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Ann Thorac Surg 2002;74:S1403-S1407
© 2002 The Society of Thoracic Surgeons

Supplement: Cardiothoracic Techniques and Technologies

The evolution of training in Off-Pump coronary surgery in a single institution

Massimo Caputo, MDa, Alan J. Bryan, FRCSa, Radek Capoun, MDa, Balakrishnan Mahesh, FRCSa, Franco Ciulli, MDa, Jonathan Hutter, FRCSa, Gianni D. Angelini, FRCSa*

a Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom

* Address reprint requests to Professor Angelini, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, BS2 8HW, United Kingdom.
e-mail: g.d.angelini{at}bristol.ac.uk

Presented at the Eighth Annual Cardiothoracic Techniques and Technologies Meeting 2002, Miami Beach, FL, Jan 23–26, 2002.


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: This study analyses the development of off-pump coronary artery bypass (OPCAB) surgery training at a single institution, and compares the early and midterm clinical outcomes of OPCAB and conventional coronary artery bypass grafting (CABG) procedures performed by trainees with or without direct consultant cardiothoracic surgeon supervision.

METHODS: Analysis was undertaken on data prospectively recorded on a computer database (Patient Analysis and Tracking System). Of the 2,422 CABG operations performed between January 1999 and December 2001, 969 (40%) were carried out by trainees either off pump (422) or on pump (547).

RESULTS: Although the total number of CABG operations performed by trainees remained constant, there was a significant increase in the number of OPCAB operations during the study period compared with conventional CABG, as well as an increase in the average number of grafts per patient in the OPCAB group (both p < 0.05). Furthermore, a significant trend towards using two or more arterial conduits in the OPCAB group was observed in the study period. The number of OPCAB operations performed by trainees as independent operators without direct consultant supervision also increased significantly (p < 0.05). Early and midterm clinical outcomes were similar between patients operated by trainees on pump or off pump as independent operators versus under direct consultant supervision.

CONCLUSIONS: The significant increase in OPCAB operations performed by trainees as independent operators or under direct consultant supervision, as well as the increase in the number of grafts per patient and arterial conduits used for myocardial revascularization, demonstrate a progression of training in beating heart surgery for cardiothoracic trainees. Improvements in the techniques have made it safe to teach trainees off-pump multivessel coronary artery revascularization.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Myocardial revascularisation without cardiopulmonary bypass (CPB) on the beating heart now has an established place as a surgical option for coronary artery disease [1–7]. Residents in cardiothoracic surgery have therefore been confronted, in recent years, with a need to gain experience in this innovative approach to coronary surgery [8, 9]. A recent survey [10] in different accredited US training centers has identified a lack of structured training programs, with the majority of residents not reaching proficiency in off-pump coronary artery bypass (OPCAB) surgery during their residency.

During the past 5 years, the number of OPCAB operations performed at our institution has increased significantly; and at the same time, more of these procedures have been undertaken by trainees. We have recently reported our early experience in teaching OPCAB surgery to cardiothoracic trainees, showing no difference in early and midterm clinical outcome whether the surgery was performed by consultant cardiothoracic surgeons or by trainees under direct supervision [8]. Since this report, OPCAB surgery has become an integral part of our specialist training program, and cardiothoracic trainees are equally exposed to OPCAB or conventional CABG surgery, initially under direct supervision and toward the end of the training program without direct consultant supervision.

This study analyzes the development of OPCAB surgery training at our institution, and compares the early and midterm clinical outcome of conventional CABG and OPCAB procedures performed by trainees with or without direct consultant supervision.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
A standard set of perioperative data are collected prospectively for all patients undergoing CABG at our institution. The dataset includes five different sections to be filled in consecutively by anesthesist, surgeon, intensive care unit, high dependence unit and ward nurses. Data are entered into the Patient Analysis and Tracking System, Dendrite Clinical Systems, London, UK. We analyzed data on 969 consecutive isolated CABG operations (40% of the total 2,422 CABG) performed by cardiothoracic trainees between January 1999 and December 2001. Myocardial revascularization was achieved either with (n = 547, on-pump group) or without (n = 422, OPCAB group) the use of CPB and cardioplegic arrest. All operations were performed by 4 trainees, in year 3 or 4 of the 5-year specialist training program in cardiothoracic surgery. Consultant supervision was defined as a case in which the consultant was scrubbed and acted as first assistant. Of the operations carried out using the OPCAB technique, 300 (71%) were performed by a supervised and 122 (29%) by an unsupervised trainee.

