures - Surgical; Royal Australasian College of Surgeons; Adelaide; South Australia; Australia
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Bakaeen FG, Sethi G, Wagner TH, Kelly R, Lee K, Upadhyay A, Thai H, Juneman E, Goldman S, Holman WL. Coronary Artery Bypass Graft Patency: Residents Versus Attending Surgeons. Ann Thorac Surg 2012; 94:482-8; discussion 488. [DOI: 10.1016/j.athoracsur.2012.04.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 03/28/2012] [Accepted: 04/02/2012] [Indexed: 11/16/2022]
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Training residents in off-pump coronary artery bypass surgery: A 14-year experience. J Thorac Cardiovasc Surg 2012; 143:1247-53. [DOI: 10.1016/j.jtcvs.2011.09.049] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 08/29/2011] [Accepted: 09/26/2011] [Indexed: 11/22/2022]
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12
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Shi WY, Hayward PA, Yap CH, Dinh DT, Reid CM, Shardey GC, Smith JA. Training in mitral valve surgery need not affect early outcomes and midterm survival: a multicentre analysis. Eur J Cardiothorac Surg 2011; 40:826-33. [PMID: 21440451 DOI: 10.1016/j.ejcts.2011.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 01/31/2011] [Accepted: 02/02/2011] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Mitral valve surgery may be regarded as less favourable for training, due to greater mortality risk, technical complexity, and difficulty for the supervisor to observe. We examined this perception by reviewing a multicentre experience. METHODS We analysed a multicentre database over a 7-year period containing 2216 isolated and combined mitral procedures. Of these, 2048 were performed by consultants and 168 by trainees (92% vs 8%) of varying seniority. Preoperative characteristics, early postoperative outcomes and 6-year survival were compared between groups. Propensity-score matching was performed to correct for group differences. RESULTS Trainees were less likely to operate on patients, who had previously undergone coronary surgery (consultant 4.3% vs trainee 1.2%, p=0.043) and those with moderate to severe mitral regurgitation (86% vs 81%, p=0.012). There were no other statistically significant differences in preoperative variables, such as urgency, endocarditis and left-ventricular dysfunction. There were similar rates of mitral valve repair (48% vs 51%, p=0.48). Trainees were more likely to operate on rheumatic valve pathology (20% vs 28%, p=0.012). Intra-operatively, trainees had longer aortic cross-clamp times (119 ± 52 vs 136 ± 50 min, p=0.0001). At 30 days, mortality was comparable (4.5% vs 3.6%, p=0.56) with a trend towards higher any mortality/morbidity in consultant procedures (33% vs 26%, p=0.059). At 6 years, survival was similar (79 ± 1.4% vs 78 ± 4.0%, p=0.73). After derivation of 142 propensity-score-matched patient pairs, trainees cases still experienced longer cross-clamp times (121 ± 58 vs 137 ± 52 min, p=0.023), but there was similar 30-day mortality (4.2% vs 3.5%, p>0.99) and any mortality/morbidity (28% vs 24%, p=0.52). Six-year survival between matched pairs was also similar (74 ± 7.2% vs 80 ± 4.4%, p=0.64). Trainee status did not predict early or late adverse events after multivariate Cox regression with and without propensity-score adjustment. CONCLUSIONS Trainee outcomes are not inferior even when corrected for risk. This suggests that excellent operative training and supervision can be achieved in mitral valve surgery.
