Teaching off-pump coronary artery bypass surgery

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.

Efficacy of simulation training for beating heart coronary anastomosis using BEAT + YOUCAN simulator

BACKGROUND

We sought to evaluate our distributed practice program developed for training for beating heart anastomosis by employing a novel beating heart simulator.

METHODS

Eleven trainees watched and reviewed instructional video recordings of coronary anastomosis methods with a BEAT  +  YOUCAN training device, then performed coronary anastomosis procedures under a beating condition. Next, they participated in a four-hour training program developed by faculty surgeons. Ten different anastomosis components were assessed on a five-point rating scale (5, good; 3, average; 1, poor). After finishing the training program, each trainee again performed a coronary anastomosis procedure. Component scores were then compared before and after the training program.

RESULTS

The mean time to completion of the procedure improved from 1033  ±  424 to 795  ±  201 s (p < 0.05). Assessment scores improved from 1.88  ±  0.41 to 2.57  ±  0.30 (p < 0.05). Improvements in some technical components related to handling of instruments were noted (p < 0.05), whereas no significant improvement was seen with arteriotomy, graft orientation, suture management, or knot tying after finishing the training program.

CONCLUSION

Trainees who participated in our four-hour focused training program for coronary anastomosis with a novel beating heart simulator showed improved ability under the beating condition in regard to technical skills related to handling instruments.

Long-term follow-up of off-pump and on-pump coronary artery bypass grafting

OBJECTIVE

Despite increasing recognition of the benefits of off-pump coronary artery bypass grafting (CABG), concerns persist regarding its impact on long-term mortality and freedom from reintervention. In this study, we assessed the impact of off-pump CABG on long-term outcomes.

METHODS

From January 2002 to December 2002, a total of 307 consecutive patients who underwent isolated multivessel off-pump CABG at our institution were compared with a control group of 397 patients who underwent multivessel on-pump CABG during the same period. Perioperative data were prospectively collected and compared. In addition, univariate and risk-adjusted comparisons between the two groups were performed at 10 years.

RESULTS

After adjusting for clinical covariates, off-pump CABG did not emerge as a significant independent predictor of long-term mortality [hazard ratio (HR), 0.91; 95% confidence interval (CI), 0.70-1.12], readmission to hospital for cardiac cause (HR, 0.96; 95% CI, 0.78-1.10), or the need for reintervention (HR, 0.93; 95% CI, 0.87-1.05).

CONCLUSIONS

At long-term follow-up, off-pump CABG remains a safe and effective myocardial revascularization strategy with no adverse impact on survival or freedom from reintervention.

Off-pump coronary artery bypass grafting: Misperceptions and misconceptions

Coronary artery bypass grafting (CABG) continues to be one of the most commonly performed cardiac surgical procedures worldwide. Conventional CABG performed on cardiopulmonary bypass termed on-pump CABG is regarded as the gold standard. However, on-pump CABG results in several physiologic derangements including but not limited to thrombocytopenia, activation of complement factors, immune suppression, and inflammatory responses leading to organ dysfunction. Furthermore, manipulating an atherosclerotic ascending aorta during cannulation and cross-clamping can predispose to embolization and stroke risk. Recognition of these detrimental effects of on-pump CABG resulted in resurgence of off-pump CABG nearly two decades ago. Off-pump CABG since its resurgence has been a subject of intensive scrutiny and speculation. Despite numerous retrospective nonrandomized studies, prospective randomized trials, and meta-analyses validating the safety and efficacy of off-pump CABG, opponents of the technique have persistently demanded abandonment of off-pump CABG. Several misconceptions and misperceptions are used as an excuse for such demands. This review article examines published scientific evidence to evaluate these misperceptions and misconceptions about off-pump CABG.

Does off-pump coronary artery bypass grafting negatively impact long-term survival and freedom from reintervention?

Recently published evidence has raised concerns about worse late mortality and increasing need for reintervention after off-pump coronary artery bypass grafting. We undertook this study to assess the impact of off-pump coronary artery bypass grafting on survival and freedom from reintervention at 10 years. From January 2002 to December 2002, 307 consecutive patients who had isolated multivessel off-pump coronary artery bypass grafting at our institution were compared to a control group of 397 patients that underwent multivessel on-pump coronary artery bypass grafting during the same period. In addition, univariate and risk-adjusted comparisons between the two groups were performed at 10 years. Kaplan-Meier survival was similar for the two cohorts. After adjusting for clinical covariates, off-pump coronary artery bypass grafting did not emerge as a significant independent predictor of long-term mortality (Hazard Ratio 0.91; 95% Confidence Interval 0.70-1.12), readmission to hospital for cardiac cause (Hazard Ratio 0.96; 95% Confidence Interval 0.78-1.10), or the need for reintervention (Hazard Ratio 0.93; 95% Confidence Interval 0.87-1.05). Off-pump coronary artery bypass grafting compared with on-pump coronary artery bypass grafting does not adversely impact survival or freedom from reintervention at a 10-year follow-up.