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Objectives: The aim of this study was to assess safety and efficiency of multiarterial coronary bypass grafting using bilateral internal thoracic arteries in T-graft technique performed by trainees., Methods: Patients from January 2005 to February 2023 who had undergone multiarterial coronary bypass grafting using bilateral internal thoracic arteries in T-graft technique were analysed. Patients were divided into 2 groups based on the primary surgeon: consultant and trainees. The primary composite outcome measure was all-cause mortality and coronary reintervention after 5 years. Safety and efficiency were assessed using cumulative sum analysis., Results: A total of 1764 patients were identified, 1114 patients (63.2%) were operated on by consultants, 650 patients (37.8%) by trainees. Mortality rates did not differ (0.8% vs 1.0%, P = 0.4). Consultants performed more distal anastomoses [3.38 (0.96) vs 3.06 (0.76); P < 0.001] and achieved more complete revascularization [n = 895 (92%)] than trainees [n = 460 (80%); P < 0.001]. In the cumulative sum analysis, safety of teaching procedures remains within the acceptable range. There was no increase in the expectation/frequency of the composite outcome measure; instead, the expected frequency decreases up to 150 operations. Duration of the operation averages decrease until the 125th operation. Performed distal anastomoses increased with the rising number of operations., Conclusions: Our study demonstrates that training operations multiarterial coronary bypass grafting using bilateral internal thoracic arteries in T-graft technique are equally safe regardless of whether they are performed by consultants or trainees. Each trainee experiences an individual learning curve that falls within acceptable error rates and, therefore, the procedure can be safely learned directly., (© The Author(s) 2025. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: We created and validated a low-cost simulation model for robotic internal mammary artery (IMA) takedown., Methods: The simulation model utilized a calf fetus thorax cavity stented open internally and secured to a table. The simulation model was validated at a 2-day robotic cardiac surgery workshop. Each participant harvested one IMA using the da Vinci Xi robot (Intuitive Surgical, Sunnyvale, CA, USA). We compared participant self-reported confidence at robotic IMA harvest before and after using the simulator., Results: Our novel thorax-securing strategy resulted in a stable structure and allowed access to both IMAs from the same 3 ports. The cost to set up the first simulation model was $176 and $133 for every subsequent model. Fifty participants used the simulation model: 42 cardiothoracic surgery attendings and 8 fellows or residents. The feedback form response rate was 78% ( n = 39). On the Likert scale, participants rated realism of the calf model to simulate robotic IMA harvesting (0 = not realistic , 10 = highly realistic ) with a median of 8 out of 10 (interquartile range [IQR] 7 to 9). Participant confidence (0 = not at all confident , 10 = very confident ) in robotic IMA harvesting before and after using the simulator increased ( P = 0.001) from a median of 5 (IQR 1 to 7) to 9 (IQR 7 to 10)., Conclusions: This robotic IMA harvest simulation model is affordable, realistic, and improved participant confidence in robotic IMA harvest. It may provide a valuable training tool for surgeons learning robotic coronary bypass surgery and allows for training frequency necessary to pass basic learning curves., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: T.S.G. is a consultant for Edwards Lifesciences and Medtronic and case observation site and proctor for Intuitive Surgical.

Introduction: A recent needs assessment in Canadian cardiac surgery programs identified the desire for a coronary artery bypass (CABG) and aortic valve replacement (AVR) simulation model for home practice. We aimed to develop and assess a portable, adjustable task trainer for cardiac surgical skills with high functional task alignment., Methods: Intraoperative measurements were taken from patients undergoing elective CABG and AVR (N = 30). Measurements were taken in 3 axes and used to create a chest cavity that resembles the mediastinal constraints of a patient undergoing CABG and AVR. The task trainer is adjustable on the following 3 levels: (1) size of the incision, (2) depth of the chest, and (3) relative position of coronary artery or aortic valve model within the chest. Three groups (novices, intermediates, and experts) of cardiac surgery members evaluated the task trainer for functional task alignment and construct validity., Results: The CABG and AVR model had high functional task alignment. There was a high satisfaction for both models and all participants would recommend the AVR and CABG model as an educational tool. Performance time significantly differed between the groups for both models (CABG: P = 0.032 and AVR: P = 0.001), as well as number of errors (CABG: P = 0.04 and AVR: P = 0.043)., Conclusions: Using real patient data, we were able to develop an adjustable task trainer for training principles of CABG and AVR. Our pilot study provides preliminary sources of evidence for validity and future study will look to assess transferability of skill to the operating room., Competing Interests: The author declares no conflict of interest., (Copyright © 2023 Society for Simulation in Healthcare.)

Background: Coronary artery bypass grafting surgery and aortic valve replacement surgery are essential treatment options for people suffering from angina pectoris or aortic valve disease. Surgery aims to prolong life expectancy, improve quality of life, and facilitate participation in society for the individuals afflicted. The aim of this review was to explore the literature on work participation in patients following coronary artery bypass grafting or aortic valve replacement surgery, and to identify demographic and clinical characteristics associated with returning to work., Methods: A scoping review framework of Arksey and O'Malley was chosen. Four electronic databases: Medline, CINAHL, Embase, and Google Scholar were searched for studies in English, Swedish, Danish or Norwegian between January 1988 and January 2020. A blinded selection of articles was performed. The data were then charted and summarized by descriptive numerical analyses and categorized into themes., Results: Forty-five out of 432 articles were included in the final full-text analysis. Absence from work following coronary artery bypass graft grafting or aortic valve replacement surgery lasted on average 30 weeks, whereas 34% of the patients never returned to work. Being female, suffering from pre-existing depression, having limited secondary education, or low income were associated with decreased return to work rates. Previous employment was a decisive factor for returning to work after surgery. Data on return to work after aortic valve replacement were scarce., Conclusions: A significant number of patients never return to work following coronary artery bypass grafting or aortic valve surgery, and the time interval until work return is longer than expected. Failure to resume work represents a threat to the patients' finances and quality of life. Nurses are in a unique position to assess work-related issues and have an active part in the multi-disciplinary facilitation of tailored occupational counselling after cardiac surgery., (© 2021 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.)

