Cardiothoracic surgery in the new millennium: challenges and opportunities in a time of paradox

Wisdom from Past Presidents of the Society of Thoracic Surgeons

The Society of Thoracic Surgeons (STS) is a highly impactful professional organization in cardiothoracic surgery and an important network of mentors for trainees. Annually, STS presidents deliver an address encapsulating their professional experiences, lessons learned, and future vision for the field. We sought to summarize these lessons into salient points for trainees. Transcriptions from 1964 to 2018 were reviewed by residents and expounded into categories of importance for readers. Six overarching themes were identified which included: (1) leadership, (2) education, (3) clinical excellence and innovation, (4) humanism and professionalism, (5) diversity and inclusion, and (6) the future of cardiothoracic surgery.

Need of the hour: Structural heart intervention training for trainee surgeons in India

Cardiothoracic surgery is on the verge of undergoing a major metamorphosis from being a conventional surgical branch to a technologically powered specialty with plenty of emphasis on learning the minimally invasive techniques, and a step forward is the advent of interventional techniques to treat most of the major cardiac ailments. Though the world of interventions has been traditionally dominated by the physicians, it is time we surgeons get ourselves actively involved in learning and performing these interventional procedures to stay relevant. This is not an attempt to disrupt the physician-surgeon harmony but to nurture a symbiotic relationship between the two specialties for advancement in cardiac science and technological growth, ultimately to benefit the patient. In this article, we discuss the Indian and the global scenario of the role of surgeons in the interventional arena and various training modalities available for surgeons to learn the art of cardiac interventions. We tried to understand the impediments in implementing interventional training for surgeons and also propose certain amendments to the way the future cardiothoracic surgeons are trained.

Surgeon length of service and risk-adjusted outcomes: linked observational analysis of the UK National Adult Cardiac Surgery Audit Registry and General Medical Council Register

OBJECTIVES

To explore the relationship between in-hospital mortality following adult cardiac surgery and the time since primary clinical qualification for the responsible consultant cardiac surgeon (a proxy for experience).

DESIGN

Retrospective analysis of prospectively collected national registry data over a 10-year period using mixed-effects multiple logistic regression modelling. Surgeon experience was defined as the time between the date of surgery and award of primary clinical qualification.

SETTING

UK National Health Service hospitals performing cardiac surgery between January 2003 and December 2012.

PARTICIPANTS

All patients undergoing coronary artery bypass grafts and/or valve surgery under the care of a consultant cardiac surgeon.

MAIN OUTCOME MEASURES

All-cause in-hospital mortality.

RESULTS

A total of 292,973 operations performed by 273 consultant surgeons (with lengths of service from 11.2 to 42.0 years) were included. Crude mortality increased approximately linearly until 33 years service, before decreasing. After adjusting for case-mix and year of surgery, there remained a statistically significant (p=0.002) association between length of service and in-hospital mortality (odds ratio 1.013; 95% CI 1.005-1.021 for each year of 'experience').

CONCLUSIONS

Consultant cardiac surgeons take on increasingly complex surgery as they gain experience. With this progression, the incidence of adverse outcomes is expected to increase, as is demonstrated in this study. After adjusting for case-mix using the EuroSCORE, we observed an increased risk of mortality in patients operated on by longer serving surgeons. This finding may reflect under-adjustment for risk, unmeasured confounding or a real association. Further research into outcomes over the time course of surgeon's careers is required.

External chest brace for clam shell sternal instability following bilateral sequential lung transplant: a case series

Background:

A common surgical incision for bilateral lung transplantation is the ‘clam shell’ approach via bilateral anterior thoracotomies and a transverse sternotomy to allow for the replacement of the lungs sequentially (Macchiarini et al, 1999; Karnak et al, 2006 ). Although popular, the clam shell incision (CSI) can be associated with significant postoperative pain, bony overriding or disruptions at the sternotomy site in 32%-60% of patients (Macchiarini et al, 1999; Venuta et al, 2003 ; Richards et al, 2004 ; Karnak et al, 2006 ). The subsequent non-union and sternal instability cause significant morbidity and mortality with reported rates of 34% and 26%, respectively ( Karnak et al, 2006 ).

Content:

The literature revealed a myriad of surgical approaches to this clinical problem, but a paucity of conservative external chest bracing solutions for transverse sternal instability. This case series describes the clinical management of three post bilateral sequential lung transplant (BSLTX) recipients that necessitated the design and development of a custom made external chest orthosis (brace) with input from a multidisciplinary team.

Conclusion:

This brace is offered as a solution for transverse sternal instability and pain following lung transplantation.