Anesthetic and surgical technique
Anaesthetic technique was standardized for every patient and consisted of a protocol previously reported [2, 3]. Cardiopulmonary bypass was instituted using ascending aortic cannulation, a two-stage venous cannulation in the right atrium and a standard circuit as previously reported [2, 3]. Systemic temperatures was kept between 34° and 36°C. Myocardial protection was achieved using intermittent anterograde hyperkalemic warm blood cardioplegia [2, 3]. In the OPCAB patients, the method of exposure to perform the anastomoses has also been previously reported [11, 12]. Briefly, a half-folded swab was snared to the posterior pericardium (using a single-stitch, 0-silk suture), halfway between the inferior vena cava and the left inferior pulmonary vein. Traction was applied on the two limbs of the swab and the snare. These were then fixed to the surgical drapes to facilitate exposure of the target coronary vessels. All anastomoses were performed, whenever possible, with an intracoronary shunt and a pressure stabiliser.

Postoperative management
At the end of surgery, patients were transferred to the intensive care unit and extubated as soon as they met the following criteria: hemodynamic stability, no excessive bleeding (<80 mL/h), normothermia, and consciousness with adequate pain control. Fluid management postoperatively consisted of crystalloid solution infused at 1 mL · kg-1 · h-1, with additional synthetic colloid solutions or blood to maintain normovolemia and hematocrit greater than 24%.

Early mortality was defined as any death that occurred within 30 days of operation. Perioperative myocardial infarction, inotropic support, pacing requirement and arrhythmias, were recorded and defined as previously reported [2, 3]. Pulmonary complications included chest infection, respiratory failure, reintubation and tracheostomy [3]. Postoperative blood loss was defined as total chest tube drainage [5]. Neurologic complications included permanent and transient stroke [13]. Renal complications included acute renal failure as defined by the requirement for hemodialysis or a postoperative creatinine level of more than 200 µmol/L [6]. Finally, infective complications included septicemia and both sternal and leg wound infections, as defined by positive culture and administration of antibiotic therapy.

We aim to discharge patients undergoing CABG on postoperative day 5. The suitability of patients to be discharged home is made by an independent physician according to our unit protocol [3].

Patient follow-up
Follow-up was performed by outpatient visit 6 weeks after surgery, and then by telephone interview by a departmental clinical trial coordinator. Patients were assessed for survival and cardiac events, which included the need for a further coronary revascularization procedure (whether reoperation or percutaneous transluminal coronary angioplasty) or coronary angiography, myocardial infarction, congestive heart failure, arrhythmia or recurrent angina. Clinical diagnostic criteria for all cardiac events other than recurrence of angina have been previously reported [2, 3]. Recurrence of angina was evaluated clinically, supported by an exercise echocardiographic test when indicated. Hospital admissions were examined by obtaining the clinical notes or by general practitioner telephone interview to confirm or to ascertain diagnosis and treatments.

Statistical analysis
All statistical analyses were performed with the aid of the computer software package Statview for Windows (SAS Institute Inc, Cary, NC). Continuous variables are expressed as mean ± standard deviation, and categorical variables presented as either absolute numbers or percentages. Data were checked for normal distribution before statistical analysis. Categorial variables were analyzed using either the {chi}2 test or Fisher’s exact test. Continuous variables were compared using Student’s t test or Mann-Whitney test when appropriate.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
There was a significant increase in the number and proportion of OPCAB procedures during the study period, and a concomitant decrease in conventional on-pump CABG. At the same time, there was a significant increase in the number of OPCAB surgery performed without direct supervision, when the consultant was not scrubbed with the trainee in the operating theater (Fig 1).



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  		Fig 1. Percentage of CABG procedures performed by trainees either on pump (striped bars) or off pump (open bars), and percentage of unsupervised (dotted bars) and supervised (filled bars) off-pump procedures during the study period.

