Coronary Revascularization in a Teaching Hospital and Tertiary Care Center: Where Do We Stand?

Objectives: Coronary artery bypass grafting (CABG) poses a central teaching procedure in cardiac surgery while being technically demanding and subjected to frequent guideline developments. To ensure patient safety in a teaching hospital, a prudent strategy is of main concern.

Methods: Patient selection, surgical techniques and short-term outcome in our institution were retrospectively analyzed from 2017 to 2019 (n = 1,421).

Result: Of all CABG procedures, 20.5% (n = 292) were performed by residents, which make up 33% of the team. Altogether eight colleagues were trained during the studied period. Significant differences in patient selection were found. While age and gender distribution were equal, significantly less patients showed previous myocardial infarction <48 hours (3.4 vs. 12.6%). Also, significantly fewer emergency cases were treated by residents (2.1 vs. 10.1%) while left ventricular ejection fraction was significantly more often preserved (LVEF > 50%) in resident's cases (81.8 vs. 66.3%). Further, the patients treated by the residents were significantly healthier. While ASA class I and II were seen more often in training cases (4.5 vs. 2.2% and 18.5 vs. 12.5), ASA class III (53.4 vs. 58.1), IV (23.6 vs. 26.6) and V (0 vs. 0.6%) were predominantly treated by a senior surgeon.

The rate of off-pump technique (OPCAB) was lower in residents (16.1 vs. 43.7%). Still, the number of distal arterial anastomoses (1.98 vs. 1.84) as well as the amount of total arterial revascularization (71.6 vs. 60.1%) was significantly higher in the residents. This is paralleled by a higher amount of distal venous anastomoses exerted by the senior surgeons (0.36 vs. 0.6). Duration of surgery did not differ significantly (255 vs. 241 minutes).

The patients' outcome was comparable: The same rate of patients was discharged home (84.6 vs. 84.0%). Resternotomy rate (2.4 vs. 3.0%), postoperative myocardial infarction rate (1.4 vs. 1.6%), incidence of mediastinitis (0.7 versus 0.3%) and 30-day mortality (1.0 vs. 1.4%) did not diverge between the groups as well.

Conclusion: Providing judicious patient selection and recognizing the recommendation of using preferably arterial grafts also in teaching procedures, surgical training without negative influence on patient safety can be ensured. While TAR seems to be more frequent in healthy patients, venous grafts are still needed in severely ill patients. And in spite of being technically more challenging, OPCAB can be part of professional training with success.

Publication History

Article published online:
19 February 2021