Why choose cardiothoracic surgery as a career?

The future of cardiothoracic surgery faces a lofty challenge with the advancement of percutaneous technology and minimally invasive approaches. Coronary artery bypass grafting (CABG) surgery, once a lucrative operation and the driving force of our specialty, faces challenges with competitive stenting and poor reimbursements, contributing to a drop in applicants to our specialty that is further fueled by the negative information that members of other specialties impart to trainees. In the current era of explosive technological progress, the great diversity of our field should be viewed as a source of excitement, rather than confusion, for the upcoming generation. The ideal future cardiac surgeon must be a "surgeon-innovator," a reincarnation of the pioneering cardiac surgeons of the "golden age" of medicine. Equipped with the right skills, new graduates will land high-quality jobs that will help them to mature and excel. Mentorship is a key component at all stages of cardiothoracic training and career development. We review the main challenges facing our specialty--length of training, long hours, financial hardship, and uncertainty about the future, mentorship, and jobs--and we present individual perspectives from both residents and faculty members.

Weathering the storm: how can thoracic surgery training programs meet the new challenges in the era of less-invasive technologies?

OBJECTIVE

The introduction of new technologies has shifted some resident index procedures to nonsurgical specialists. We examined the operative case volume of thoracic surgery residents during the last 6 years to objectively identify changes and trends.

METHODS

Program and resident data from 2002 to 2007 were entered into a database and analyzed. Program match information was obtained from the National Resident Matching Program. Resident operative experience and board examination results were obtained from the American Board of Thoracic Surgery.

RESULTS

A total of 795 residents qualified for the written American Board of Thoracic Surgery examination; 627 residents graduated from 2-year programs, and 168 residents graduated from 3-year programs. The total number of resident cases was higher in 3-year programs compared with 2-year programs in all 10 index categories studied (P < .01). The total volume of cases has not significantly increased in 2-year programs. The volume of coronary artery bypass graft surgeries decreased in every resident program model studied. The volume of general thoracic cases increased in all program models. Two-year, 2-resident programs had the lowest volume in 5 of the 10 categories, reaching significance in 3 categories. The written board pass rate was lower among 2-year programs than among 3-year programs (86% vs 95%, respectively, P = .003).

CONCLUSION

Training programs have so far weathered the storm by maintaining index volume with a new case mix, but significant trends in revascularization procedures are concerning. This study indicates a significant advantage in case volume and board pass rates among 3-year programs. Thoracic residency programs should be reorganized so that the number of residents does not exceed the capacity of the program to provide a meaningful experience.

Trunk stabilisation exercises reduce sternal separation in chronic sternal instability after cardiac surgery: a randomised cross-over trial

QUESTION

Do trunk stabilisation exercises reduce sternal separation and pain, and improve the quality and control of the performance of tasks in individuals with chronic sternal instability?

DESIGN

Randomised crossover study with concealed allocation and intention-to-treat analysis.

PARTICIPANTS

Nine individuals with chronic sternal instability following a median sternotomy for cardiac surgery.

INTERVENTION

The experimental intervention consisted of six weeks of trunk stabilisation exercises; the control intervention was no exercises.

OUTCOME MEASURES

Outcomes were sternal separation measured by ultrasound in mm, pain during the performance of nine everyday tasks measured on a 100-mm visual analogue scale, and the quality and control of the performance of two tasks scored on a 100-mm visual analogue scale.

RESULTS

Overall, sternal separation during the period of trunk stabilisation exercises decreased by 6.2 mm (95% CI 3.5 to 8.9) more than during the control period. Overall, pain decreased when performing everyday tasks by 14 mm (95% CI 5 to 23) more than during the control period. Overall, task performance during the period of trunk stabilisation exercises did not improve (mean difference 10 mm, 95% CI -3 to 22) more than during the control period.

CONCLUSION

Trunk stabilisation exercises should be included in the rehabilitation of individuals who experience sternal instability following cardiac surgery. A larger trial is warranted to determine if stabilisation exercises are beneficial in improving the quality and control of task performance.

Comparative Evaluation of Multimedia Driven, Interactive, and Case-Based Teaching in Heart Surgery

BACKGROUND

Multimedia-augmented instruction with various approaches is used in heart surgery. There is little evidence which instructional techniques and media are of advantage to impart knowledge more effectively and lead to better application of knowledge in the operation room.