Background: The role of simulation-based training in coronary artery bypass grafting remains undefined. Barriers to simulator use include clinical and personal obligations, insufficient materials, and lack of mentorship. The purpose of this study was to implement a longitudinal, residency-wide coronary anastomosis simulation curriculum., Methods: A prospective observational study was conducted from 2018 to 2019 at a single academic center. All residents of the Thoracic Surgery training program participated. Each participant was provided a low-fidelity coronary anastomosis simulator, high-quality instruments, and faculty mentor. Formal assessments were held quarterly, and residents were encouraged to practice alone and with their mentor. Baseline and follow-up metrics were compared with simple descriptive statistics., Results: Seventeen residents and 12 faculty participated in the study. Residents demonstrated increased use of the simulator, with 21% participating in independent practice at baseline and 82% in the fourth quarter (P = .02). The median score on the Thoracic Surgery Directors Association Vessel Anastomosis Assessment improved from 42 out of 65 at baseline to 54 out of 65 in the fourth quarter (P = .04), and mean anastomosis time was reduced by 5 minutes 6 seconds (P = .02). Over 12 months, junior residents demonstrated a mean reduction in anastomosis time of 6 minutes 36 seconds, and senior residents decreased anastomosis time by 3 minutes 6 seconds (P = .02)., Conclusions: Providing residents with a low-fidelity coronary anastomosis trainer with high-quality instruments and a faculty mentor improved rates of independent practice, Thoracic Surgery Directors Association assessment scores, and anastomosis time. Our next step is validating the coronary simulator curriculum by measuring improvement of resident performance in the operating room., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the effect of our uniquely designed beating heart simulator for coronary artery bypass surgery residency training., Methods: The balloon of intra-aortic balloon pump (IABP) was inserted into the left ventricle of an isolated porcine heart to form a beating heart simulator. This model simulated off-pump coronary artery bypass grafting (OPCABG), and the nonbeating heart model simulated the on-pump coronary artery bypass grafting (ONCABG) for training of surgeons. From 2017 to 2019, 60 trainees were randomly divided into nonbeating and beating heart simulator training groups. The training period was 3 months. The performance of anastomosis was evaluated at the beginning (after 1 month), midpoint (after 2 months), and at the end of the assessment (after 3 months)., Results: Trainees improved their performance of coronary artery anastomosis respectively after 3 months of training, whether they were trained on beating heart simulator or nonbeating heart simulator (P < .05). On both nonbeating and beating heart simulator test, trainees in the beating group performed better than those in the nonbeating group in the use of microsurgical instruments, anastomotic quality, and anastomotic speed after 3 months of training (P < .05)., Conclusions: The effect of our uniquely developed beating heart simulator training was better than those of nonbeating heart simulator for OPCABG and ONCABG training of surgeons during residency., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Several training devices have been developed to train anastomotic skills in off-pump coronary artery bypass grafting (OPCAB). However, assessment of trainees' improvement remains challenging. The goal of this study was to develop a new practical scoring chart and investigate its reliability and utility for anastomotic skills in OPCAB and minimally invasive direct coronary artery bypass (MIDCAB)., Methods: A training device was used, which included a beating heart model installed in a dedicated box. A soft plastic tube was used as the left anterior descending artery, and a porcine ureter was used as the left internal mammary artery. Five cardiac surgery fellows (Fellows, > 5 year of surgical experience) and five residents or medical students (Residents, ≤ 5 year of surgical experience) were enrolled for this study. Before and after training, skills were evaluated using a scoring chart that took into account anastomotic time, leakage, shape, flow measurement, and self-estimation., Results: Mean total score of all trainees was 15.4 ± 4.0 at pre-training and 18.5 ± 2.4 at post-training (P = 0.05). Before training, there was a significant difference in the total score between Fellows and Residents (18.6 ± 2.2 vs 12.2 ± 2.4 points, P = 0.002), which disappeared after training (19.4 ± 2.5 vs 17.6 ± 2.2 points, P = 0.262). Residents benefitted from training with improvements in their time, total score, score for time, score for flow and subtraction score; however, these effects were not seen in Fellows. The most evident training effect was improvement of self-estimation, which was also seen in Fellows., Conclusions: Residents were most likely to derive benefit from these training models with regard to both efficiency and quality. Training models seem to have an important role in making surgeons feel more comfortable with the procedure.

Background: To evaluate the effect of minimally invasive direct coronary artery bypass (MIDCAB) simulator for cardiac residency training., Methods: A total of 26 resident surgeons who had never trained for coronary artery anastomosis participated in this training program. They received coronary artery anastomosis training on off-pump coronary artery bypass grafting (OPCAB) simulator for 15 h. After training, their performance of anastomosis was evaluated on the OPCAB simulator according to 12 items and a 5-point global rating scale. Based on the total score of assessment, those with an individual score of 12-36 formed group A, while group B was composed of the remaining trainees. The two groups then received another 15 h coronary artery anastomosis training on the MIDCAB simulator, and the performance was assessed., Results: Trainees improved their performance of coronary artery anastomosis after training on the OPCAB simulator. Group A was composed of 7 trainees with an individual with a total score of 12-36 points and group B was composed of the remaining 19 trainees. After MIDCAB simulator training, significant differences were noted in the pre- and post-training values in the A group (P < .001), and the assessment value of group A was significantly better than those of group B (P < .05). No significant difference was detected between pre- and post-training values in group B after MIDCAB simulator training (P > .05)., Conclusion: We concluded that trainees who performed well in OPCAB simulation training can also perform better in MIDCAB, and our designed MIDCAB simulator was useful for residency training.

Objective: Many countries are facing a shortage of cardiac surgeons, who are crucial in meeting the demands of growing number of patients in need of coronary artery bypass grafting. This situation poses a serious challenge, especially in China. The purpose of this study is to determine whether cardiac surgeons are suitable for training in coronary artery anastomosis at an earlier stage in their career., Methods: We divided 12 cardiac surgeons with no prior experience in coronary artery anastomosis into senior and junior groups for training and assessment. All trainees received training in coronary artery anastomosis for a defined period. We performed in vivo and in vitro examinations before and after training, respectively. Additionally, we assessed individual surgical performance of surgeons by using performance rating scores, including different aspects of surgical skills rated on a five-point scale., Results: The post-training scores (overall, junior, senior) were significantly higher than the pre-training scores (overall, junior, and senior). We observed no differences in pre-training and post-training scores between the junior and senior groups., Conclusion: Senior surgeons did not had any significant advantages over junior surgeons with respect to coronary artery anastomosis in the absence of training. Junior surgeons achieved the same results as the senior surgeons after training.