 
Preoperative characteristics of both study groups are shown in Table 1. The two groups were similar with respect to age, sex, diabetes mellitus, angina class, and priority of the operation. In the on-pump group, more patients had double- and triple-vessel disease and less single-vessel disease compared with the OPCAB group, reflecting the fact that trainees are initially exposed to single-vessel OPCAB revascularization. Five patients in the OPCAB group (1.2%) had to be converted into conventional CABG for hemodynamic or electrical instability (4 by supervised and 1 by unsupervised trainees). The average number of grafts per patient was significantly higher in the on-pump (2.9 ± 0.7) compared with the OPCAB (2.4 ± 0.8) group (p < 0.0001; Table 2). There was, however, a significant increase in the average number of grafts per patient during the study period in the OPCAB group (from 2.08 ± 0.8 in 1999 to 2.62 ± 0.8 in 2001, p < 0.05), whereas this number remained relatively constant in the on-pump group (from 2.93 ± 0.9 in 1999 to 2.85 ± 0.8 in 2001). A significantly higher number of left anterior descending coronary artery anastomoses and lower number of circumflex coronary artery anastomoses was performed in the OPCAB compared with the on-pump group, respectively (p < 0.0001, Table 2). Figure 2 shows changes in the pattern of coronary anastomoses in the OPCAB group during the study period. The number of circumflex coronary artery anastomoses increased from 20% in 1999% to 29% in 2001, whereas the number of LAD coronary artery anastomoses decreased from 57% in 1999% to 46% in 2001. The number of right coronary artery anastomoses remained constant. The percentage of arterial conduits other than the left internal mammary artery used for myocardial revascularization increased significantly in the OPCAB group (from 8% in 1999 to 18% in 2001, p < 0.05) during the study period, whereas remaining constant in the on-pump group (from 18% in 1999 to 20% in 2001). Postoperative morbidity and mortality are shown in Table 3. Three patients in the on-pump group died, two of multiorgan failure as a consequence of postoperative low cardiac output syndrome, and another of respiratory failure. Two patients died in the OPCAB group died, with both deaths secondary to heart failure. The incidence of perioperative myocardial infarction and of respiratory, neurologic, and renal complications were similar in the two groups. In the on-pump group, there was a significant increase in postoperative inotropic use and transfusion requirement, as well as a significantly longer intubation time. There were no differences in the intensive care unit and hospital stays in the two groups.


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  		Table 1. Baseline Characteristics of Study Patients

 

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  		Table 2. Intraoperative Data

 


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  		Fig 2. Percentage of off-pump coronary artery anastomoses performed during the study period: circumflex coronary artery (filled bars), right coronary artery (striped bars), and left anterior descending coronary artery (open bars) anastomoses.

 

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  		Table 3. Postoperative Data

 
Table 4 shows follow-up data in the two study groups. The mean duration was 21.2 ± 9.5 months in the OPCAB group and 22.5 ± 9.2 months in the on-pump group. In both groups, there was a significant decrease in the angina class compared to preoperative status (p = 0.001). No differences were observed in survival or in the incidence of cardiac events between groups.


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  		Table 4. Midterm Follow-Up Results

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
The rapid evolution of OPCAB surgery in recent years has resulted in its widespread popularization as an alternative to conventional CABG surgery. Residents in cardiothoracic surgery are confronted with a need to gain experience in this novel approach to myocardial revascularization, at the same time as their seniors. Consultants therefore face a dilemma between their duty to deliver the highest possible standard of care to their patients and the duty both to learn themselves and to teach surgeons in training developing techniques of coronary surgery. A recent survey [10] from several cardiothoracic training centers in the United States showed that only 22% of residents had performed 20 or more OPCAB procedures during their training, and only 12% had performed 20 or more complete myocardial revascularizations. Of these, only 4% had performed OPCAB circumflex coronary artery revascularization. The survey clearly demonstrated that the majority of residents did not reach proficiency in OPCAB surgery at the end of their residency. Our study summarizes the experience of a single institution in training cardiothoracic residents to OPCAB surgery. We did not find any difference in the perioperative morbidity and mortality and early-term follow-up results in patients operated on by trainees with or without the use of CPB. The study data prove the point that multivessel OPCAB surgery is a safe and reproducible surgical technique and can be taught successfully to cardiothoracic surgery residents. All 4 trainees in this study had already performed a minimum of 30 on-pump CABG operations before starting to perform off-pump revascularization. Nevertheless, in the last 2 years, junior surgeons have been exposed to beating-heart coronary surgery at the same time they are starting to perform conventional CABG. Trainees routinely participate in the preoperative patient and technique selection and are allowed to perform operations unsupervised when they have satisfied the senior surgeon with regard to their decision making and surgical ability (generally after 30 to 40 supervised cases).

During the study period, there was a significant increase in the number of distal coronary anastomoses, in the use of a second arterial graft other than the left internal mammary artery and in the number of OPCAB circumflex coronary artery anastomoses performed, all indicating the evolution of OPCAB surgery training. Residents are started on simple OPCAB cases requiring only left anterior descending coronary artery or diagonal grafts, before gradually moving to posterior descending artery grafting and finally to the circumflex system, which remains technically more challenging from a topographic standpoint. At the same time there is an increase in the use of a second arterial conduit other than the left internal mammary artery (ie, right internal mammary or the radial artery) to achieve a more complete arterial revascularization.

