Monitoring the performance of residents during training in off-pump coronary surgery.

OBJECTIVE: Control charts (eg, cumulative sum charts) plot changes in performance with time and can alert a surgeon to suboptimal performance. They were used to compare performance of off-pump coronary artery bypass surgery between a consultant and four resident surgeons and to compare performance of off-pump coronary artery bypass surgery and conventional coronary artery bypass grafting within surgeons. METHODS: Data were analyzed for consecutive patients undergoing coronary artery bypass grafting who were operated on by one consultant or one of four residents. Conversions were analyzed by intention to treat. Perioperative death or one or more of 10 adverse events constituted failure. Predicted risks of failure for individual patients were derived from the study population. Variable life-adjusted displays and risk-adjusted sequential probability ratio test charts were plotted. RESULTS: Data for 1372 patients were analyzed; 769 of the procedures were off-pump coronary artery bypass operations (56.0%). The consultant operated on 382 patients (293 off-pump, 76.7%), and the residents operated on 990 (474 off-pump, 47.9%). Patients operated on by residents tended to be older, more obese, more likely to require an urgent operation, and more likely to need a circumflex artery graft but less likely to have triple-vessel disease. There were 7 conversions (consultant 5, residents 2). The overall failure rate was 8.5% (9.2% for consultant's operations and 8.2% for residents' operations), including 10 deaths (0.7%). Predicted and observed risks of failure were similar for all five surgeons. After 100 off-pump coronary artery bypass operations, performance was the same or better for the residents as for the consultant. For all surgeons, performance was the same or better for off-pump as for conventional coronary artery bypass grafting. CONCLUSIONS: Off-pump coronary artery bypass surgery can be safely taught to cardiothoracic residents. Implementation of continuous performance monitoring for residents is practicable

Off-pump versus on-pump coronary artery bypass grafting: Insights from the Arterial Revascularization Trial

Background: The long-term effects of off-pump coronary artery bypass continue to be controversial because some studies have reported increased adverse event rates with off-pump coronary artery bypass when compared with on-pump coronary artery bypass. The Arterial Revascularization Trial compared survival after bilateral versus single internal thoracic artery grafting. The choice of off-pump coronary artery bypass versus on-pump coronary artery bypass was based on the surgeon's discretion. We performed a post hoc analysis of the Arterial Revascularization Trial to compare 5-year outcomes with 2 strategies. Methods: Among 3102 patients enrolled in the Arterial Revascularization Trial, we selected 1260 patients who underwent off-pump coronary artery bypass versus 1700 patients who underwent on-pump coronary artery bypass with cardioplegic arrest for the present comparison. Primary outcomes were 5-year mortality and incidence of major cardiac and cerebrovascular events, including cardiovascular death, myocardial infarction, cerebrovascular accident, and revascularization after index procedure. Propensity score matching selected 1260 pairs for final comparison. Stratified Cox models were used for treatment effect estimate. Results: Hospital mortality was comparable between off-pump coronary artery bypass and on-pump coronary artery bypass groups (12 [1.0%] vs 15 [1.2%]; P = .7). Conversion rate to on-pump during off-pump coronary artery bypass was 29 of 1260 (2.3%). When compared with off-pump coronary artery bypass not converted, off-pump coronary artery bypass converted to on-pump presented a remarkably higher hospital mortality (10.3% vs 0.7%; P < .001). At 5 years, the mortality rate was 110 (8.9%) versus 102 (8.3%) in the off-pump coronary artery bypass and on-pump coronary artery bypass groups, respectively, with no significant difference (hazard ratio, 1.14; 95% confidence interval, 0.86-1.52; P = .35). Incidence of major cardiac and cerebrovascular events was 175 (14.3) versus 169 (13.8) in the off-pump coronary artery bypass and on-pump coronary artery bypass groups, respectively, with no significant difference (hazard ratio, 1.05; 95% confidence interval, 0.84-1.31; P = .65). Conclusions: The present post hoc Arterial Revascularization Trial analysis supports the hypothesis that both off-pump coronary artery bypass and on-pump coronary artery bypass are equally effective and safe

René Géronimo Favaloro : pioneer of Cardiac Surgery

Dr. René G. Favaloro moved to the Cleveland Clinic in 1962 and proceeded to reshape the face of cardiac surgery as we knew it. Together with his colleagues at the Cleveland Clinic, Drs. Effler, Sones, Proudfit, Groves, Sheldon and countless others, he contributed to the double internal mammary arterymyocardial implantation by the Vineberg method, and by May 1967, he reconstructed the right coronary artery by the saphenous vein graft interposition. These landmark procedures paved the way for the aorto-coronary saphenous vein bypass graft in October 1967. Many similar breakthroughs ensued, with the application of the bypass technique to the left coronary artery, the combination of coronary artery bypass graft with left ventricular reconstruction and valve repair/replacement and finally, by December, a double bypass to the right coronary artery and anterior descending branch of the left coronary artery. In June, 1971, Dr. Favaloro decided to leave the Cleveland Clinic and return to Argentina where he created a medical centre, a teaching unit, a research department and finally an Institute of Cardiology and Cardiovascular Surgery. This was his greatest personal ambition. Over and above his brilliant mind and craft, Dr. Favaloro was a man of integrity, courage, honesty and humility, whose name will never cease to reverberate throughout the history of medicine.peer-reviewe