Objectives: The amount of intense and focused training with the specific goal to improve performance (i.e. deliberate practice) is a predictor of expert-level performance in multiple domains of psychomotor skill learning. Simulation training improves surgical skills in cardiac surgery. We established a training programme that enables early surgical exposure and assessment. We investigated the training effects in coronary surgery simulations in trainees with different levels of surgical experience., Methods: The early surgical exposure and assessment programme comprises a low- and high-fidelity simulation, self-organized training, instructed workshops and a stepwise challenge increase. Performance was assessed with a multidimensional skill matrix using video recordings. Two groups of trainees [students (N = 7), 1-/2-year residents (N = 6)] completed introductory training (pretraining, level 1) and two 3-week training periods (levels 2 and 3). Fellows (N = 6) served as controls. Residents and students underwent deliberate practice training with specific training targets. Fellows performed regularly scheduled coronary surgery cases. Entry and exit assessments were conducted for levels 2 and 3., Results: Fellows did not improve overall performance. Residents and students showed significant improvements in both technical accuracy and completion times. Residents reached an overall performance level comparable to fellows. Students reached similar accuracy of surgical skills with longer completion times [level 3 exit score/time: fellows 27 (24-29)/min; residents 27 (21-30)/min, P = 0.94; students 17 (17-25)/min, P = 0.068]., Conclusions: Deliberate practice training resulted in a fast and substantial increase in surgical skills in residents and students. Unexperienced residents reach performance levels of fellows. Deliberate practice simulation programmes should be a mandatory component of surgical training., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background and Aims: During coronary artery bypass graft (CABG) surgery, the residual hemostasis procedures, from weaning cardiopulmonary bypass to closing sternotomy, are always completed by residents and supervised by attending surgeons. We want to evaluate the teaching effectiveness for residents under the supervision of attending surgeons with different levels of seniority., Materials and Methods: Between January 1st 2001 and December 31st 2010, 2279 consecutive CABG surgeries were performed in our medical center. In total, 83 patients underwent a reexploration for postoperative bleeding. All causes of bleeding were identified and recorded. Competent attending surgeons were defined as having >3 years' experience and young attending surgeons with ≦3 years' experience. We compared the reexploration rate and aimed to identify the common sources of bleeding by the two groups. We also assessed the impact of attending experience on the outcomes and major complications after reexploration., Results: There were 36 surgical bleeding and 17 non-surgical bleeding in the young group and 16 surgical bleeding and 14 non-surgical bleeding in the competent group. The young group experienced more mediastinal drainage before a reexploration and a longer time interval to a reexploration. However, both are without statistical significance. Furthermore, the young group has a significant longer hospital stay. The most common intra-pericardium surgical bleeding included two-stage cannulation, side branch of the left internal mammary artery (LIMA), and side branch of vein grafts. The most common extra-pericardium surgical bleeding included a puncture hole by sternal wires, LIMA bed, and fragile sternum., Conclusion: Young attending surgeons indeed had both higher incidence of reexploration and surgical bleeding after a CABG. However, the supervisor experience only impacted hospital stay, not major complications or mortality after a reexploration. This might imply the competent attending surgeons provide higher teaching effectiveness for the hemostasis procedure after CABG., (Copyright © 2018. Published by Elsevier B.V.)

Surgeons typically rely on their past training and experiences as well as visual aids from medical imaging techniques such as magnetic resonance imaging (MRI) or computed tomography (CT) for the planning of surgical processes. Often, due to the anatomical complexity of the surgery site, two dimensional or virtual images are not sufficient to successfully convey the structural details. For such scenarios, a 3D printed model of the patient's anatomy enables personalized preoperative planning. This paper reviews critical aspects of 3D printing for preoperative planning and surgical training, starting with an overview of the process-flow and 3D printing techniques, followed by their applications spanning across multiple organ systems in the human body. State of the art in these technologies are described along with a discussion of current limitations and future opportunities.

Background: Evidence shows a likely survival benefit with the use of bilateral internal mammary arteries (BIMA) compared with a single internal mammary artery (SIMA). Nonetheless, BIMA use is often not used or taught because of a perceived increase in operative time and complexity. This study aimed to evaluate operative time, morbidity, and mortality in both resident and nonresident cases using BIMA compared with SIMA., Methods: Consecutive patients undergoing isolated coronary artery bypass grafting (October 2012 to April 2015) at a single institution were reviewed. Cases were stratified on the basis of the use of SIMA versus BIMA and resident teaching versus nonresident teaching cases. Primary outcomes included operative time, postoperative morbidity, and mortality., Results: A total of 416 patients were identified; 335 of 416 (81%) patients received a SIMA, and 81 of 416 (19%) patients received BIMA. A total of 184 of 416 (44%) were resident cases: 143 of the 335 (43%) SIMA cases and 41 of the 81 (51%) BIMA cases. Use of BIMA in resident cases was associated with a longer operative and cardiopulmonary bypass (CPB) time than resident SIMA cases, but this increased time did not affect morbidity or mortality. Use of SIMA versus BIMA in nonresident cases had no significant difference on total operative time, CPB time, postoperative morbidity, or mortality. Overall, operative and 1-year mortality rates were similar in the SIMA and BIMA groups (SIMA: 1.2%, 1.8%, respectively; BIMA: 0%, 0%, respectively; p = NS)., Conclusions: In the hands of an experienced surgeon, BIMA use can be effectively performed without an increase in operative or CPB time. In resident teaching cases, BIMA use may increase operative time, but it can be safely taught without affecting morbidity or mortality., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Surgical skill assessment tools frequently reflect the opinions of small groups of surgeons. That raises concerns over their generalizability as well as their utilization when applied broadly. A Delphi approach could engage a broad group of experts to identify key elements for a checklist assessing coronary anastomotic skill, improving generalizability., Methods: Expert surgeons in North America (10 or more years in practice, actively teaching coronary artery surgery) were contacted randomly to participate. Consenting surgeons first provided items they believed were mandatory when performing a coronary artery bypass. These were then entered into a three-round Delphi. Positive consensus was reached when 75% or more of participants ranked an item mandatory., Results: Sixteen faculty consented to participate. Each participant provided 25 ± 10 items. The 407 items provided were condensed, resulting in 146 items in the final list, divided into six sections based on the conduct of the operation. Twenty-three items reached consensus in the first round, 14 in the second, and 3 in the third. These 40 items represented only 27% of the initial 146 items. Agreement within sections varied widely, from 0% for "management of assistants" to 47% for "testing and final steps.", Conclusions: A randomly selected group of experts using a Delphi approach can generate a checklist to assess construction of a coronary artery bypass. Considerable disagreement among experts regarding what steps are mandatory calls into question the generalizability of any locally developed checklist., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: We describe our original dry-lab training system for nonrobotic and beating heart endoscopic coronary artery anastomosis., Methods: All the materials used for this training were commercially available. We selected a boxed machine, which can produce pulsatile movements of artificial vessels, and on its roof, we installed a two-dimensional home video camera and a monitor. A multiple-holed plate was placed in front of the machine, and through these holes, a trainee inserted endoscopic surgical instruments and anastomosed the artificial vessels by running fashion while watching the monitor. This training program has four stages. During the first stage, a trainee has to demonstrate mastery in conducting a conventional off-pump coronary artery anastomosis without assistance. The second stage is the "nonbeating" version, and the third stage is the "beating" version with the model mentioned previously. After a trainee gets accustomed to the third stage, the original artificial vessel is replaced with an extremely fragile one, and this is the fourth stage. Our trainee conducted one hundred fourth-stage anastomoses and each procedure was recorded with the video camera. We analyzed several factors from the videos and evaluated the efficacy of the training method. We compared the outcomes of the first 50 consecutive anastomoses with the following 50 ones and described the learning curves., Results: The comparison showed a significant decrease in anastomotic time and vessel injury. We considered the quality of anastomosis acceptable after 47 anastomoses, and anastomotic time fell below 15 minutes at the 81st training at the fourth stage., Conclusions: Our dry-lab system might be an effective training method for endoscopic coronary anastomosis.