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Affiliation(s)
- William Y Shi
- Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia
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Halkos ME, Puskas JD. Teaching off-pump coronary artery bypass surgery. Semin Thorac Cardiovasc Surg 2010; 21:224-8. [PMID: 19942120 DOI: 10.1053/j.semtcvs.2009.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2009] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Michael E Halkos
- Division of Cardiothoracic Surgery, Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia 30308, USA
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Porena M, Lazzeri M, Bini V, Zucchi A, del Zingaro M, Costantini E. Patients of surgical educational course may have a poorer outcome for pelvic organ prolapse repair and higher complication rate: a case-control study in urogynecology. Int Urogynecol J 2010; 21:693-8. [PMID: 20155352 DOI: 10.1007/s00192-009-1086-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 12/14/2009] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To investigate the outcome of the surgical educational course setting in patients undergoing urinary incontinence (UI)/pelvic organ prolapse (POP) repair. METHODS A case-control study of patients who underwent surgery for UI and/or POP during educational post-graduate courses (group A) or during routine hospital work (control--group B). The primary outcome measures were changes in the incontinence rate, presence/absence of POP, and complications. For 2 x 2 tables, chi (2) test was used. Multivariate logistic regression models were developed. RESULTS One hundred eighty-six patients belonged to group A and 158 to group B; median follow-up was 46.7 months. Failure, complication, and re-operation rates for UI repair were not significantly different in the two groups: p = 0.162, p = 0.110, p = 0.188, respectively. The logistic regression analysis for POP repair showed that group A has higher risk for failure (OR = 2.71; 95% CI: 1.31-5.61) and higher complication rate (OR = 2.38; 95% CI: 1.31-4.32). CONCLUSION Patients who underwent surgery during educational course developed a poorer outcome after POP repair and higher complication rate.
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Affiliation(s)
- Massimo Porena
- Department of Medical-Surgical Specialties and Public Health, Urology and Andrology Section, Ospedale S Maria della Misericordia Loc S Andrea delle Fratte, Perugia 06100, Italy
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Agostini M, Fino C, Torchio P, Di Gregorio V, Feola M, Bertora M, Lugli E, Grossi C. High OPCAB surgical volume improves midterm event-free survival. Heart Surg Forum 2010; 12:E250-5. [PMID: 19833590 DOI: 10.1532/hsf98.20091034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the midterm results of the initial phase of off-pump coronary artery bypass (OPCAB) surgery adoption in a single surgical unit, assessing the impact of procedural volume. METHODS Study participants were 312 patients who underwent OPCAB during the period between August 2000 and January 2005 at S. Croce Hospital. Of these patients, 126 patients with an indication selected for comorbidities or 1-vessel disease underwent OPCAB performed by 4 low-volume surgeons, and 186 unselected patients underwent OPCAB performed by a single high-volume surgeon. RESULTS OPCAB performed by low-volume surgeons was associated with less complete revascularization and less arterial conduit use. Early result analysis showed a low rate of in-hospital or 30-day adverse events. The 5-year survival was 0.88 (0.02 SE). OPCAB performance by a high-volume surgeon and complete revascularization were shown have a protective effect for midterm major adverse cardiac events (respectively, hazard ratio = 0.28, 95% confidence interval 0.11-0.74 and hazard ratio = 0.33, 95% confidence interval 0.15-0.73). CONCLUSION Our study on the initial phase of OPCAB adoption suggests a benefit on midterm outcome from surgery performed by a high-volume surgeon.
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Affiliation(s)
- Marco Agostini
- Cardiovascular Department, S. Croce e Carle Hospital, Cuneo, Italy.
