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Ann Thorac Surg 2000;69:42-45
© 2000 The Society of Thoracic Surgeons

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Original Articles

Perspectives of a cardiac surgery resident in-training on off-pump coronary bypass operation

^a Division of Cardiothoracic Surgery, State University of New York at Buffalo, Buffalo, New York, USA
^b Section of Cardiothoracic Surgery, Veterans Administration Medical Center, Buffalo, New York, USA
^c Kaleida Health, Buffalo General Hospital, Buffalo, New York, USA

Address reprint requests to Dr Salerno, Center for Less Invasive Cardiac Surgery, Buffalo General Hospital at Kaleida Health, 100 High St, Buffalo, NY 14203
e-mail: sur237{at}pol.bgh.edu

Presented at the Postgraduate Program of the Thirty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1999.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Contemporary residency training in the cardiac component of cardiothoracic operation is focused mainly on attaining technical proficiency in coronary artery revascularization. Most trainees in cardiothoracic operation are required to perform 35 cases of coronary revascularization in order to fulfill the minimum requirements for certification by the American Board of Thoracic Surgery. Although experience in minimally invasive coronary revascularization is not required for board certification in cardiothoracic operation, it is recognized by both trainees and program directors as an important component of contemporary training in less-invasive surgical approaches (LISA) for coronary artery disease. The objective of this study was to describe the training of residents in off-pump coronary revascularization in an accredited training program.

Methods. A retrospective analysis of a single resident’s experience in minimally invasive coronary revascularization over an 18 month period in a 2-year residency program in cardiothoracic operation was carried out.

Results. Of the 166 total cases of coronary bypass operation, the resident performed 61 cases (37% of the total) off-pump as primary surgeon with attending supervision. Patients undergoing off-pump coronary bypass had an average of 2.4 grafts (range 1 to 5) and conventional coronary artery surgeon (on cardiopulmonary bypass) performed by the resident had an average of 4 grafts (range 2 to 5). The marginal/circumflex system was bypassed in patients that required revascularization of the marginal/circumflex system, which was 56% (n = 36 of 62) in the off-pump group and 90% for the conventional group using cardiopulmonary bypass. The conversion rate from off-pump technique to conventional coronary bypass using cardiopulmonary bypass was 3.2% in this series.

Conclusions. Technical innovations and evolution of techniques to better stabilize the heart for off-pump coronary revascularization have made the procedure both effective and safe. Our experience has shown that cardiothoracic residents can be taught the skills necessary to perform coronary revascularization off cardiopulmonary bypass. There are currently no standards for the training of cardiothoracic residents in off-pump coronary artery operation. We propose that at least 50 cases be performed under supervision by a trained surgeon to obtain adequate credentials in minimally invasive coronary revascularization.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
The less invasive surgical approach (LISA) for coronary revascularization off cardiopulmonary bypass (CPB) has evolved rapidly at our institution. Initially, off CPB coronary revascularization was performed primarily by senior surgeons who were instrumental in popularizing beating heart operation as a safe alternative to traditional coronary artery bypass grafting (CABG) [1]. As such, resident experience was initially limited because of evolving techniques and acceptance of beating heart coronary revascularization, both by cardiac surgeons and cardiologists, as an equal alternative to conventional CABG, which depended on the demonstration of superior patient outcome. Since 1997, we have used the LISA procedure to perform complete revascularization of the heart off CPB [2, 3]. In parallel with these developments, a systematic effort has been made to teach cardiothoracic residents to be proficient in techniques used to completely revascularize the heart off CPB.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
The new era in less invasive techniques for coronary revascularization was ushered into our institution in 1995 with the introduction of the left anterior small thoracotomy (LAST) procedure. The LAST procedure was used to perform a single bypass graft to the left anterior descending artery (LAD) using the left internal mammary artery (LIMA) as a conduit. Since the number of patients with isolated LAD disease is a small fraction of those who present for coronary revascularization, our surgical technique evolved to accommodate patients who required multiple bypass grafts. Given our experience with the LAST procedure, we next focused on revascularization of other anterior and anterolateral vessels of the heart (diagonals, intermediate vessels) off CPB using a median sternotomy approach. Proximal right coronary vessels were revascularized, as well, using the LISA procedure. Initially, we used crude instruments that have since been referred to as first generation stabilizers. In time, with growing clinical experience, we refined our technical approach and incorporated the use of more sophisticated stabilizers. This has allowed us to routinely perform complete revascularization of the heart off CPB, ie, LISA procedure in over 95% of our cases [4]. The development of instruments to perform coronary anastomoses safely without CPB, coincides with our goal to teach cardiothoracic residents these newer techniques.