Coronary artery bypass is often the first procedure cardiac surgeons are confronted with during their residencies. This article discusses the surgical steps and the potential difficulties encountered during this procedure and how they can be solved. The "point of view" of an experienced surgeon is provided to the trainees and to the readers., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Outcomes after coronary artery bypass graft surgery (CABG) are known to be dependent on attending surgeon volume, but the impact of resident experience is unknown. Our objective was to assess the influence of resident experience to understand the learning curve for CABG., Methods: From 2008 to 2014, all isolated on-pump CABG (n = 1,668) during which a resident performed the entire operation (including sternotomy, mammary artery harvest, coronary anastomoses, and closure) were reviewed. Operations were stratified by individual resident CABG experience. Primary outcomes included operative time, which was further divided into "opening time" (incision to bypass initiation), cardiopulmonary bypass times, cross-clamp times, and "closing times" (bypass termination to close). Secondary outcomes included 30-day mortality and major complications., Results: Operative time was 29.7 minutes longer (p < 0.001) during residents' first 30 CABG, primarily driven by longer opening and closing times. After controlling for resident, attending physician, preoperative risk, number of grafts, and redo status, the completion of 30 operations improved operative time by 25 minutes (p < 0.001), the majority of which included opening time (13 minutes, p < 0.001). Minor differences in bypass and cross-clamp times were not clinically meaningful, and there were no differences in 30-day mortality or major complications with respect to resident experience., Conclusions: Total operative time during CABG is dependent on resident experience, with significant improvement by approximately the 30th case. Importantly, these differences do not translate into worse outcomes. These data support trainees performing all components of CABG-even early in the residency experience., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The learning curve of coronary artery bypass grafting (CABG) with multiple arterial grafting (MAG) is perceived to be associated with increased surgical morbidity and potentially poorer long-term outcomes. We compared short-term outcomes and long-term survival in patients who underwent CABG with MAG performed by attending surgeons or resident trainees at a single institution over a period of 19 years. Using our institutional database, we identified 3039 patients undergoing MAG from 1996-2015. Of those, 958 (32%) were operated on by residents and 2081 (68%) by attending surgeons. Propensity score matching and mixed-effects models were used to compare the 2 groups. Operative mortality rate was 0.3% and 0.4% among patients operated by residents and attending surgeons, respectively (P = 0.71), with no significant differences among the groups in postoperative complications. After a mean follow-up time of 11 ± 4 years, survival probability at 5, 10, and 15 years was 95.1% ± 0.7% vs 96.4% ± 0.6%, 87.0% ± 1.1% vs 87.8% ± 1.1%, and 76.6.% ± 1.8% vs 77.6% ± 1.8% in the resident and attending surgeon group, respectively. Resident and attending surgeon cases showed comparable risk of death (hazard ratio [HR] = 1.01; 95% CI: 0.80-1.28; P = 0.92). The equipoise between the 2 groups was confirmed among cases receiving bilateral internal thoracic arteries only (HR = 0.88; 95% CI: 0.54-1.43; P = 0.61), radial artery (HR = 1.22; 95% CI: 0.92-1.61; P = 0.15), or their combination (HR = 0.74; 95% CI: 0.33-1.65; P = 0.47). The present analysis confirms that adequately supervised trainees can perform CABG with MAG without compromising patient safety and long-term survival., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Developing cardiac surgical skills and experience takes years of practice. Cardiac trainees need to develop technical proficiency in order to enhance quality of care and patient safety. Simulation-based models are common resources for teaching procedural skills in both undergraduate and postgraduate medical education. Suitable and accessible educational platforms can play a progressively important role in the training process for young surgeons in the area of cardiac surgery. Coronary artery bypass graft (CABG) surgery consists of a wide range of pathologic anatomies and surgical techniques. In this paper we introduce a novel, synthetic, biomimetic platform that allows for the realistic practice of the CABG surgery. The prototype uses a polyvinyl alcohol hydrogel which has been designed to mimic the geometric properties of vasculature. The proposed models look and feel like human tissue and possess somewhat consistent mechanical properties. In this study, we apply the platform to simulate a case of autogenous saphenous vein bypass grafting of a patient. An autogenous saphenous vein graft is placed from the aorta to the left anterior descending coronary artery. The standard procedures of the coronary artery bypass surgery were successfully simulated. Using the proposed technology, other complicated surgeries such as end to end, side to end, and sequential anastomoses can be simulated such that these models lend themselves very well to various types of anastomoses.

Objective: The single-crossclamp technique for coronary artery bypass grafting is recognized to reduce manipulation of the ascending aorta, and thereby improve neurological outcomes. However, there is a perceived disadvantage of long cardiopulmonary bypass and crossclamp times. Our objective was to evaluate outcomes with this technique and determine whether it is safe for training., Methods: Patients undergoing coronary artery bypass between October 2005 and February 2014 with use of the single-crossclamp method were divided into 2 groups: a consultant group (n = 1024), and a trainee group (n = 504), depending on the primary surgeon. Their outcomes were compared., Results: The consultants operated on more nonelective patients who had a higher risk profile (mean additive EuroSCORE I 4.05 vs. 3.80, p = 0.085; logistic EuroSCORE I 4.36 vs. 3.64, p = 0.002). There were 9 (0.9%) deaths in the consultant group and 5 (1%) in the trainee group. The mean number of grafts in the consultant group was greater, but the crossclamp time was similar and cardiopulmonary bypass time was shorter. There were 4 (0.4%) cerebrovascular events in the consultant group and 3 (0.6%) in the trainee group. Postoperative stay was shorter in the trainee group (7.19 vs. 7.97 days, p = 0.033). Other complication rates were similar., Conclusions: The technique has excellent outcomes, especially neurological, and is safe for training junior surgeons., (© The Author(s) 2016.)

