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Ann Thorac Surg 2000;70:479-482
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Survey of resident training in beating heart operations

^a Division of Cardiothoracic Surgery and Center for Minimally Invasive Cardiac Surgery, Buffalo General Hospital and SUNY at Buffalo, Buffalo, New York, USA
^b Department of Surgery, University of California at San Diego, San Diego, California, USA

Address reprint requests to Dr Hratch Karamanoukian, Division of Cardiothoracic Surgery, Buffalo General Hospital, 100 High St, Buffalo, NY 14203
e-mail: lisbon5{at}yahoo.com

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. "Off-pump" coronary artery operations are done with increasing frequency in the treatment of coronary artery disease. As a result, residents in thoracic surgery have been confronted with the necessity of gaining experience in this innovative approach to coronary surgery. The aim of this study was to assess the importance of training in minimally invasive coronary revascularization as it was perceived by thoracic surgery residents.

Methods. A postal, multiple-choice survey questionnaire was sent to all cardiothoracic surgery residents (n = 327) of accredited training programs in the United States. Responses were tabulated and analyzed.

Results. The overall response rate was 68% (222 of 327 residents). The attending staff was very interested (37%), or had some interest (63%), in beating heart coronary revascularization. Ninety-eight percent of the programs had at least one surgeon performing off-pump procedures. Although 88% of the responding residents showed some interest in off-pump coronary operations, only 22% of them had performed more than 20 off-pump cases, and even less (12%) had performed more than 20 cases of off-pump complete revascularization, or off-pump circumflex revascularization (4%). Sixteen percent of them had no clinical experience with these techniques. Regarding career intentions, 88% of the residents indicated that off-pump coronary operations were expected to be part of the practice, and 58% of them were interested in pursuing additional training in less invasive heart procedures.

Conclusions. The results of this survey suggest that training in off-pump coronary revascularization is variable across training programs, and that the majority of residents may not reach proficiency in coronary procedures on the beating heart during their residency. This may adversely affect their future expectations, as 88% of them would like to practice off-pump coronary surgery once the training is completed.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) has been recently introduced and popularized as an alternative to conventional myocardial revascularization in the treatment of coronary artery disease [1, 2]. Although the long-term results of beating heart coronary revascularization have not been fully elucidated, the short- and midterm efficacy and safety of CABG without CPB have been substantiated by numerous investigations [3–6]. Refinements in techniques of cardiac elevation avoiding hemodynamic compromise [7, 8], target vessels exposure, and mechanical epicardial stabilization [9] have substantially improved the safety and reliability with which distal coronary anastomoses on the beating heart can now be constructed. In this regard, the value of such approach have been substantiated by several series, which conclu-sively demonstrated that distal anastomoses constructed without CPB are associated with patency rates comparable to those of distal anastomoses performed on the electromechanically arrested heart [3, 5, 6, 10]. Although coronary artery grafting without CPB was introduced many years ago [11, 12], recent technical advances have caused a remarkable resurgence of interest for this technique, and have greatly affected the feasibility of complete myocardial revascularization without CPB. Given the ever-growing popularization, it appears that CABG without CPB has gained a definitive role in the armamentarium of therapeutic options for coronary artery disease.

On the basis of these considerations, several questions and concerns may arise as to whether, and to which extent, coronary artery grafting without the utilization of CPB should be considered an integral part of the education in thoracic surgery for residents who are engaged in residency training programs [13]. The aim of the present study was to assess and delineate the importance of training in minimally invasive coronary revascularization as it is perceived by current trainees in thoracic surgery.

	Material and methods

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At the beginning of 1999, a postal, multiple-choice survey questionnaire was sent to all the residents (n = 327) who were actively engaged in accredited training programs in Thoracic Surgery in the United States. The questions included in the questionnaire were formulated in an attempt to define the exposure of residents to "off-pump" CABG, and assess their interest in acquiring the technical skills necessary to embark on this technique once in practice. Questions were formulated to quantify the total number of off-pump coronary procedures, along with the number of complete off-pump revascularizations through a median sternotomy, the number of cases with revascularization of the circumflex territory, and the number of minimally invasive direct coronary artery bypass performed by the residents. In addition, several questions were formulated so as to identify the interest of the thoracic surgery residents in acquiring skills in off-pump coronary revascularization. All the responses received from the residents were tabulated and analyzed. Residents who did not respond were categorized as nonresponders. The survey questions are listed in Table 1.

	Results

Top Abstract Introduction Material and methods Results Comment References

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
During the past decade, the evolution of techniques of myocardial revascularization without CPB has resulted in the widespread popularization of this technique as a valid alternative to conventional coronary revascularization [4, 14, 15]. This phenomenon has occurred widely around the world, and has concerned private medical facilities and academic teaching institutions alike. As a result, residents in thoracic surgery have been confronted, in recent years, with the necessity of gaining experience in this innovative approach to coronary operations.

The data shown in our survey, along with numerous studies and investigations on techniques of off-pump myocardial revascularization recently published in the literature [1, 2, 4, 15], clearly demonstrate that the interest of thoracic surgery residents for this modality of coronary revascularization is remarkable. Nevertheless, the instruction and the exposure that residents receive in off-pump coronary procedures in various training programs is highly variable and is largely dependent on the interest of the teaching faculty at the training institution.

