Off-Pump Coronary Artery Bypass Graft Surgery: A Training Course for Novices and its Learning Curve

Abstract

Background: The learning curve for off-pump coronary artery bypass grafting (OPCABG) surgery still requires further discussion. Training programs aimed at the conversion of conventional coronary artery bypass grafting (CABG) to OPCABG have mainly been geared towards those persons who already have much experience in conventional CABG. The goals of this study were to retrospectively analyze the training process of two trainees who had no previous coronary surgery experience and to discuss the efficiency and feasibility of the training. Methods: Two cardiac surgeons were enrolled in this study; they had different surgical backgrounds but neither had ever previously performed coronary surgery. They were trained to become independent surgeons capable of performing OPCABG procedures by a supervising surgeon who had performed more than 2 000 OPCABG surgeries. Clinical data were collected from each trainee subject's first 100 cases of OPCABG surgery and grouped according to the following scheme: Group A₁ (Doctor A's first 50 cases), Group A₂ (Doctor A's second 50 cases), Group B₁ (Doctor B's first 50 cases) and Group B₂ (Doctor B's second 50 cases). A consecutive series of 50 cases of OPCABG surgery performed by the supervising surgeon served as the control group (Group C). Cumulative sum failure analysis for each subject was used to complete the learning curve study. Results: The training time was 28 months for Doctor A and 24 months for Doctor B; the difference in training time was presumably due to their different surgical backgrounds. Among the cases in Group A₁, Group A₂ and Group B₁, there were fewer distal anastamoses, fewer sequential grafts, and less marginal branch grafting in the left circumflex artery than in the Group C cases. Operating times and ICU stay were longer in Group A₁ than in Group C. There were no group differences with regard to total mortality or the incidence of complications. CUSUM analysis showed that the curves of the two trainees had a small steep elevation during the first 30 cases, and proceeded smoothly thereafter, never passing the 80 % alert lines. Conclusions: The appropriate qualifications for OPCABG trainees and the optimal OPCABG training program have not yet been resolved. In this study, the observed learning curves of cardiac surgeons who had no prior coronary surgery experience during their training to perform the OPCABG procedure by a sophisticated OPCABG surgeon indicated that the training program employed was feasible and its outcomes were reasonable.

coronary artery bypass - off‐pump - learning curve

References

• 1 Mack M, Bachand D, Acuff T. et al . Improved outcomes in coronary artery bypass grafting with beating heart techniques.  J Thorac Cardiovasc Surg. 2002;  124 598-607
• 2 Angelini G D, Taylor F C, Reeves B C. et al . Early and midterm outcome after off pump and on pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2) – a pooled analysis of two randomised controlled trials.  Lancet. 2002;  359 1194-1199
• 3 Novick R J, Fox S A, Stitt L W. et al . Assessing the learning curve in off-pump coronary artery surgery via CUSUM failure analysis.  Ann Thorac Surg. 2002;  73 S358-S362
• 4 Novick R J, Fox S A, Stitt L W. et al . Cumulative sum failure analysis of a policy change from on-pump to off-pump coronary artery bypass grafting.  Ann Thorac Surg. 2001;  72 S1016-S1021
• 5 Song H K, Petersen R J, Sharoni E. et al . Safe evolution towards routine off-pump coronary artery bypass: negotiating the learning curve.  Eur J Cardiothorac Surg. 2003;  24 947-952
• 6 Ricci M, Karamanoukian H L, D'Ancona G. et al . Survey of resident training in beating heart operations.  Ann Thorac Surg. 2000;  70 479-482
• 7 Baird C, Modi P, Bayes S M. et al . A survey of specialist registrar training in OPCAB surgery in the UK.  Eur J Cardiothorac Surg.
• 8 Edmunds L H, Clark R E, Cohn L H. et al . Guidelines for reporting morbidity and mortality after cardiac valvular operations.  Ann Thorac Surg. 1988;  46 257-259
• 9 Nathoe H M, van Dijk D, Jansen E W. et al . A comparison of on pump and off pump coronary bypass surgery in low-risk patients.  N Engl J Med. 2003;  348 394-402
• 10 Ascione R, Reeves B C, Taylor F C. et al . Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2) – quality of life at mid-term follow-up in two randomised trials.  Eur Heart J. 2004;  25 765-770
• 11 Sabik J F, Blackstone E H, Lytle B W. et al . Equivalent midterm outcomes after off-pump and on-pump coronary surgery.  J Thorac Cardiovasc Surg. 2004;  127 142-148
• 12 Caputo M, Reeves B, Rogers C. et al . Monitoring the performance of residents during training in off-pump coronary surgery.  J Thorac Cardiovasc Surg. 2004;  128 907-915
• 13 Jenkins D, Al Ruzzeh S, Khan S. et al . Multivessel off-pump coronary artery bypass grafting can be taught to trainee surgeons.  J Card Surg. 2003;  18 419-424
• 14 Grunkemeier G L, Wu Y X, Furnary A P. Cumulative sum techniques for assessing surgical results.  Ann Thorac Surg. 2003;  76 663-667