Background: The present study aimed to describe and compare the operative experience of cardiothoracic surgical residents for basic and advanced cardiac surgical procedures., Methods: Data were obtained from the 2015 Thoracic Surgery Directors Association Survey administered to all thoracic surgical residents taking the yearly In-Service Training Examination (n = 356). Residents were asked whether they routinely served as the operative surgeon on various cardiac operations and operative tasks. Results were stratified by postgraduate year (PGY), residency type, and primary career interest., Results: The survey response rate was 100%. Considering all training pathways, only 2 of 13 cardiac operations surveyed were routinely performed by graduating chief residents as the operative surgeon: coronary artery bypass grafting (CABG; 92%) and aortic valve replacement (AVR; 88%). Off-pump CABG, minimally invasive mitral valve operation, and transcatheter aortic interventions were infrequently (<30% of the time) performed by graduating residents as the operative surgeon. These results were similar when residents with a career interest in general thoracic surgery were excluded from the analysis. For the operative progression of integrated 6-year (I-6) residents, most began to routinely cannulate for cardiopulmonary bypass, perform proximal coronary anastomoses, and harvest the mammary artery during PGY3. The majority (>50%) of I-6 residents performed CABG as the operative surgeon by PGY4., Conclusions: There is pronounced heterogeneity in the cardiac operative experience of cardiothoracic surgical residents in the United States, with only CABG and AVR routinely performed by graduating residents as the operative surgeon. This heterogeneity may lead to insufficient training in certain procedures for many graduates., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: In recent years, concerns have been raised about the learning opportunities available to cardiac surgical trainees. This meta-analysis was conducted to assess the impact of trainee operator status on clinical outcomes after coronary artery bypass graft (CABG) surgery., Methods: Medline, EMBASE, and the Cochrane Library were systematically searched for studies that reported CABG outcomes according to the training status of the primary operator (consultant vs trainee). Data were independently extracted by 2 investigators; a meta-analysis was conducted according to predefined clinical endpoints., Results: Sixteen observational studies (n = 52,966) met criteria for inclusion, with 8 studies (n = 36,479) reporting propensity-adjusted analyses. Trainee cases were associated with increased aortic crossclamp duration (mean difference: 4.80; 95% confidence interval [CI], 0.76-8.83) and cardiopulmonary bypass duration (mean difference: 4.24; 95% CI, 0.00-8.47). Perioperative mortality was similar for CABG performed primarily by trainees versus consultants (odds ratio 0.98; 95% CI, 0.81-1.18). No significant difference was found in the incidence of perioperative stroke, myocardial infarction, acute renal failure, reoperation for bleeding, or wound infection. Trainee operator status was not associated with increased midterm mortality (hazard ratio 1.00; 95% CI, 0.90-1.11). In subgroup analysis that included 5 studies and 8025 patients, off-pump CABG trainee cases were not associated with increased perioperative mortality or morbidity., Conclusions: With appropriate supervision, conventional CABG can be performed by trainee surgeons without an adverse impact on perioperative outcomes or midterm survival. Data regarding off-pump CABG are limited, and further research is warranted to ascertain the impact of trainee operator status on long-term outcomes after off-pump CABG., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We hypothesized that increased postgraduate surgical experience correlates with improved operative efficiency and long-term survival in standard cardiac surgery procedures., Methods: Utilizing a prospectively collected retrospective database, we identified patients who underwent isolated coronary artery bypass grafting (CABG) (n = 3726), aortic valve replacement (AVR) (n = 1626), mitral valve repair (n = 731), mitral valve replacement (MVR) (n = 324), and MVR + AVR (n = 184) from January 2002 through June 2012. After adjusting for patient risk and surgeon variability, we evaluated the influence of surgeon experience on cardiopulmonary bypass and crossclamp times, and long-term survival., Results: Mean surgeon experience after fellowship graduation was 16.0 ± 11.7 years (range, 1.0-35.2 years). After adjusting for patient risk and surgeon-level fixed effects, learning curve analyses demonstrated improvements in cardiopulmonary bypass and crossclamp times with increased surgeon experience. There was marginal improvement in the predictability (R(2) value) of cardiopulmonary bypass and crossclamp time for CABG with the addition of surgeon experience; however, all other procedures had marked increases in the R(2) following addition of surgeon experience. Cox proportional hazard models revealed that increased surgeon experience was associated with improved long-term survival in AVR (hazard ratio [HR], 0.85; P < .0001), mitral valve repair (HR, 0.73; P < .0001), and MVR + AVR (HR, 0.95; P = .006) but not in CABG (HR, 0.80; P = .15), and a trend toward significance in MVR (HR, 0.87; P = .09)., Conclusions: In cardiac surgery, not including CABG, surgeon experience is an important determinant of operative efficiency and of long-term survival., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To establish a model for a high-volume intracranial carotid bypass operation., Methods: High-volume internal carotid-middle cerebral artery bypass was performed on 9 cadaver heads with arteries of porcine forearms as grafts by 6 residents with no previous experience in vascular anastomosis on cadavers. The intima was dissected immediately after the anastomoses were completed to observe the patency of anastomosis., Results: After different duration periods of training using this model, 36 vascular anastomoses on 18 sides were successfully performed by the 6 residents with a self-made difficulty regulation device. As the difficulty level increased, the time needed for anastomosis lengthened and patency rate showed a decreasing trend. As the amount of training increased, the residents were able to decrease the amount of time to complete the operation with increasing patency rates., Conclusions: The model of high-volume internal carotid-middle cerebral artery bypass with arteries of porcine forearms has the advantages of material similarity, easy access of grafts, better simulation of intraoperative conditions, and adjustable difficulties. Our results suggest that this new procedure has a better simulation-training platform which is closer to the real surgical procedure for surgeons willing to master the technique of a high-volume bypass operation., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objective: Previous work has demonstrated high inter-rater reliability in the objective assessment of simulated anastomoses among experienced educators. We evaluated the inter-rater reliability of less-experienced educators and the impact of focused training with a video-embedded coronary anastomosis assessment tool., Methods: Nine less-experienced cardiothoracic surgery faculty members from different institutions evaluated 2 videos of simulated coronary anastomoses (1 by a medical student and 1 by a resident) at the Thoracic Surgery Directors Association Boot Camp. They then underwent a 30-minute training session using an assessment tool with embedded videos to anchor rating scores for 10 components of coronary artery anastomosis. Afterward, they evaluated 2 videos of a different student and resident performing the task. Components were scored on a 1 to 5 Likert scale, yielding an average composite score. Inter-rater reliabilities of component and composite scores were assessed using intraclass correlation coefficients (ICCs) and overall pass/fail ratings with kappa., Results: All components of the assessment tool exhibited improvement in reliability, with 4 (bite, needle holder use, needle angles, and hand mechanics) improving the most from poor (ICC range, 0.09-0.48) to strong (ICC range, 0.80-0.90) agreement. After training, inter-rater reliabilities for composite scores improved from moderate (ICC, 0.76) to strong (ICC, 0.90) agreement, and for overall pass/fail ratings, from poor (kappa = 0.20) to moderate (kappa = 0.78) agreement., Conclusions: Focused, video-based anchor training facilitates greater inter-rater reliability in the objective assessment of simulated coronary anastomoses. Among raters with less teaching experience, such training may be needed before objective evaluation of technical skills., (Published by Elsevier Inc.)

Objective: It is unclear whether novice trainees can be taught safely to perform adult cardiac surgery without any impact on early or late outcomes., Methods: All patients (n = 1305) data were obtained from an externally validated, mandatory institutional database (2003-2010). 'Novice' is defined as a trainee who required substantial assistance or supervision to perform part or whole of the specified procedure (Intercollegiate Surgical Curriculum Programme UK, Competency Level ≤2). Outcome measures were in-hospital mortality, composite score of in-hospital mortality-morbidities, mid-term survival and revascularisation rate after CABG. Follow-up up to 7 years (median 3.2 years) was determined., Results: Some 39 % (n = 510) of the cases involved novice (28 %-part, 11 %-whole procedure), 12 % (n = 157) competent trainees and 49 % (n = 638) consultant. Median EuroSCORE was higher in consultant group (p < 0.001). Without risk adjustment, composite outcome score and mid-term mortality were higher in consultant group (p = 0.03). With adjustment using EuroSCORE and propensity scores, EuroSCORE was significantly predictive of in-hospital mortality [odd ratio (OR) 1.38, 95 %CI 1.20-1.57, p < 0.001], composite outcome (OR 1.26, 95 %CI 1.15-1.37, p < 0.001) and mid-term mortality (HR 1.24, 95 %CI 1.18-1.31, p < 0.001) but not the operator categories. Further analysis of subcohort undergoing first-time, isolated CABG (n = 1070) showed that EuroSCORE remained predictive of adjusted in-hospital mortality (OR 1.39, 95 %CI 1.13-1.71, p = 0.002), composite outcome (OR 1.33, 95 %CI 1.19-1.49, p < 0.001) and mid-term mortality (HR 1.22, 95 %CI 1.10-1.35, p < 0.001). The operator categories were not associated with adjusted outcome measures including revascularisation rate after CABG., Conclusion: Supervised training in adult cardiac surgery can be achieved safely at the early learning curve phase without compromising both early and mid-term clinical outcomes.

