Ann Thorac Surg 2007;83:462-467
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Training of Cardiac Surgeons for Bosnia and Herzegovina: Outcomes in Coronary Bypass Grafting Surgery
Jacob Bergsland, MDa,d,e,*,
Emir Kabil, MD, PhDd,
Emir Mujanovic, MD, PhDd,
Ibrahim Terzic, MDd,
Jo Røislien, PhDc,f,
Jan L. Svennevig, MD, PhDb,
Erik Fosse, MD, PhDa
a The Interventional Center, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
b Department of Thoracic Surgery, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
c Department of Biostatistics, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
d Cardiovascular Clinic, University Clinical Medical Center, Tuzla, Bosnia and Herzegovina
e Buffalo General Hospital, Kaleida Health, Buffalo, New York
f Department of Biostatistics, Faculty of Medicine, University of Oslo, Norway
Accepted for publication September 1, 2006.
* Address correspondence to Dr Bergsland, The Interventional Center, Rikshospitalet-Radiumhospitalet Medical Center, NO-0027 Oslo, Norway (Email: nielsb{at}aol.com).
 |
Abstract
|
|---|
BACKGROUND: Bosnia and Herzegovina did not have invasive cardiac diagnosis or cardiac surgery before the recent war. With assistance from the United States and Norway, a cardiovascular clinic was developed. This study reports center-specific and surgeon-specific clinical outcomes. Since off-pump coronary bypass grafting surgery was prioritized in the treatment of coronary disease, a comparison was made between operations performed with and without cardiopulmonary bypass.
METHODS: Surgeons and key staff members were trained in the United States. A Norwegian data management system for cardiac surgery was implemented and cases entered after quality review of the data. A total of 1276 patients were entered; operations were performed with cardiopulmonary bypass in 540 and without in 736. The primary surgeon was entered as a variable in an anonymous fashion.
RESULTS: Overall mortality for coronary bypass grafting surgery was 1.6%, and the major complication rate was 4.5%. Patients operated on off-pump received fewer grafts and had a shorter length of stay. Unfavorable outcome was more common in patients when cardiopulmonary bypass was used in the operation. Regression analysis demonstrated that the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and use of cardiopulmonary bypass were predictors of poor outcome. The individual surgeon factor did not impact on outcomes.
CONCLUSIONS: Our study confirms that coronary artery bypass grafting surgery may be performed safely in a poor country in a hospital without experience with cardiac surgery. Selection of talented staff and cooperation with international cardiac centers are crucial. Off-pump coronary artery bypass grafting surgery is suitable for a new center and does not require more training than standard procedures.
|
Introduction
|
|---|
After the disintegration of Yugoslavia and the subsequent war, Bosnia and Herzegovina (BIH) emerged as an independent country. The war left the country with drastically reduced resources and increased demands for medical services because advanced medical care had previously been provided in other parts of Yugoslavia. A serious deficiency was the lack of cardiac invasive diagnosis and treatment and lack of cardiac surgery. It was not possible for BIH to continue the policy of sending cardiac patients out of the republic for treatment. Coronary artery disease and rheumatic valvular disease are common in BIH, which after the war has one of the lowest income levels in Europe.
A center for cardiology and cardiovascular surgery was developed between 1995 and 1998 in the medium-sized city of Tuzla. Resources and training were obtained mainly from the United States (US) and Norway, and the clinical program was initiated after 3 years of preparation. This report describes the training program and reviews the results of coronary bypass grafting surgery (CABG) in the new center.
|
Material and Methods
|
|---|
Training
Surgeons were trained at Buffalo General Hospital, an institution affiliated with the State University of New York. Technical expertise, certification in general and vascular surgery, and ability to communicate in English were mandatory requirements. Surgeons underwent 6 months of hands-on and didactic training, and participated in preoperative, perioperative, and postoperative care as well as in local conferences and in one major national conference. US textbooks about cardiac surgery and open access to the library gave opportunity for self-study.
