Impact of Surgical Experience on Operative Mortality After Reoperative Cardiac Surgery

Morbidity and mortality outcomes of patients requiring isolated tricuspid valve surgery: a retrospective cohort study of 537 patients in New South Wales between 2002 and 2018

OBJECTIVES

The aim of the study was to evaluate mortality and morbidity outcomes following open-heart isolated tricuspid valve surgery (TVSx) with medium to long-term follow-up.

DESIGN

Retrospective cohort study.

SETTING

New South Wales public and private hospital admissions between 1 January 2002 and 30 June 2018.

PARTICIPANTS

A total of 537 patients underwent open isolated TVSx during the study period.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was all-cause mortality tracked from the death registry to 31 December 2018. Secondary morbidity outcomes, including admission for congestive cardiac failure (CCF), new atrial fibrillation (AF), infective endocarditis (IE), pulmonary embolism (PE) and insertion of a permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD), were tracked from the Admitted Patient Data Collection database. Independent mortality associations were determined using the Cox regression method.

RESULTS

A total of 537 patients underwent open isolated TVSx (46% male): median age (IQR) was 63.5 years (43.9-73.8 years) with median length of stay of 16 days (10-31 days). Main cardiovascular comorbidities were AF (54%) and CCF (42%); 67% had rheumatic tricuspid valve. In-hospital and total mortality were 7.4% and 39.3%, respectively (mean follow-up: 4.8 years). Cause-specific deaths were evenly split between cardiovascular and non-cardiovascular causes. Predictors of mortality included a history of CCF (HR=1.78, 95% CI 1.33 to 2.38, p<0.001) and chronic pulmonary disease (HR=2.66, 95% CI 1.63 to 4.33, p<0.001). In-hospital PPM rate was 10.0%. At 180 days, 53 (9.9%) patients were admitted for CCF, 25 (10.1%) had new AF, 7 (1.5%) had new IE and <1% had PE, post-discharge PPM or ICD insertion.

CONCLUSION

Open isolated TVSx carries significant mortality risk, with decompensated CCF and new AF the most common morbidities encountered after surgery. This report forms a benchmark to compare outcomes with newer percutaneous tricuspid interventions.

Volume-Outcome Relationship of Resternotomy Coronary Artery Bypass Grafting

BACKGROUND

We assessed volume-outcome relationships of resternotomy coronary artery bypass grafting (CABG).

METHODS

We studied 1,362,218 first-time CABG and 93,985 resternotomy CABG patients reported to The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2010 and 2019. Primary outcomes were in-hospital mortality and mortality and morbidity (M&M) rates calculated per hospital and per surgeon. Outcomes were compared across 6 total cardiac surgery volume categories. Multivariable generalized linear mixed-effects models were used considering continuous case volume as the main exposure, adjusting for patient characteristics and within-surgeon and hospital variation.

RESULTS

We observed a decline in resternotomy CABG unadjusted mortality and M&M from the lowest to the highest case-volume categories (hospital-level mortality, 3.9% ± 0.6% to 3.3% ± 0.1%; M&M, 18.5% ± 1.1% to 15.7% ± 0.4%, P < .001; surgeon-level mortality, 4.1% ± 0.3% to 4.1% ± 1.3%; M&M, 18.5% ± 0.6% to 14.5% ± 2.2%, P < .001). Looking at outcomes vs continuous volume showed that beyond a minimum annual volume (hospital 200-300 cases; surgeon 100-150 cases, approximately), mortality and M&M rates did not further improve. Using individual-level data and adjusting for patient characteristics and clustering within surgeon and hospital, we found higher procedural volume was associated with improved surgeon-level outcomes (mortality adjusted odds ratio, 0.39/100 procedures; 95% CI, 0.24-0.61; M&M adjusted odds ratio, 0.37/100 procedures; 95% CI, 0.28-0.48; P < .001 for both). Hospital-level adjusted volume-outcomes associations were not statistically significant.

CONCLUSIONS

We observed an inverse relationship between total cardiac case volume and resternotomy CABG outcomes at the surgeon level only, indicating that individual surgeon's experience, rather than institutional volume, is the key determinant.

Hanging up the surgical cap: Assessing the competence of aging surgeons

BACKGROUND

As the average age of surgeons continues to rise, determining when a surgeon should retire is an important public safety concern.

AIM

To investigate strategies used to determine competency in the industrial workplace that could be transferrable in the assessment of aging surgeons and to identify existing competency assessments of practicing surgeons.

METHODS

We searched websites describing non-medical professions within the United States where cognitive and physical competency are necessary for public safety. The mandatory age and certification process, including cognitive and physical requirements, were reported for each profession. Methods for determining surgical competency currently in use, and those existing in the literature, were also identified.

RESULTS

Four non-medical professions requiring mental and physical aptitude that involve public safety and have mandatory testing and/or retirement were identified: Airline pilots, air traffic controllers, firefighters, and United States State Judges. Nine late career practitioner policies designed to evaluate the ageing physician, including surgeons, were described. Six of these policies included subjective performance testing, 4 using peer assessment and 2 using dexterity testing. Six objective testing methods for evaluation of surgeon technical skill were identified in the literature. All were validated for surgical trainees. Only Objective Structured Assessment of Technical Skills (OSATS) was capable of distinguishing between surgeons of different skill level and showing a relationship between skill level and post-operative outcomes.

CONCLUSION

A surgeon should not be forced to hang up his/her surgical cap at a predetermined age, but should be able to practice for as long as his/her surgical skills are objectively maintained at the appropriate level of competency. The strategy of using skill-based simulations in evaluating non-medical professionals can be similarly used as part of the assessment of the ageing surgeons' surgical competency, showing who may require remediation or retirement.

Modern practice and outcomes of reoperative cardiac surgery

OBJECTIVES

To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest.

METHODS

From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect.

RESULTS

Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2).

CONCLUSIONS

Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy.

The relationship between cardiac surgeon experience and average patient risk profile: CA and NY statewide analysis

BACKGROUND

It is unknown how high and low-risk cases are distributed among cardiac surgeons of different experience levels. The purpose of this study was to determine if high and low-risk coronary artery bypass grafting (CABG) cases are distributed among surgeons in such a way that would optimize outcomes in light of recent studies that show mid-career surgeons may obtain better patient outcomes on more complex cases.

METHODS

We performed a cross-sectional study using aggregated New York (NY) and California (CA) statewide surgeon-level outcome data, including 336 cardiac surgeons who performed 43,604 CABGs. The surgeon observed and expected mortality rates (OMR and EMR) were collected and the number of years-in-practice was determined by searching for surgeon training history on online registries. Loess and linear regression models were used to characterize the relationship between surgeon EMR and surgeon years-in-practice.

RESULTS

The median number of surgeon years-in-practice was 20 (interquartile range [IQR] 11-28) with a median annual case volume of 46 (IQR 19, 70.25). The median surgeon observed to expected mortality (O:E) ratio was 0.87 (IQR 0.19-1.4). Median EMR for CA surgeons was 2.42% and 1.44% for NY surgeons. Linear regression models showed EMR was similar across years in practice. Regression models also showed surgeon O:E ratios were similar across years-in-practice.

CONCLUSION

High and low-risk CABG cases are relatively equally distributed among surgeons of differing experience levels. This equal distribution of high and low-risk cases does not reflect a triaging of more complex cases to more experienced surgeons, which prior research shows may optimize patient outcomes.