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Does the Level of Experience of Residents Affect Outcomes of Coronary Artery Bypass Surgery? Ann Thorac Surg 2009; 87:1127-33; discussion 1133-4. [DOI: 10.1016/j.athoracsur.2008.12.080] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Revised: 12/17/2008] [Accepted: 12/18/2008] [Indexed: 11/20/2022]
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Abstract
PURPOSE OF REVIEW Off-pump coronary artery bypass (OPCAB) grafting has been increasingly adopted in an effort to prevent deleterious effects of cardiopulmonary bypass, including the associated inflammatory response, global myocardial ischemia and the risks of aortic manipulation. In many studies, the greatest benefit of OPCAB has been in high-risk patients. This review will summarize the recent literature examining outcomes of OPCAB versus on-pump coronary artery bypass in high-risk subgroups, and will examine the safety of routine application of OPCAB in these patients. RECENT FINDINGS Prospective randomized trials have shown that in comparison to on-pump coronary artery bypass, OPCAB reduces perioperative morbidity, but have failed to show a mortality benefit, owing to small sample sizes. However, numerous large retrospective series and meta-analyses have demonstrated a reduction in risk-adjusted mortality and morbidity with respect to the following outcomes: stroke, pulmonary function, renal function, atrial fibrillation, need for early reoperation, blood transfusion requirements, length of ICU and hospital stay, and hospital costs. An even greater benefit has been seen in the following high-risk patients: those with acute myocardial infarction, left ventricular dysfunction, previous history of stroke, renal insufficiency, women, elderly patients, and those undergoing reoperations. SUMMARY Risk-adjusted outcomes are superior after OPCAB versus on-pump coronary artery bypass for mortality and numerous morbidity endpoints. This benefit is most easily demonstrated in high-risk patient populations.
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Stoica SC, Kalavrouziotis D, Martin BJ, Buth KJ, Hirsch GM, Sullivan JA, Baskett RJF. Long-term results of heart operations performed by surgeons-in-training. Circulation 2008; 118:S1-6. [PMID: 18824740 DOI: 10.1161/circulationaha.107.756379] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We investigated the association between trainees performing supervised operations and late outcomes of patients undergoing cardiac surgery. METHODS AND RESULTS Data were prospectively collected on patients who underwent coronary artery bypass graft surgery, aortic valve replacement, or a combination of these between 1998 and 2005 at the Maritime Heart Center, Halifax, Canada. In-hospital mortality and a composite outcome of in-hospital mortality, stroke, bleeding, intra-aortic balloon pump insertion, renal failure, and sternal infection was compared between teaching (n=1054) and nonteaching cases (n=5877). Late survival and cardiovascular hospital readmissions were also examined. To adjust for baseline risk disparities, we used logistic regression for dichotomous in-hospital outcomes and Cox proportional hazards regression for survival data. Resident cases were significantly more likely to have high-risk features such as depressed ventricular function, redo operation, and urgent or emergent procedure. Resident as primary operator was not independently associated with in-hospital mortality (OR, 1.09; 95% CI, 0.75 to 1.58; P=0.66) or with the composite outcome (OR, 1.01; 95%, CI 0.82 to 1.26; P=0.90). The Kaplan-Meier event-free survival of the 2 groups was equivalent at 1, 3, and 5 years (log-rank P=0.06). By Cox regression, resident cases were not associated with late death or cardiovascular rehospitalization (hazard ratio, 1.05; 95% CI, 0.94 to 1.17; P=0.42). CONCLUSIONS Cases performed by senior-level cardiac surgery residents were more likely to have greater acuity and complexity than staff surgeon-performed cases. However, clinical outcomes were similar in the short- and long-term. Allowing residents to perform cardiac surgery is not associated with adverse patient outcomes.
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Affiliation(s)
- Serban C Stoica
- Queen Elizabeth II Health Sciences Centre, 1796 Summer Street, Room 2269, Halifax, Nova Scotia, Canada.
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19
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Sinha P. Training of pediatric cardiac surgeon in India. Ann Pediatr Cardiol 2008; 1:156. [PMID: 20300263 PMCID: PMC2840742 DOI: 10.4103/0974-2069.43887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Medical Center, 111, Michigan Avenue, NW, Washington-200 10, DC - USA
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20
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Haan CK, Milford-Beland S, O'Brien S, Mark D, Dullum M, Ferguson TB, Peterson ED. Impact of residency status on perfusion times and outcomes for coronary artery bypass graft surgery. Ann Thorac Surg 2007; 83:2103-10. [PMID: 17532407 DOI: 10.1016/j.athoracsur.2007.01.052] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2006] [Revised: 01/22/2007] [Accepted: 01/23/2007] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Constance K Haan
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida 32209, USA.
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