The study period in the United States was followed by training in BIH under the supervision of a US surgeon. The training focused on management of adult cardiac procedures and especially CABG, a main priority from the outset. Major effort was placed on off-pump bypass surgery (OPCAB), which was considered the most cost-effective therapy [1–3]. It was, of course, an important issue to educate both surgeons and perfusionist trainees in the use of cardiopulmonary bypass (CPB). The surgeons had extensive experience with operations for atherosclerotic peripheral vascular disease and vascular war injuries; therefore the techniques of vascular anastomosis had already been acquired. Knowledge about CPB, cardiac ischemia, and management of arrhythmias and low cardiac output syndrome was limited, however.
One of the 6 surgeons who underwent training in the United States was the previous chief of general surgery and became the chief of cardiac surgery, 3 others became staff cardiac surgeons, and 2 continued to focus on vascular surgery. Parallel with the surgical program, 2 cardiologists, 3 anesthesiologists, 2 perfusionists, 5 intensive care unit (ICU) nurses, 1 x-ray technician, and 1 clinical engineer were also trained in Buffalo.
Physical Resources
Rebuilding of facilities destroyed by war was accomplished with help from the United States and Norway. The US Agency for International Development (USAID) supported the educational program through a project run by the American International Health Alliance (AIHA) and contributed funds for reconstruction of operating rooms and the ICU. Resources allocated for the cardiac program included 4 beds in ICU, 2 cardiac catheterization laboratories, 2 cardiac operating rooms, and a ward with 25 beds. Equipment was donated or purchased, and operational expenses were initially covered by patients and subsequently by insurance funds.
Patients
A large number of patients were referred to the clinic. Intake was limited by capacity and financial resources, but gradually increased to almost 2000 catheterizations and more than 400 operations yearly. About 70% of the patients had coronary disease as their main problem. Patients with single-vessel disease were usually treated by percutaneous coronary intervention or minimally invasive direct coronary grafting, and patients with more than single-vessel disease received CABG using CPB (ONCAB) or OPCAB.
Surgical Techniques
All patients included in this analysis were operated on through a median sternotomy. In general, the left internal thoracic artery was used to bypass the left anterior descending coronary artery. The remaining bypasses were usually performed using saphenous veins. Some patients, usually the younger ones, received more arterial grafts. In ONCAB, aortic and right atrial cannulations and antegrade blood cardioplegia were used. Retrograde cardioplegia was occasionally added. CPB circuits were not coated, but membrane oxygenator and arterial filter were routinely used. OPCAB was performed using the "Lima" stitch for cardiac exposure [4] and a pressure type stabilizer. A cell-saving device was used when more than 2 grafts were planned or there was more bleeding than usual. An intravascular shunt [5] was used during anastomosis in most patients to prevent ischemia.
The decision to perform the operation on-pump or off-pump was somewhat arbitrary, with a tendency to assign to OPCAB those patients with more risk factors such as peripheral vascular disease and low ejection fraction. Patients requiring more than 4 grafts were often assigned to ONCAB. The 4 local surgeons and the US trained surgeon were assigned cases by consensus. The chief surgeon (one of the local surgeons) initially operated on most of the patients to obtain enough experience. All operations were performed by one surgeon assisted by a colleague.
Data Collection
The DatacorR software developed at Rikshospitalet University Hospital in Norway [6] was used to enter clinical data on the cardiac surgery patients. Data were entered by the operating surgeon and quality controlled by one of the authors (EM). In addition to demographic data, left ventricular ejection fraction and European System for Cardiac Operative Risk Evaluation (EuroSCORE) [7] were recorded.
Mortality was recorded as death before discharge or before postoperative day 30. Stroke was recorded as a neurologic deficit lasting more than 24 hours. Perioperative myocardial infarction was recorded when new Q-waves were seen on the electrocardiogram and levels of serum creatine kinase-MB isoenzymes were elevated. A major adverse event was recorded when a patient died or a stroke or myocardial infarction occurred. The time on a respirator was recorded in hours from entrance in the ICU until extubation, and length of stay was recorded in days from the operation until the time of discharge from the hospital. Postoperative bleeding was recorded in milliliters from chest closure until 24 hours after the operation or until removal of chest drains, whichever occurred first.
Data collection was complete for mortality, complications, and EuroSCORE. Data for ejection fraction were lacking in 27 patients and in 3 for the number of distal anastomoses. In the beginning, reporting of bleeding (531 missing values) and respiratory time (560 missing value) was poor, but this improved later. Seven of the 700 patients for whom time on the respirator was recorded had very prolonged respirator times (>24 hours) and were excluded from analysis for this variable.