METHODS

Sixty-nine students learned with an interactive, case-based teaching (ICBT) course about aortic valve replacement. They were compared with historic controls exposed to identical information provided by a multimedia module presenting content systematically (SMM; n = 69) and a print medium (PM; n = 57). Motivation, computer knowledge, and didactic quality were evaluated with psychometric tests. All groups performed multiple choice pretests and posttests and participated in live surgery during which their performance was assessed.

RESULTS

All groups had equal computer knowledge, but the ICBT group felt significantly less-motivated and more challenged. Multiple choice posttest results were comparable (ICBT 80.2% +/- 10.9%, SMM 76.7% +/- 13.3%, PM 76.9% +/- 11.1). During surgery, the ICBT (79.2% +/- 16%) and SMM groups (82.9% +/- 10%) performed significantly better than the PM group (64.7% +/- 12%; both p < 0.0001). Overall didactic assessment was significantly worse in the ICBT group when compared with the SMM and PM groups.

CONCLUSIONS

For novices in heart surgery, ICBT was less motivating than traditionally structured content (SMM and PM). The ICBT did not improve performance in the operation room. However, both multimedia groups could better apply their knowledge during live surgery. The PM is as effective as multimedia when factual knowledge has to be retained.

Multimedia-driven teaching significantly improves students' performance when compared with a print medium

BACKGROUND

In this study, we compared the educational value of a multimedia module about aortic valve replacement as a preparation for the operating room with a print medium of identical content.

METHODS

One hundred twenty-six students were randomly assigned in a prospective study to either use the multimedia course (n = 69) or a print version (n = 57). A 20-item multiple-choice test was performed before and after learning with the respective medium. Both groups participated in an operation during which they were evaluated with 28 standardized tasks and questions. Individual motivation, computer literacy, and didactic quality of both media were assessed with psychometric tests.

RESULTS

There were no significant differences in the multiple-choice pretest (multimedia, 30.6% +/- 12.4% versus print, 27.9% +/- 11.4%) and posttest responses (multimedia, 76.7% +/- 13.3% versus print, 76.9% +/- 11.1). Mean percentage of correct answers during the operation was 82.9% +/- 10% in the online group and 64.7% +/- 12% in the print group (p < 0.0001). The multimedia group needed significantly (p < 0.001) less study time (105 +/- 24 minutes) when compared with the text group (122 +/- 30 minutes). There were no statistically significant differences in motivation, computer literacy, and didactic quality of either medium.

CONCLUSIONS

Regarding factual knowledge, there is no difference between multimedia-driven learning and a print medium. During heart operations, when understanding of complex temporal and spatial events is essential, students' performance is significantly improved by multimedia-enhanced teaching. The latter further proved to be more efficient in terms of study time.

Is it safe to train residents to perform cardiac surgery?

BACKGROUND

The impact of surgical training on patient outcomes in cardiac surgery is unknown.

METHODS

All cases performed by residents from 1998 to 2001 were compared to staff surgeon cases using prospectively collected data. Operative mortality and a composite morbidity of: reoperation for bleeding perioperative myocardial infarction, infection, stroke, or ventilation more than 24 hours were compared using multivariate analysis.

RESULTS

Four residents performed 584 cases. The cases were as follows: coronary artery bypass grafting (CABG), 366 cases; aortic valve replacement (AVR) with or without CABG (AVR +/- CABG), 86 cases; mitral valve replacement, 31 cases; mitral valve repair, 25 cases; thoracic aneurysm/dissection, 22 cases; aortic root, 20 cases; transplantations, 14 cases; and adult congenital defect repairs, 20 cases. There were 2,638 CABGs and 363 AVR +/- CABG performed by the staff during the same period. Crude operative mortality in CABG patients was 2.5% (resident) and 2.9% (staff) (p = 0.62). In multivariate analysis, resident was not associated with operative mortality odds ratio (OR) of 0.59 (p = 0.19). Resident cases had a higher incidence of the composite morbidity outcome for CABG cases (19.4% vs 13.6% for staff; p = 0.003). However, in multivariate analysis, resident was not associated with increased morbidity (OR = 1.23, p = 0.16). The AVR +/- CABG crude mortality was 3.6% (resident) and 2.8% (staff) (p = 0.69). Because of the small number of cases (n = 447), operative mortality was combined with the composite morbidity outcome for the AVR +/- CABG model. In all, 16.7% of resident cases and 19.8% of staff cases had the composite outcome or died (p = 0.51). In multivariate analysis resident was not associated with this outcome (OR = 0.74, p = 0.35).

CONCLUSIONS

In this analysis of our experience with residency training, the operative morbidity and mortality in CABG and AVR patients was similar for residents and staff. Training residents to perform cardiac surgery appears to be safe.