High OPCAB surgical volume improves midterm event-free survival

Impact of Surgeon Experience and Centre Volume on Outcome After Off-Pump Coronary Artery Bypass Surgery: Results From the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) Registry

AIM

The aim of this study was to assess the impact of surgeon experience and centre volume on early operative outcomes in patients undergoing off-pump coronary artery bypass (OPCAB) surgery.

METHOD

Of 7,352 patients in the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry, 1,549 underwent OPCAB and were included in the present analysis. Using adjusted regression analysis, we compared major early adverse events after procedures performed by experienced OPCAB surgeons (i.e., ≥20 cases per year; n=1,201) to those performed by non-OPCAB surgeons (n=348). Furthermore, the same end points were compared between procedures performed by OPCAB surgeons in high OPCAB volume centres (off-pump technique used in >50% of cases; n=894) and low OPCAB volume centres (n=307).

RESULTS

In the experienced OPCAB surgeon group, we observed shorter procedure times (β -43.858, 95% confidence interval [CI] -53.322 to -34.393; p<0.001), a lower rate of conversion to cardiopulmonary bypass (odds ratio [OR] 0.284, 95% CI 0.147-0.551; p<0.001), a lower rate of prolonged inotrope or vasoconstrictor use (OR 0.492, 95% CI 0.371-0.653; p<0.001), a lower rate of early postprocedural percutaneous coronary interventions (OR 0.335, 95% CI 0.169-0.663; p=0.002), and lower 30-day mortality (OR 0.423, 95% CI 0.194-0.924; p=0.031). In high OPCAB volume centres, we found a lower rate of prolonged inotrope use (OR 0.584, 95% CI 0.419-0.814; p=0.002), a lower rate of postprocedural acute kidney injury (OR 0.382, 95% CI 0.198-0.738; p=0.004), shorter duration of intensive care unit (β -1.752, 95% CI -2.240 to -1.264; p<0.001) and hospital (β -1.967; 95% CI -2.717 to -1.216; p<0.001) stays, and lower 30-day mortality (OR 0.316, 95% CI 0.114-0.881; p=0.028).

CONCLUSIONS

Surgeon experience and centre volume may play an important role on the early outcomes after OPCAB surgery.

Is there a surgeon or hospital volume-outcome relationship in off-pump coronary artery bypass surgery?

A best evidence topic was written according to a structured protocol. The question addressed was whether there is a surgeon or hospital volume-outcome relationship in patients undergoing off-pump coronary artery bypass surgery. A total of 281 papers were found using the reported searches, of which six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The studies found analysed the outcomes of off-pump coronary artery bypass surgery in relation to surgeon or hospital volume and evaluated the presence of a volume-outcome relationship. Reported measures included mortality and major adverse cardiovascular and cerebrovascular events. The methodological quality and strength of each study for exploring volume-outcome relationships were quantitatively assessed using a predefined scoring system. Three studies analysed surgeon volume and three studies analysed hospital volume. The two largest and most recent studies presented a significant volume-outcome relationship in mortality and postoperative complications. Perhaps owing to the smaller sample size, this significant relationship in mortality was not observed in the four smaller studies; however, one of these studies demonstrated a significantly positive relationship for postoperative complications and another study demonstrated a similar significant relationship for the number of grafts and the degree of completeness of revascularization. While the volume-outcome relationship in coronary artery bypass graft surgery is very well-documented, the technically challenging nature of off-pump surgery, the length of the learning curve associated with the operation and the higher risk profile of patients undergoing off-pump surgery in comparison with routine on-pump surgery render these results difficult to interpret. Although our review does support the idea of a volume-outcome relationship in off-pump coronary artery bypass surgery, this relationship may not be so clearly defined and requires further analysis by higher-quality studies.

The effect of surgeon volume on the need for transfusion following primary unilateral hip and knee arthroplasty

INTRODUCTION

we reviewed transfusion practice following primary hip and knee arthroplasty with emphasis on the relationship between surgeon volume and the need for transfusion.

MATERIALS/METHODS

review of a consecutive series of 508 primary, elective, unilateral arthroplasties (248 THR/260 TKR) performed over a 12-month period. Data were analysed to determine the overall rate of transfusion and the details of any such transfusion. Secondarily, multivariate regression was performed to determine the effects of surgeon volume and other recorded variables upon the need for transfusion. For the purpose of analysis we classified surgeons doing more than 52 arthroplasties a year as "high volume" and surgeons performing less than this number as "low volume".

RESULTS

transfusion rates were 10% and 7% following THR and TKR. Multivariate analysis demonstrated that surgeon volume (<52 operations/yr vs. >52 operations/yr) and preoperative Hb<12g/dl were the only significant determinants of a need for postoperative transfusion (p<0.01). High volume and low volume surgeons transfused 5% vs. 17%, respectively (RR=3.3 (95%CI 1.5-9.1) p=0.003) following THR and 4% vs. 13% (RR=3.6 (95%CI 1.4-9.3) p=0.006) following TKR.

DISCUSSION AND CONCLUSION

High volume surgeons have significantly lower transfusion rates when compared to nationally accepted figures.