Statistical Analysis
Data were analyzed using SPSS 12R (SPSS Inc, Chicago, IL). Categoric data were analyzed with 
2 and logistic regression analysis. Continuous variables were analyzed by analysis of variance, t test, and linear regression. When continuous variables were not normally distributed, nonparametric tests were used. Because of skewed data for bleeding and length of stay, a logarithmic transformation of these values was done before linear regressions were performed so that analyses would be mathematically valid. Differences were considered statistically significant if p < 0.05.
|
Results
|
|---|
The analysis included 1276 patients: 736 OPCAB and 540 ONCAB. The ONCAB patients received a mean ± SD of 3.18 ± 0.78 distal anastomosis compared with 2.42 ± 0.90 for OPCAB (p < 0.001)
Preoperative risk factors and postoperative complications are listed in Table 1
and Table 2. Ejection fraction and gender distribution were similar. Age and EuroSCORE in the OPCAB group were higher than in ONCAB. Overall mortality was 1.6%, and the incidence of major adverse events was 4.5%. Mortality and major adverse events were significantly lower in OPCAB patients. Median EuroSCORE (interquartile difference) in both groups was 2.0 (1 to 3). Mortality was not significantly different in patients with a EuroSCORE of 2 or less vs 3 or more (p = 0.2); however, major adverse events were significantly more common when the EuroSCORE was 3 or more (33/247 versus 24/492; p = 0.001).
Table 3
presents a comparison between the surgeons, listing preoperative risk factors, the use of CPB, and number of grafts per patient. There were 5 operating surgeons: 1 who had undergone formal US training and the 4 Bosnian surgeons. Postoperative outcomes are summarized in Tables 4 and 5.
Surgeon 1 performed more operations initially and used ONCAB more frequently. His volume decreased after the early phase, making the number of operations per year more evenly distributed (Fig 1). Surgeon 2 operated on patients with higher EuroSCOREs than did surgeons 1 and 3 because of his longer experience. There were also some differences noted between surgeons in the number of grafts performed and the incidence of arrhythmias.
View larger version (31K):
[in this window]
[in a new window]
|
Fig 1. All coronary operations. Numbers 1 to 5 indicate the 5 operating surgeons. Values represent percentage of patients operated by surgeon each year.
|
|
Mortality occurred more frequently in ONCAB patients, with an odds ratio of 4.18 with confidence interval 1.51–11.56 favoring OPCAB (p = 0.006). Major adverse events increased with EuroSCORE and use of CPB by univariate and multivariate analysis (Table 6). Age (p = 0.01) and EuroSCORE (p = 0.03) were significant factors for the occurrence of postoperative arrhythmias.
Postoperative bleeding, time on the respirator, and length of hospital stay were compared between ONCAB and OPCAB patients and between surgeons by using nonparametric tests. OPCAB patients bled more, but had shorter respirator times and shorter lengths of stay than ONCAB patients. By analysis of variance and nonparametric tests, there were also significant differences in some of these variables between surgeons. The linear regression analysis (Table 7) demonstrated that female gender decreased postoperative bleeding, whereas increasing age was a risk for increased respirator time and length of stay. The surgeon did not constitute a risk factor for any of these outcomes.
|
Comment
|
|---|
Cardiac surgery training in the United States has traditionally been based on a foundation of general surgery, followed by an intensive training period in cardiac surgery of at least 2 years [8]. BIH emerged from a destructive war as an independent nation with a destroyed infrastructure. The gross national product was reduced by 80% compared with prewar levels. An important deficit in the health care system was the lack of cardiac surgery and interventions. Although the incidence of coronary disease in BIH may be somewhat lower than in Northern Europe [9], the incidence appears to be increasing as it is in other Eastern European countries [10]. The population in BIH appears to have had an increase in both fatal cardiac events [11] and acute coronary syndromes [12], possibly because of effects of the war, which increased stress level and made control of risk factors difficult.