Although the results of our study refer only to the proportion of residents (68%) who responded to the questionnaire, they clearly demonstrate that the interest for off-pump operations is considerable. This may have been partly explained by the fact that 88% of them believe they might perform this procedure once in practice. As a result, based on the increasing popularization of this technique, a question may arise as to whether part of the training in thoracic surgery should be devoted to the acquisition of technical skills in off-pump coronary artery procedures.

These considerations are largely based on the fact that thoracic surgery residents already face the challenge of having to acquire skills in diverse and complex fields of the specialty, such as conventional coronary surgery, valve surgery, surgery of the aorta, general thoracic surgery, transplantation, pediatric cardiac surgery, and many others [16]. As a result, there has been concern regarding the ability that residents may have in familiarizing, and ultimately mastering, all components of the education in thoracic surgery [13]. Moreover, there has been considerable skepticism on the potential that residents may have in acquiring the technical ability and expertise in a technically complex field such as coronary revascularization without CPB.

Despite these adverse factors, several training programs across the country, including ours [13], have shown that the acquisition of skills in off-pump coronary operations is not only feasible, but safe. In this regard, we strongly believe that the instruction in off-pump coronary procedures has been considerably facilitated by modern technological advances, such as those concerning mechanical stabilizers of the new generation [9]. In our experience [13], as well as in those of others, we have observed that training in off-pump coronary operations can, and probably should, begin early on during the course of the training in thoracic surgery, especially if this is limited to a 2-year period. Although a brief period for acquiring and refining the skills in conventional coronary operations seems appropriate, and probably beneficial, we have observed that residents should simultaneously direct their attention to off-pump coronary procedures from the very beginning, possibly during the first few weeks or few months of residency. Some of the skills required for constructing vascular anastomoses, in fact, should have been already acquired as an essential component of the instruction in general surgery. As a result, after only a brief period of practice in conventional coronary surgery on the electromechanically arrested heart, residents could rapidly focus on the acquisition of skills necessary to perform off-pump operations, first by learning the modalities adopted to obtain coronary exposure and mechanical stabilization. In this regard, they should initially become familiar with techniques of exposure of target coronary arteries while maintaining adequate hemodynamic measurements, which entail placing a suture in the oblique sinus of the posterior pericardium to elevate the heart [8], and manipulating the heart by anterior and lateral displacement [9]. The next step, in our experience, is usually represented by acquisition of the skills involved in positioning the mechanical stabilizer, regardless of its type, to eliminate motion. As the experience progressively increases, exposure of "topographically" difficult coronary arteries, such as those located on lateral and inferior wall of the heart, may be practiced. Acquisition of the skills involved in elevation, exposure, and stabilization may require, in our experience, approximately 8 to 10 operations. Once the fundamentals of these strategies are acquired, the next important step is to familiarize with the technical maneuvers required to perform distal anastomoses on the beating heart [9], and learn their proper sequence of revascularization. These encompass placement of the coronary "snare" (a 5-0 Prolene suture [Ethicon, Sommerville, NJ] placed around the coronary artery proximally to the site where the distal anastomosis is constructed), the arteriotomy, the insertion of the intracoronary shunt, and the use of the blower/aerosolizer to maintain a bloodless operative field [17]. Finally, the acquisition of the technical skills required to hand-saw distal anastomoses is necessary. At least initially, revascularization of coronary arteries located on the anterior wall of the heart is practiced. As the experience of the resident progresses, more difficult distal anastomoses, such as those involving coronaries located in the circumflex system and distal branches of the right coronary artery, are constructed. In contrast to what is commonly thought, construction of distal anastomoses does not always represent the most difficult component of the operation, as is often the case when ideal exposure and stabilization have been accomplished. In this regard, we have noted that the use of intracoronary shunts during construction of distal anastomoses not only diminishes the likelihood of a technical error, but also increases the margin of safety by improving distal perfusion, particularly advantageous as extra time may be required by less experienced trainees. In addition, it provides a bloodless field by shunting blood and prevents "backwalling" during suturing.

Although the exact number of procedures required for the acquisition of the skills in off-pump coronary revascularization may be difficult to identify, and obviously varies from resident to resident, the experience of residents at our institution has shown that approximately 15 to 20 operations are generally required to perform complete myocardial revascularization under supervision. In contrast, although standards for training in off-pump coronary surgery are lacking, there has been evidence to suggest that as many as 50 procedures may be necessary for the trainee to become proficient with these techniques and perform these procedures independently [13].

In light of these considerations, it appears obvious that, despite 98% of the responding residents demonstrated some interest in off-pump coronary surgery, and 88% of them would see themselves engaged in performing these procedures once in practice, only 22% of them had performed 20 or more off-pump operations during training, and only 12% had performed 20 or more complete myocardial revascularization on the beating heart. Similarly, our survey has shown that only 4% of them had performed off-pump circumflex revascularization. Although these figures do not accurately describe the experience of all the residents in training in the US (32% of them did not respond), and do not represent the overall operative experience of the residents at the end of their training (but only at the time at which the questionnaire was sent), the results of our survey suggest that the majority of residents may not reach proficiency in off-pump coronary procedures at the end of their residency. This may adversely affect their future expectations, as 88% of them would like to practice off-pump coronary surgery after the training is completed.

	References

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