Objective: We examined the effects of learning curve on clinical outcomes and operative time in minimally invasive coronary artery bypass grafting (MICS CABG)., Methods: We studied 210 consecutive MICS CABG cases performed by the same surgeon, composed of 3 cardiopulmonary bypass (CPB)-assisted single-vessel small thoracotomy (SVST), 87 off-pump SVST, 51 CPB-assisted multivessel small thoracotomy (MVST), and 69 off-pump MVST. For each MICS CABG technique, the frequency of early clinical events (mortality, reopening, stroke, myocardial infarction, and revascularization) was compared between the first 25 cases and the remainder. Logarithmic curve regression analysis and a cumulative summation technique were performed to assess the correlation between operative time and the performed number of each technique., Results: There was no mortality, and there were 10 conversions to standard sternotomy, all of which were intended as off-pump MVST (P < 0.001, vs other procedures). Experience was otherwise not associated with perioperative outcome. However, experience numbers correlated with operative time in off-pump SVST and off-pump MVST (122 ± 30 minutes, R = 0.18, P < 0.001, and 241 ± 80 minutes, R = 0.38, P < 0.001, respectively) but not in CPB-assisted MVST (258 ± 44 minutes, R = 0.004, P = 0.7). No complications occurred as a result of CPB assistance., Conclusions: Minimally invasive coronary artery bypass grafting can be safely initiated, with a very low perioperative risk. Pump assistance is a good strategy to alleviate some of the learning curve and avoid conversions to sternotomy when initiating a multivessel MICS CABG program.

Background: The commencement of new academic cycle in July is presumed to be associated with poor patient outcomes, although supportive evidence is limited for cardiac surgery patients. We sought to determine if the new academic cycle affected the outcomes of patients undergoing Coronary Artery Bypass Grafting., Methods: A retrospective analysis was performed on 10-year nationwide in-hospital data from 1998-2007. Only patients who underwent CABG in the first and final academic 3-month calendar quarter were included. Generalized multivariate regression was used to assess indicators of hospital quality of care such as risk-adjusted mortality, total complications and "failure to rescue" (FTOR) - defined as death after a complication., Results: Of the 1,056,865 CABG operations performed in the selected calendar quarters, 698,942 were at teaching hospitals. The risk-adjusted mortality, complications and FTOR were higher in the beginning of the academic year [Odds ratio = 1.14, 1.04 and 1.19 respectively; p < 0.001 for all] irrespective of teaching status. However, teaching status was associated with lower mortality (OR 0.9) despite a higher complication rate (OR 1.02); [p < 0.05 for both]. The July Effect thus contributed to only a 2.4% higher FTOR in teaching hospitals compared to 19% in non teaching hospitals., Conclusions: The July Effect is reflective of an overall increase in morbidity in all hospitals at the beginning of the academic cycle and it had a pronounced effect in non-teaching hospitals. Teaching hospitals were associated with lower mortality despite higher complication rates in the beginning of the academic cycle compared to non-teaching hospitals. The July effect thus cannot be attributed to presence of trainees alone., Ultramini Abstract: This study compares the July effect in teaching and non-teaching hospitals and demonstrates that this effect is not unique to teaching hospitals for CABG patients. In fact, teaching hospitals have somewhat better outcomes at the beginning of the academic cycle and the July effect is a much broader seasonal variation.

Objective: Robotic-assisted techniques are continuing to cement their role in coronary surgery, particularly in facilitating the endoscopic harvesting of the left internal mammary artery (LIMA), regardless of how the subsequent bypass grafting is performed. As more surgeons attempt to become trained in robotic-assisted procedures, we sought to better define the learning curve associated with robotic-assisted endoscopic LIMA harvest., Methods: Between January 2011 and July 2012, a total of 77 patients underwent robotic-assisted minimally invasive direct coronary artery bypass surgery at our institution. The LIMA was harvested endoscopically in all patients, using standard robotic instruments, followed by direct grafting to anterior wall myocardial vessels via a small thoracotomy. Intraoperative times for various components of the procedure were collated and analyzed., Results: The mean ± SD time taken to insert and position the ports for the robotic instruments was 3.9 ± 1.4 minutes. The mean ± SD LIMA harvest time was 31.8 ± 10.1 minutes, and the mean ± SD total robotic time was 44.2 ± 12.9 minutes. All time variables consistently continued to decrease as the experience of the operating surgeon increased, with the greatest magnitude of improvement being evident within the first 20 cases. The logarithmic learning curves for LIMA harvest time and total robot time during our entire experience were both calculated as 90%, correlating to an expected 10% improvement in performance for each doubling of cases completed., Conclusions: Coronary surgeons can rapidly become proficient in robotic-assisted endoscopic LIMA harvest, with significant improvement in operative times evident within the first 20 cases completed. These data may be useful in designing appropriate training programs for newer surgeons seeking to gain experience in robotic-assisted coronary surgery.

Objectives: Gaining cardiac surgical competence is a complex, multifactorial process that may take years of experience and on-the-job training. It is critical to provide suitable educational opportunities to gain the necessary knowledge, judgment and skills. In response to the multitude of factors (e.g. European Working Time Directive) currently influencing cardiac surgical training, there have been concerted efforts to reform training practices. Simulation plays an increasingly important role in the educational process and serves to fill the most important gap in the current training model, i.e. operative exposure. Therefore, a contest has been written out for cardiac surgical trainees to construct their own coronary anastomosis simulator using everyday materials., Methods: Cardiac surgical trainees were invited to construct their own coronary anastomosis simulator. An international jury of cardiac surgeons assessed the simulator and its presentation according to preset developmental criteria (low fidelity concept, innovative character, general presentation and description, general attractiveness to the scholar, ergonomical issues, perceived haptics, number of applicable components, transportability, ease of construction, repeatability and overall costs of the simulator)., Results: Six prototypes of simulators built by cardiac surgical trainees were generated. A general evaluation of each simulator prototype is provided according to the preset developmental criteria., Conclusions: All simulator prototypes have provided a considerable contribution to the field of surgical simulation. By designing simulator prototypes, the trainees have demonstrated their 'out of the box' thinking capability, which is of paramount importance for the development of future innovative surgical techniques and procedures. The Valladolid cardiac team coronary anastomosis simulator box was selected for the EACTS Ethicon Simulation Award 2011. This project will be mass produced and distributed to the participants of structured simulation sessions for coronary anastomoses.