On-Pump and Off-Pump Coronary Artery Bypass Grafting Is An Open Heart Surgery Procedure In Management Of Coronary Heart Disease

Introduction: Coronary heart disease is a condition in which fatty deposits in the heart's coronary arteries change the role and shape of the streets and obstruct blood flow to the heart. Invasive management is known as coronary artery bypass grafting and is divided into two techniques: on-pump coronary artery bypass and off-pump coronary artery bypass. Method: The method used in this study is a systematic review. The literature study conducted by the author is by searching various written sources, whether in the form of books, archives, magazines, articles and journals, or documents that are relevant to the problem being studied. Discussion: The on-pump coronary artery bypass technique is performed using a cardiopulmonary bypass machine which replaces the function of the heart and lungs during the operation process, and the off-pump coronary artery bypass technique is performed without using a cardiopulmonary bypass machine so that the heart keeps beating during the operation. Both of these techniques give equally good results, and their selection depends on the clinical situation of the patient and the cardiac surgeon. Conclusion: Coronary artery bypass grafting is a surgical technique that is currently the choice in managing coronary heart disease patients when treatment and Percutaneous coronary intervention do not provide the best results. There are two techniques for performing CABG, namely on-pump coronary artery bypass and off-pump coronary artery bypass Key Word: Coronary heart disease,&nbsp; Coronary Artery, On pump coronary artery bypass, off-pump coronary artery bypass &nbsp; Pendahuluan: Penyakit jantung koroner adalah suatu kondisi di mana timbunan lemak di arteri koroner jantung mengubah peran dan bentuk jalan dan menghalangi aliran darah ke jantung. Penatalaksanaan invasif dikenal sebagai pencangkokan bypass arteri koroner dan dibagi menjadi dua teknik: bypass arteri koroner on-pump dan bypass arteri koroner off-pump. Metode: Metode yang digunakan dalam penelitian ini adalah sistematika review. Studi kepustakaan yang dilakukan penulis adalah dengan menelusuri berbagai sumber tertulis, baik berupa buku, arsip, majalah, artikel dan jurnal, maupun dokumen-dokumen yang relevan dengan masalah yang diteliti. Diskusi: Teknik bypass arteri koroner on-pump dilakukan dengan menggunakan mesin cardiopulmonary bypass yang menggantikan fungsi jantung dan paru-paru selama proses operasi, dan teknik bypass arteri koroner off-pump dilakukan tanpa menggunakan mesin cardiopulmonary bypass sehingga jantung terus berdetak selama operasi. Kedua teknik ini memberikan hasil yang sama baiknya, dan pemilihannya tergantung pada situasi klinis pasien dan ahli bedah jantung.Kesimpulan: Pencangkokan bypass arteri koroner merupakan teknik bedah yang saat ini menjadi pilihan dalam penanganan pasien penyakit jantung koroner ketika pengobatan dan intervensi koroner perkutan tidak memberikan hasil terbaik. Ada dua teknik untuk melakukan CABG, yaitu bypass arteri koroner on-pump dan bypass arteri koroner off-pump Kata Kunci: Pneumothorax, Pneumothorax Spontan, Aspirasi Jarum, Chest tub

Time trends in survival and readmission following coronary artery bypass grafting in Scotland, 1981-96: retrospective observational study

Improvements in coronary revascularisation techniques and an increase in the use of percutaneous interventions1 have led to a rise in the number of coronary artery bypass grafting operations in older patients with more severe cardiac disease and worse comorbidity and who have previously undergone revascularisation procedures. 2 3 Advances in surgical and anaesthetic techniques have prevented a worsening risk profile from being translated into an increase in perioperative deaths. 2 3 The aim of our study was to examine time trends in major outcomes up to two years after coronary artery bypass grafting

One-year outcomes of coronary artery bypass graft surgery versus percutaneous coronary intervention with multiple stenting for multisystem disease: A meta-analysis of individual patient data from randomized clinical trials