In the OPCAB group, 122 patients were operated on by trainees without direct consultant supervision, and the number increased during the study period from 10% in 1999 to 42% in 2001. Trainees will have performed between 30 and 40 multivessel OPCAB revascularizations as first surgeon under consultant supervision, before starting performing the operation with the consultant not scrubbed in theater but supervising from outside. The perioperative mortality and morbidity in this subgroup of patients operated on by trainees without direct consultant supervision was not statistically and significantly different from that of patients operated by trainees scrubbed with the consultant.

One limitation of this study was its observational nature. Higher-risk cases or more technically demanding cases might have been selectively performed using CPB, although this did not seem to have produce two dissimilar group of patients.

In conclusion, our data show that OPCAB surgery can be safely taught to cardiothoracic trainees, with similar early and midterm clinical outcomes in comparison to conventional CABG surgery. We believe that a modern surgical program should expose trainees to both on-pump and off-pump techniques, given the fact that the latter has to become an integral part of coronary surgery. We also strongly recommend the development of specific OPCAB training programs in those centers with senior surgeons proficient in the technique. This will positively affect the future expectations of many cardiothoracic trainees who are likely to practice off-pump coronary surgery after their training is completed.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
The Garfield Weston Trust, The National Heart Research Fund and the British Heart Foundation supported this work.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Mack M.J. Pro: beating-heart surgery for coronary revascularisation: is it the most important development since the introduction of the heart-lung machine?. Ann Thorac Surg 2000;70:1774-1778.[Free Full Text]
  2. Ascione R., Lloyd C.T., Gomes W.J., Caputo M., Bryan A.J., Angelini G.D. Beating versus arrested heart revascularisation: evaluation of myocardial function in a prospective randomized study. Eur J Cardio-thorac Surg 1999;15:685-690.[Abstract/Free Full Text]
  3. Ascione R., Caputo M., Calori G., Lloyd C.T., Underwood M.J., Angelini G.D. Predictors of atrial fibrillation after conventional and beating heart coronary surgery: A prospective, randomized study. Circulation 2000;102:1530-1535.[Abstract/Free Full Text]
  4. van Dijk D., Nierich A.P., Jansen E.W.L. Early outcome after off-pump versus on-pump coronary bypass surgey: results from a randomised study. Circulation 2001;104:1761-1766.[Abstract/Free Full Text]
  5. Ascione R., Williams S., Lloyd C.T., Sundaramoorthi T., Pitsis A.A., Angelini G.D. Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations: a prospective randomized study. J Thorac Cardiovasc Surg 2001;121:689-696.[Abstract/Free Full Text]
  6. Ascione R., Lloyd C.T., Underwood M.J., Gomes W.J., Angelini G.D. On-pump versus off-pump coronary revascularisation: evaluation of renal function. Ann Thorac Surg 1999;68:493-498.[Abstract/Free Full Text]
  7. Buffolo E., de Andrade C.S., Branco J.N., Teles C.A., Aguiar L.F., Gomes W.J. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-66.[Abstract/Free Full Text]
  8. Caputo M., Chamberlain M.H., Ozalp F., Underwood M.J., Ciulli F., Angelini G.D. Off-pump coronary operations can be safely taught to cardiothoracic trainees. Ann Thorac Surg 2001;71:1215-1219.[Abstract/Free Full Text]
  9. Karamanoukian H.L., Panos A.L., Bergsland J., Salerno T.A. Perspectives of a cardiac surgery resident in-training on off-pump coronary bypass operation. Ann Thorac Surg 2000;69:42-46.[Abstract/Free Full Text]
  10. Ricci M., Karamanoukian H.L., D’Ancona G. Survey of resident training in beating heart operations. Ann Thorac Surg 2000;70:479-482.[Abstract/Free Full Text]
  11. Watters M.P., Ascione R., Ryder I.G., Ciulli F., Pitsis A.A., Angelini G.D. Hemodynamic changes during beating heart coronary surgery with the "Bristol Technique". Eur J Cardio-thorac Surg 2001;19:34-40.[Abstract/Free Full Text]
  12. Bergsland J., Karamanoukian H.L., Soltoski P.R., Salerno T.A. "Single suture" for circumflex exposure in off-pump coronary artery bypass grafting. Ann Thorac Surg 1999;68:1428-1430.[Abstract/Free Full Text]
  13. Lloyd C.T., Ascione R., Underwood M.J., Gardner F., Black A., Angelini G.D. Serum S-100 protein release and neuropsychologic outcome during coronary revascularization on the beating heart: a prospective randomised study. J Thorac Cardiovasc Surg 2000;119:148-154.[Abstract/Free Full Text]



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