Background: Research has demonstrated equivalent patient safety outcomes for various cardiac procedures when the primary surgeon was a supervised trainee. However, cardiac surgery cases have become more complex, and the Canadian cardiac surgery education model has undergone some changes. We sought to compare patient safety and efficiency of aortic valve replacement (AVR) between Canadian patients treated by senior cardiac trainees and those treated by certified cardiac surgeons., Methods: We completed a single-centre, case-matched, prospectively collected and retrospectively analyzed study of AVR. Patients were matched between trainees and consultants for age, sex, New York Heart Association and Canadian Cardiovascular Society status, urgency of operation and diabetes status., Results: We analyzed 1102 procedures: 624 isolated AVRs and 478 AVRs with coronary artery bypass graft (CABG). For isolated AVR, there was no significant difference in 30-d mortality (p = 0.13) or in major adverse events (p = 0.38) between the groups. In the AVR+CABG group, there was no significant difference in 30-day mortality (p = 0.10) or in the rates of major adverse events (p = 0.37) between the groups. Secondary outcomes (hospital and intensive care unit lengths of stay, valve size and type) did not differ significantly between the groups for isolated AVR or AVR+CABG., Conclusion: Despite a higher-risk patient population and changes in the cardiac surgery training model, it appears that outcomes are not negatively affected when a senior trainee acts as the primary surgeon in cases of AVR.

Objective: No previous studies have specifically addressed the effect of training on outcomes after concomitant aortic valve replacement and coronary artery bypass grafting. This study evaluated the early and late outcomes after concomitant aortic valve replacement and coronary artery bypass grafting performed by surgeons in training., Methods: A retrospective analysis of data collected prospectively by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database between June 2001 and December 2009 was performed. Concomitant aortic valve replacement and coronary artery bypass grafting was performed in 2540 patients; of these procedures, 290 (11.4%) were by trainees. Patient demographics, intraoperative characteristics, and early morbidity were compared between trainee and staff cases using chi-square analysis and t tests. Multivariate analyses were used to determine the independent association of training status with 30-day and late mortality., Results: Compared with staff cases, trainee cases were younger (mean age, 73.0 vs 74.2 years; P = .025) and less likely to present with triple vessel disease (27.9% vs 38.3%, P = .001) or previous cardiac surgery (6.3% vs 2.8%, P = .016). Trainee cases had longer mean perfusion (160.4 vs 144.6 minutes, P < .001) and crossclamp (125.2 vs 114.6 minutes, P < .001) times. The incidence of early complications was similar between the 2 groups. On multivariate analysis, trainee status was not associated with an increased risk of 30-day mortality (2.4% vs 4.0%, P = .348). Moreover, there was no significant difference in long-term outcomes, and 5-year survival was comparable in both groups (79.6% vs 77.4%, P = .200)., Conclusions: Concomitant aortic valve replacement and coronary artery bypass grafting can be safely and effectively performed by properly supervised trainees in the contemporary era. It is imperative to offer training opportunities to junior surgeons in this complex procedure to ensure quality patient outcomes in the future., (Crown Copyright © 2013. Published by Mosby, Inc. All rights reserved.)

Objectives: Individual surgeon experience and the cumulative experience of the surgical team have both been implicated as factors that influence surgical efficiency. We sought to quantitatively evaluate the effects of both individual surgeon experience and the cumulative experience of attending surgeon-cardiothoracic fellow collaborations in isolated coronary artery bypass graft (CABG) procedures., Methods: Using a prospectively collected retrospective database, we analyzed all medical records of patients undergoing isolated CABG procedure at our institution. We used multivariate generalized estimating equation regression models to adjust for patient mix and subsequently evaluated the effect of both attending cardiac surgeon experience (since fellowship graduation) and the number of previous collaborations between attending cardiac surgeons and cardiothoracic fellow pairs on cardiopulmonary bypass and crossclamp times., Results: From 2001 to 2010, 4068 consecutive patients underwent isolated CABG procedure at our institution performed by 11 attending cardiac surgeons and 73 cardiothoracic fellows. Mean attending experience after fellowship graduation was 10.9 ± 8.0 years and mean number of cases between unique pairs of attending cardiac surgeons and cardiothoracic fellows was 10.0 ± 10.0 cases. After patient risk adjustment, both attending surgical experience since fellowship graduation and the number of previous collaborations between attending surgeons and cardiothoracic fellows were significantly associated with a reduction in cardiopulmonary bypass and crossclamp times (P < .001). The influence of attending-fellow pair experience far exceeded the influence of surgical experience with beta estimates for attending-fellow pair experience nearly three times that of attending surgeon experience., Conclusions: Cumulative experience of attending cardiac surgeons and cardiothoracic fellows has a dramatic effect on both cardiopulmonary bypass and crossclamp times, whereas attending cardiac surgeon learning curves following fellowship graduation are clinically insignificant. Taken together, these findings suggest that the primary driver of operative efficiency in CABG procedure is the collaborative experience of the attending surgeon-cardiothoracic fellow operative team, rather than the individual experience of the attending surgeon., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Procedural outcomes can be used to assess the performance of specialists and trainees. This article establishes a systematic evidence base for the safety of training in the operating theatre. It also explores the possibility of using early, intermediate and late procedural outcomes of cardiac surgical operations to evaluate the performance of the clinicians and the healthcare system., Methods: Medline, EMBASE and PsycINFO databases were searched. Comparative studies evaluating quality indicators of cardiac surgical procedures (coronary artery bypass grafting (CABG) and valve surgery) were included. guidelines from the preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used., Results: Fourteen studies met the inclusion criteria. For CABG, meta-analysis of outcomes did not show any significant differences between the technical and non-technical skills of trainees versus specialists apart from bypass time (less for specialists) and intensive care unit (ICU) length of stay (less for trainees). Studies reporting outcomes on valve surgery also did not report any statistically significant differences amongst the outcomes., Conclusion: This systematic review did not discern any significant differences between the procedural outcomes of trainees and specialists, which indicates that trainees are safe to operate under senior supervision. In addition, this article recommends that various procedural outcomes can be used to evaluate the performance of clinicians and healthcare systems. Prospective studies need to be performed, taking into account the specific contribution of trainees and specialists during the procedure. This will give a clearer indication of safety and performance of trainees and specialists in the operating theatre.

Objective: Robotic-assisted coronary artery bypass is a minimally invasive alternative to traditional coronary artery bypass surgery via median sternotomy with an associated learning curve. The purpose of this study was to investigate the reasons for conversion to sternotomy., Methods: From October 2009 to June 2012, two surgeons at one US academic institution performed 271 consecutive robotic-assisted coronary artery bypass procedures. For all cases, isolated, off-pump left internal mammary artery (LIMA) to left anterior descending coronary artery grafting was planned via a 3- to 4-cm sternal-sparing thoracotomy after robotic internal mammary artery harvest and pericardiotomy., Results: Conversion to sternotomy occurred in 15 of 271 (5.5%) patients. The most common reason was technical difficulty with the anastomosis, which occurred in 6 (40.0%) patients. Others included LIMA dissection, 2 (13.3%); wrong vessel grafted, 2 (13.3%); ventricular fibrillation and cardiac arrest, 1 (6.7%); equipment malfunction, 1 (6.7%); adhesions, 1 (6.7%); and other. Two underwent emergent conversion. Six underwent multivessel bypass after conversion instead of hybrid coronary revascularization. No mortality occurred among converted patients. Two patients had postoperative myocardial infarction and one had a superficial sternal wound infection. Conversion rate was relatively stable among the four different time quartiles (range, 3.0%-7.4%), although the reasons for conversion were different., Conclusions: Conversion to sternotomy is an infrequent complication of robotic-assisted coronary artery bypass, most commonly because of technical difficulties during the LIMA harvest and the LIMA to left anterior descending anastomosis. Anatomic and patient variables as well as inherent technical problems with minimally invasive procedures make conversion unavoidable in some patients.