Once a resident attains experience with coronary revascularization using the ideal teaching conditions of conventional CABG (ie, in a situation where the heart is arrested and technical skill in anastomosing coronary vessels are learned), they are introduced to the LISA procedure. Residents learn to work on anterior vessels, and in time become more proficient and learn to perform all anastomoses on the beating heart. This paper describes our philosophy and methods for teaching the LISA procedure to cardiothoracic residents. The clinical experience of one of our residents is used to describe our commitment to teach these techniques in an academic environment.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
The surgical experience of one of our residents in coronary revascularization is shown in Table 1. Of the 166 total cases of coronary revascularization as a surgeon, spanning a period of 18 months (July 1, 1997 to January 22, 1998), the resident performed 61 LISA procedures (37%) using the median sternotomy approach. Redo cases represented 9% of the LISA procedures and 1% of the conventional CABG experience for this resident. All of the above reported cases were performed by the resident as primary surgeon with attending supervision.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
As the population ages, the proportion of elderly patients requiring coronary revascularization has increased. The potential benefits of the LISA procedure are probably greater for the elderly, who have a higher risk of multisystem organ disease, and are at higher risk for the detrimental complications of CPB [5]. The aim of the less invasive surgical approach is to improve patient outcome while performing complete coronary revascularization on the beating heart. We [1] and others have shown that the LISA procedure can be performed safely and can be applied to a large population of patients. The current analysis addresses the training of one of our residents in cardiothoracic operation regarding off-pump coronary artery operation.

This report summarizes the experience of a single resident, training in cardiothoracic operation, in complete revascularization of the heart off CPB. It is technically feasible to teach residents in training to perform these operations under ideal conditions, using current generation stabilizers, blowers, and with modification of the LIMA stitch into a single-suture technique [6]. The latter technique allows the heart to be mobilized with minimal hemodynamic consequence [3], allowing for revascularization of all coronary vessels [4, 6]. This simple modification has significantly improved on the ability to perform anastomoses on the marginal/circumflex arteries. LISA patients in this series, requiring revascularization of the marginal/circumflex system were revascularized, based on perioperative evaluation by angiography. Overall, thirty-four patients (56%) in the LISA group required revascularization of the marginal/circumflex system in this series. This ratio was approximately 90% in patients undergoing conventional CABG.

Conversion to conventional CABG occurred on 2 occasions (conversion rate = 3.2%). One of the patients was converted from LISA to conventional CABG because of hemodynamic instability arising from electrocardiogram changes, minutes after starting the LIMA to LAD anastomosis, while the patient had a functioning intracoronary shut. We believe that compression of the left ventricular outflow tract by the stabilizer contributed to the hemodynamic compromise of this patient. Fortunately, the patient was placed on CPB expeditiously, had completion of two additional grafts, and suffered no untoward complications postoperatively. This patient had a critical lesion of the left anterior descending coronary artery as well as left main disease that was associated with recent myocardial injury. Compression of the ventricular outflow tract further compromised ventricular function contributing to our inability to perform the operation without CPB.

Another patient was converted from LISA to conventional CABG due to failure to tolerate manipulation, especially maneuvers causing cardiac compression. This patient was also placed on CPB before attempting the LISA approach. This experience in more than 60 patients demonstrates that complete revascularization of the heart can be taught safely under excellent circumstances.

We are especially pleased to have incorporated a unique opportunity to provide our residents with a large case experience in the LISA procedure at two institutions, the Buffalo General Hospital at Kaleida Health, and the Veterans Administration Medical Center (VAMC) at Buffalo. The rotation at the VAMC is unique because it is presumed that the patient population is more uniform in its characteristics. We analyzed the resident’s experience to determine if the demographics of patients that underwent conventional CABG was identical to that who underwent LISA procedure (Table 2). The data demonstrate that patient age, CCS class, percent of patients with ejection fraction less than 40%, and the number of grafts performed were nearly identical in both groups. A determined effort was made to teach off-pump coronary operation techniques. During the first month, the second year resident performed CABG on pump while the resident became familiar with the attending and the operating room team. Then we begin to perform off-pump CABG starting with single anterior vessels, progressing to complete revascularization using median sternotomy. The residents in our program have repeatedly commented that this experience, although structured serendipitously, is excellent in that it allows the trainee to appreciate the nuances of both operations. According to the trainees, conventional CABG is technically easier than the LISA procedure. It provides the residents with ample opportunity to perfect their technical abilities because of the ideal teaching conditions, ie, in a situation where the heart is arrested. During this experience, this resident and others have come to appreciate that there are important similarities and differences between these operations. For example, the residents have learned that the sequence of grafting is different in LISA and conventional CABG. In conventional CABG, the sequence of grafts is first to the right coronary artery or its branches, followed by anastomoses to the circumflex system, and finally, anastomoses to the anterior vessels terminating in the revascularization of the LAD. The sequence of revascularization is different for the LISA procedure. We routinely perform the anastomosis to the LAD first, followed with revascularization of the right coronary artery, and finally perform anastomoses to the marginal/circumflex system. This allows the surgeon to become progressively more adept in performing more difficult anastomoses as the operation is completed, culminating in the anastomosis of the marginal/circumflex system, which is technically more challenging, from a topographic standpoint.