The development of a cardiac program necessitated modifications compared with a traditional training pattern. BIH had no training site. When the opportunity to cooperate with a major US institution opened, a training program was quickly organized. Funding was available only for 2 years through the USAID program, and the training period in the United States was therefore limited to 6 months for each individual. The short-term goal was to develop surgeons capable of performing CABG procedures, subsequently expanding the scope to other cardiac surgical procedures, utilizing intermittent foreign supervision.
To monitor the quality of treatment, a cardiac surgery database developed in Norway [6] was introduced to analyze outcomes for the cardiac service as a whole and for individual surgeons. Many cardiac programs now report similar data through programs organized by hospitals [13], regional voluntary projects [14, 15], or as publicly enforced registers [16]. Increasing public demand for transparency has made outcome results in cardiac surgery part of the public domain [17]. BIH and the former Yugoslavia are, along with many Eastern European countries, considered relatively nontransparent societies. Data are lacking for utilization, outcome reporting, and financial results within the health system. As part of our effort to be transparent, a clinical database for monitoring of outcome data was developed. Outcome data are made available to physicians, surgeons, and health care providers. The results of CABG surgery are similar to what has been reported in other studies, including what has been reported from the Norwegian registry using the same data collection and analytical methods [6]. Similar to what was found by others [7], a higher EuroSCORE was associated with adverse outcomes.
One of the surgeons had a much higher volume than the other 4, and another was more experienced with formal training from the United States. Despite this, all surgeons had similar outcomes. This may have been the result of good cooperation between individuals and because the first assistant was usually one of the other surgeons. Intensive consultation and assistance was available in difficult cases.
Mortality and adverse events were more common in ONCAB patients, despite their lower EuroSCORE. Although a number of publications document the benefit of OPCAB, especially on morbidity in high-risk patients [1, 18, 19], other factors could be responsible for the differences seen in this series. The selection of patients could have been influenced by risk factors that were not reported, such as poor distal vessels and clinical instability. We did not use intention-to-treat criteria, and patients operated on with CPB were considered ONCAB regardless of the initial plan. In our experience, conversions have not increased mortality, even if emergent conversions may increase adverse events [20].
No catastrophic perfusion incidents occurred causing death or major air embolus in the ONCAB patients; however, perfusion methods may not have been ideal because of the shortened training period for the perfusionists. All the surgeons entering the cardiac surgery training were expert vascular surgeons, which may have made them especially suited to perform OPCAB surgery. The anesthesiologists had extensive experience with war surgery and the management of unstable hemodynamic situations, but had limited experience with patients on CPB.
The quality assessment of CABG surgery reported here demonstrated overall acceptable results. We could not demonstrate differences in outcome between surgeons in death rates or major adverse events. Regression analysis did not demonstrate a surgeon effect on postoperative bleeding, time on the respirator, or length of stay. The use of CPB, however, had an unfavorable effect on mortality, adverse events, time on the respirator, and length of stay. The ONCAB patients had less bleeding despite more grafts being performed, which contrasts with most other reports [1]. This may be due to incomplete reversal of heparin in OPCAB patients or the routine use of 
-aminocaproic acid in ONCAB patients.
In conclusion we have demonstrated that successful CABG surgery may be introduced rapidly in poor countries. Similar to what has been shown by Caputo and colleagues [21], OPCAB can be implemented safely during the residency training period. Rapid implementation of cardiac surgery under difficult conditions requires selection of highly qualified and motivated personnel and cooperation with other centers experienced in the training of physicians and other health care professionals.
|
Acknowledgments
|
|---|
The support from the staff and administration at Buffalo General Hospital, Buffalo, New York, and Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway, is greatly appreciated. USAID and the Royal Norwegian Foreign Department provided financial and logistic support for the training programs, reconstruction of facilities, and the supply of crucial equipment.
|
References
|
|---|
- Puskas J, Cheng D, Knight J, et al. Off-pump versus conventional coronary artery bypass grafting: a meta-analysis and consensus statement from the 2004 ISMICS consensus conference Innovations 2005;1:3-27.