Objective: Off-pump coronary artery bypass grafting (OPCAB) is an established procedure in many cardiothoracic centers. For it to be widely applicable, however, teaching methods must be developed for surgical trainees. Early clinical outcomes and long-term survival of patients who underwent OPCAB at our institution by trainees supervised and unsupervised were compared with those of patients whose procedures were performed by senior surgeons. To evaluate evolution of training, outcomes were analyzed according to 3 different periods (1996-1999, 2000-2004, 2005-2009) and trainee seniority level., Methods: This was a retrospective, observational cohort study of prospectively collected data from 5566 consecutive patients who underwent isolated OPCAB performed by trainees (1589, 28.6%; 1111 supervised, 478 unsupervised) and by senior surgeons (3977, 71.4%)., Results: Patients of senior surgeons were more likely to have left ventricular dysfunction (P = .001), peripheral vascular disease (P = .05), more extensive coronary artery disease (P = .001), and higher EuroSCOREs than patients of trainees. In addition, trainees were less likely to have performed urgent operations (P = .02) or reoperations (P = .03) but more likely to have operated on patients with previous percutaneous coronary intervention (P = .006). Early clinical outcomes and long-term survival were similar between groups and not related to trainee seniority, level of supervision by senior surgeon, or period during which training took place., Conclusions: OPCAB is a safe and reproducible surgical technique that can be taught successfully to cardiothoracic trainees. Clinical outcomes are unrelated to level of supervision or seniority of trainees., (Crown Copyright © 2012. Published by Mosby, Inc. All rights reserved.)

Objective: Hospitals with a high volume and academic status produce better patient outcomes than other hospitals after complex surgical procedures. Risk models show that concomitant aortic valve replacement and coronary artery bypass grafting pose a greater risk than isolated coronary artery bypass grafting or aortic valve replacement. We examined the relationship of hospital teaching status and the presence of a thoracic surgery residency program with aortic valve replacement/coronary artery bypass grafting outcomes., Methods: By using the Nationwide Inpatient Sample database, we identified patients who underwent concomitant aortic valve replacement/coronary artery bypass grafting from 1998 to 2007 at nonteaching hospitals, teaching hospitals without a thoracic surgery residency program, and teaching hospitals with a thoracic surgery residency program. Multivariate analysis was performed to identify intergroup differences. Risk-adjusted multivariable logistic regression analysis was used to assess independent predictors of in-hospital mortality and complication rates., Results: The 3 groups of patients did not differ significantly in their baseline characteristics. Patients who underwent aortic valve replacement/coronary artery bypass grafting had higher overall risk-adjusted complication rates in nonteaching hospitals (odds ratio 1.58; 95% confidence interval, 1.39-1.80; P < .0001) and teaching hospitals without a thoracic surgery residency program (odds ratio 1.42; 95% confidence interval, 1.26-1.60; P < .0001) than in thoracic surgery residency program hospitals. However, no difference was observed in the adjusted mortality rate for nonteaching hospitals (odds ratio 0.95; 95% confidence interval, 0.87-1.04; P = .25) or teaching hospitals without a thoracic surgery residency program (odds ratio 1.00; 95% confidence interval, 0.92-1.08; P = .98) when compared with thoracic surgery residency program hospitals. Robust statistical models were used for analysis, with c-statistics of 0.98 (complications) and 0.82 (mortality)., Conclusion: Patients who require complex cardiac operations may have better outcomes when treated at teaching hospitals with a thoracic surgery residency program., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Cardiac rehabilitation has a beneficial effect on the prognosis and quality of life of cardiac patients, and has been found to be cost-effective. This report describes a comprehensive and low cost educational intervention designed to increase the attendance at cardiac rehabilitation programs of patients who have undergone coronary artery bypass graft surgery., Methods/design: A controlled prospective intervention trial. The control arm comprised 520 patients who underwent coronary artery bypass graft surgery between January 2004 and May 2005 in five medical centers across Israel. This group received no additional treatment beyond usual care. The intervention arm comprised 504 patients recruited from the same cardiothoracic departments between June 2005 and November 2006. This group received oral and written explanations about the advantages of participating in cardiac rehabilitation programs and a telephone call two weeks after hospital discharge intended to further encourage their enrollment. The medical staff attended a one-hour seminar on cardiac rehabilitation. In addition, it was recommended that referral to cardiac rehabilitation be added to the letter of discharge from the hospital. Both study groups were interviewed before surgery and one-year post surgery. A one-year post-operative interview assessed factors affecting patient attendance at cardiac rehabilitation programs, as well as the structure and content of the cardiac rehabilitation programs attended. Anthropometric parameters were measured at pre- and post-operative interviews;- and medical information was obtained from patient medical records. The effect of cardiac rehabilitation on one- and three-year mortality was assessed., Discussion: We report a low cost yet comprehensive intervention designed to increase cardiac rehabilitation participation by raising both patient and medical staff awareness to the potential benefits of cardiac rehabilitation., Trial Registration: ClinicalTrials.gov: NCT00356863.

Objective: We evaluated focused training in coronary artery anastomosis with a porcine heart model and portable task station., Methods: At "Boot Camp," 33 first-year cardiothoracic surgical residents participated in 4-hour coronary anastomosis sessions (6-7 attending surgeons per group of 8-9 residents). At beginning, midpoint, and session end, anastomosis components were assessed on a 3-point rating scale (1 good, 2 average, 3 below average). Performances were video recorded and reviewed by 3 surgeons in a blinded fashion. Participants completed questionnaires at session end, with follow-up surveys at 6 months., Results: Ten to 18 end-to-side anastomoses with porcine model and task station were performed. Initial assessments ranged from 2.11 +/- 0.58 (forceps use) to 2.44 +/- 0.48 (needle angles). Midpoint scores ranged from 1.76 +/- 0.63 (forceps use) to 1.91 +/- 0.49 (needle angles). Session end scores ranged from 1.29 +/- 0.45 (needle holder use) to 1.58 +/- 0.50 (needle transfer and suture management and tension; P < .001). Video recordings confirmed improved performance (interrater reliability >0.5). All respondents agreed that task station and porcine model were good methods of training. At 6 months, respondents noted that the anastomosis session provided a basis for training; however, only slightly more than half continued to practice outside the operating room., Conclusions: Four-hour focused training with porcine model and task station resulted in improved ability to perform anastomoses. Boot Camp may be useful in preparing residents for coronary anastomosis in the clinical setting, but emphasis on simulation development and deliberate practice is necessary., (Published by Mosby, Inc.)