Our data also show that the average number of grafts performed by LISA technique is 2.4 and 4 for conventional CABG. It should be remembered that this is a study looking at the experience of a single resident, and that the clinical significance of this observation cannot be derived outside of prospective studies looking at patients undergoing either of the two procedures in a randomized manner. It should be noted that none of the conversions were for patients undergoing redo operations. Technical complications occurred in 2 patients in the LISA experience (3.2%). Inadvertent injury to the posterior wall of a circumflex vessel was made during the arteriotomy that required suture repair using 8-0 Prolene (Ethicon, Somerville, NJ). Another patient had ST-segment elevations in the anterior leads after uneventful LIMA to LAD and saphenous vein graft to the obtuse marginal vessel. This occurred after chest closure and was duplicated with each attempt despite patent grafts as confirmed by flow measurements. The patient underwent placement of an additional saphenous vein graft to a more distal segment of the LAD and tolerated closure of the chest. Postoperative cardiac enzymes were negative.

Along with the evolution of techniques in off-pump CPB for coronary revascularization, we have refined our training program to teach cardiothoracic residents these techniques. This was justified because the quality control of anastomoses was made ideal with current stabilization technology. Furthermore, our refinement of the LIMA stitch (single-suture technique) has been used to expose the elusive circumflex marginal vessels for safe anastomosis [1, 3, 4, 6]. Successful completion of the LISA procedure depends on the ability of the anesthesiologist to keep the patient hemodynamically stable throughout the operation, especially during manipulation of the heart. However, with the advent of the single-suture technique, hemodynamic instability has been less of an issue as the heart is mobilized very easily with little hemodynamic compromise for anastomoses of the lateral and posterior vessels. Visualization is also made ideal using the air blower (Baxter, Newport Beach, CA) and intracoronary shunting (Cardiothoracic Systems, Cupertino, CA) allowing the resident to perform the anastomosis unhurried with technical ease. Finally, we routinely measure flow in the grafts after the anastomoses are completed in order to verify their integrity. At the Buffalo General Hospital we use the Medi-Stim device (Medi-Stim, Oslo, Norway) which gives a quantitative assessment of flow, and at the VA Medical Center we use a vascular operation Doppler instrument. Such technical refinements have justified the teaching of these procedures to the cardiothoracic resident without compromising patient care.

In summary, the technical innovations and evolution of techniques to better stabilize the heart for the LISA procedure has made it a safe technique for both the patient and the surgeon. The beneficial aspects of performing complete revascularization of the heart without CPB are well known. Our experience has shown that cardiothoracic residents can be safely taught the surgical skills to perform the LISA for coronary revascularization off CPB. The current trainees will have to become familiar with the LISA operation, among others, in order to have the broadest surgical armamentarium to offer patients. The new generation of cardiac surgeons will need to acquire skills in revascularization of the coronaries off CPB. There are currently no standards for the training of cardiothoracic residents in off-pump CPB coronary artery operation. The authors hope that these perspectives will guide those who are interested in off CPB operation.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Calafiore A.M., Angelini G.D., Bergsland J., Salerno T.A. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;62:1545-1548.[Abstract/Free Full Text]
2. Bergsland J., Schmid S., Yanulevich J., Hasnain S., Lajos T.Z., Salerno T.A. Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB). Heart Surg Forum 1998;1:107-110.[Medline]
3. Bergsland J., Hasnain S., Lewin A.N., Bhayana J., Lajos T.Z., Salerno T.A. Coronary artery bypass without cardiopulmonary bypass. Eur J Cardiothor Surg 1997;11:876-880.[Abstract]
4. Salerno TA. Coronary bypass surgery without cardiopulmonary bypass. In: The Society of Thoracic Surgeons 32nd Postgraduate Program; 1999; San Antonio TX Jan 25-27, 1999.
5. Taylor K.M. Central nervous system effects of cardiopulmonary bypass. Ann Thorac Surg 1998;66:S20-S24.[Abstract/Free Full Text]
6. 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]

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