BackgroundWe aimed to provide a quantitative analysis of the 1-year clinical outcomes of patients with multisystem coronary artery disease who were included in recent randomized trials of percutaneous coronary intervention with multiple stenting versus coronary artery bypass graft surgery.MethodsAn individual patient database was composed of 4 trials (Arterial Revascularization Therapies Study, Stent or Surgery Trial, Argentine Randomized Trial of Percutaneous Transluminal Coronary Angioplasty Versus Coronary Artery Bypass Surgery in Multivessel Disease 2, and Medicine, Angioplasty, or Surgery Study 2) that compared percutaneous coronary intervention with multiple stenting (N = 1518) versus coronary artery bypass graft surgery (N = 1533). The primary clinical end point of this study was the combined incidence of death, myocardial infarction, and stroke at 1 year after randomization. Secondary combined end points included the incidence of repeat revascularization at 1 year. All analyses were based on the intention-to-treat principle.ResultsAfter 1 year of follow-up, 8.7% of patients randomized to percutaneous coronary intervention with multiple stenting versus 9.1% of patients randomized to coronary artery bypass graft surgery reached the primary clinical end point (hazard ratio 0.95 and 95% confidence interval 0.74’1.2). Repeat revascularization procedures occurred more frequently in patients allocated to percutaneous coronary intervention with multiple stenting compared with coronary artery bypass graft surgery (18% vs 4.4%; hazard ratio 4.4 and 95% confidence interval 3.3’5.9). The percentage of patients who were free from angina was slightly lower after percutaneous coronary intervention with multiple stenting than after coronary artery bypass graft surgery (77% vs 82%; P = .002).ConclusionsOne year after the initial procedure, percutaneous coronary intervention with multiple stenting and coronary artery bypass graft surgery provided a similar degree of protection against death, myocardial infarction, or stroke for patients with multisystem disease. Repeat revascularization procedures remain high after percutaneous coronary intervention, but the difference with coronary artery bypass graft surgery has narrowed in the era of stenting

Comparing results of bypass surgery and percutaneous coronary intervention for left main disease by surgical revascularization pump strategy

Objective: We performed a post hoc analysis of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial to determine the effect an on-versus off-pump strategy had on outcomes when compared with percutaneous coronary intervention. Methods:All randomized patients in EXCEL (n = 1905) were included. The outcomes of interest were the primary end point composite of death from any cause, stroke, or myocardial infarction; the composite study end point or ischemia-driven revascularization; and the rate of death from any cause at 5 years. Event rates were based on Kaplan–Meier estimates in time-to-first-event analyses. Results: Propensity matching resulted in groups of 1142 patients (571 each) for on-pump coronary artery bypass grafting versus percutaneous coronary intervention and 472 patients (236 each) for off-pump coronary artery bypass grafting versus percutaneous coronary intervention. In the on-pump coronary artery bypass grafting versus percutaneous coronary intervention matched groups, the composite end point was similar (18.0% vs 22.1%, P = .19) and the composite end point or ischemia-driven revascularization (23.3% vs 31.0%, P = .01) was lower, and mortality (7.6% vs 11.8%, P = .025) was lower in the on-pump coronary artery bypass grafting group at 5 years. In the off-pump coronary artery bypass grafting versus percutaneous coronary intervention matched groups, the composite end point (19.4% vs 22.2%, P = .47), composite end point or ischemia-driven revascularization (25.9% vs 34.2%, P = .07), and mortality (12.5% vs 14.2%, P = .59) were similar at 5 years. Conclusions: In the EXCEL trial, on-pump coronary artery bypass grafting was associated with a decreased 5-year rate of the composite outcome of death, stroke, myocardial infarction, or ischemia-driven revascularization, and decreased mortality when compared with percutaneous coronary intervention, whereas outcomes of off-pump coronary artery bypass grafting were similar to percutaneous coronary intervention.</p

Coronary steal syndrome after coronary artery bypass for anomalous aortic origin of a coronary artery.

Anomalous aortic origin of a coronary artery found in a symptomatic 9-year-old boy was initially treated with coronary artery bypass grafting using a left internal mammary artery anastomoses to the left anterior descending coronary artery, but resulted in coronary ischemia, likely from a steal phenomenon. Subsequent transection of the proximal left internal mammary artery with anastomosis to the ascending aorta, and coronary ostial enlargement, resulted in a durable treatment. We recommend caution in choosing coronary artery bypass grafting using a left internal mammary artery pedicle graft for the treatment of anomalous aortic origin of a coronary artery

The Impact of Peer Education on Coronary Artery Bypass Surgery Readmission Rates

Coronary artery bypass surgery is the most common cardiovascular operation performed in the United States. Coronary artery bypass surgery lowers rates of cardiovascular death by restoring circulation to cardiac tissue in patients with coronary artery disease. However, this surgery is associated with unacceptably high readmission rates, posing both health risks for the patient and a substantial financial burden on the healthcare system. Our objective is to investigate whether peer education can improve 30-day readmission rates of patients after coronary artery bypass surgery. Adult patients undergoing a coronary artery bypass surgery will either receive the usual standard of care or four assigned group sessions with a peer educator, with the primary metric being 30-day readmission rate due to any cause. If successful, peer education could be integrated into the management of coronary artery bypass surgery patients, improving patient care and saving the healthcare-related costs

Coronary atheroma [14 cm] extracted from the right coronary artery during off-pump coronary artery bypass grafting

Coronary endarterectomy is a good option for surgical revascularization in diffusely coronary artery disease. In coronary artery bypass surgery, a diffusely diseased right coronary artery is an obstruction to accomplishing complete myocardial revascularization, subsequently increasing the likelihood of a poor postoperative prognosis. Here, we report a case of extraction of a long segment coronary atheroma (14 cm) from right coronary artery during off-pump coronary artery bypass grafting using closed endarterectomy technique followed by reconstruction with saphenous venous graft