- Kastanioti CK, Kolettis TM, Stavridis G, Goudevenos J. Cost-effectiveness of on-pump and off-pump bypass surgery Eur Heart J 2005;26:1046-1047.[Free Full Text]
- Murphy GJ, Ascione R, Angelini GD. Coronary artery bypass grafting on the beating heart: surgical revascularization for the next decade? Eur Heart J 2004;25:2077-2085.[Abstract/Free Full Text]
- D'Ancona G, Karamanoukian H, Lima R, et al. Hemodynamic effects of elevation and stabilization of the heart during off-pump coronary surgery J Card Surg 2000;15:385-391.[Medline]
- Rivetti LA, Gandra SM. Initial experience using an intraluminal shunt during revascularization of the beating heart Ann Thorac Surg 1997;63:1742-1747.[Abstract/Free Full Text]
- Svennevig JL, Bech J, Karlsen H, Amlie E, Olsen Å. [Development of a departmental computer system for thoracic and cardiovascular surgery at Rikshospitalet, Oslo.] Tidsskr Nor Legeforening 1995;115:1057-1059.
- Nashef SA, Roques P, Michel P, et al. European system for cardiac operative risk evaluation (EuroSCORE) Eur J Cardiothorac Surg 1999;6:9-13.
- Crawford FA. Thoracic surgery education-past,present and future Ann Thorac Surg 2005;79:2232-2237.
- Menotti A, Lanti M, Puddu PE, Kromhout D. Coronary heart disease incidence in northern and southern European populations: a reanalysis of the seven countries study for a European coronary risk chart Heart 2000;84:238-244.[Abstract/Free Full Text]
- Tunstall-Pedoe H, Kuulasmaa K, Amoyel P, Arveiler D, Rajakangas AM, Pajak A. Myocardial infarction and coronary deaths in the World Health Organization Monica ProjectRegistration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation 1994;90:583-612.[Abstract/Free Full Text]
- Fazlibegovic E, Hadziomerovic M, Fazlibegovic F, Raljevic E, Smajkic A. Sudden cardiac death (SCD) in Mostar in 2003 Med Arh 2004;58:31-33.[Medline]
- Bergovac M, Heim I, Vasilj I, Jembrek-Gostovic M, Bergovec M, Strnad M. Acute coronary syndrome and the 1992–1995 war in Bosnia and Herzegovina: a 10-year retrospective study Mil Med 2005;170:431-434.[Medline]
- Shahian DM, Blackstone EH, Edwards FH, et al. Cardiac surgery risk models: a position article Ann Thorac Surg 2004;78:1868-1877.[Abstract/Free Full Text]
- Shahian DM, Torchiana DF, Normand ST. Implementation of a cardiac surgery report card: lessons from the Massachusetts experience Ann Thorac Surg 2005;80:1146-1150.[Abstract/Free Full Text]
- Nashef SA, Carey F, Charman S. The relationship between predicted and actual cardiac surgical mortality: impact of risk grouping and individual surgeons Eur J Cardiothorac Surg 2001;19:817-820.[Abstract/Free Full Text]
- Hannan EL, Wu C, Bennett EV, et al. Risk stratification of in-hospital mortality for coronary artery bypass graft surgery J Am Coll Cardiol 2006;47:661-668.[Abstract/Free Full Text]
- Keogh B, Spiegelhalter D, Bailey A, Roxburgh J, Magee P, Hilton C. The legacy of Bristol: public disclosure of individual surgeons results BMJ 2004;329:450-454.[Free Full Text]
- Bergsland J, Hasnan S, Lewin AN, Bhayana J, Lajos TZ, Salerno TA. Coronary artery bypass grafting without cardiopulmonary bypassAn attractive alternative in high risk patients. Eur J Cardiothorac Surg 1997;11:876-880.[Abstract]
- Bergsland J, Hasnain S, Lajos TZ, Salerno TA. Elimination of cardiopulmonary bypass: a prime goal in reoperative coronary artery bypass surgery Eur J Cardiothorac Surg 1998;14:59-63.[Medline]
- Mujanovic E, Kabil E, Hadziselimovic M, Softic M, Azabagic A, Bergsland J. Conversions in off-pump coronary surgery Heart Surg Forum 2003;6:135-137.[Medline]
- Caputo M, Barnaby BC, Rogers CA, Ascione RA, Angelini GD. Monitoring the performance of residents during training in off-pump coronary surgery J Thorac Cardiovasc Surg 2004;128:907-915.[Abstract/Free Full Text]
Top
Abstract
Introduction
