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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

Neointima formation is promoted by surgical preparation and inhibited by cyclic nucleotides in human saphenous vein organ cultures

AbstractIntimal thickening is an important cause of late coronary vein graft occlusion, which no variation of surgical technique or pharmacologic intervention has been shown to reduce. We used a recently developed quantitative organ culture of human saphenous vein to investigate whether surgical preparative injury promotes neointima formation. We also investigated the effects on neointima formation of the lipid-soluble cyclic nucleotide analogs, 8-Br-cyclic adenosine monophosphate and 8-Br-cyclic guanosine monophosphate, and the phosphodiesterase inhibitor, isobutylmethylxanthine. These agents are pharmacologic mimetics of endothelium-derived prostacyclin and nitric oxide, which elevate vascular smooth muscle cyclic adenosine monophosphate and cyclic guanosine monophosphate concentrations, respectively, and may normally suppress neointima formation. Surgical preparation was found to promote intimal thickening and neointimal smooth muscle cell proliferation by 42% and 48%, respectively. 8-Br-cyclic adenosine monophosphate, 8-Br-cyclic guanosine monophosphate, or isobutylmethylxanthine (which elevated endogenous cyclic adenosine monophosphate concentrations) inhibited intimal thickening by 80%, 40%, and 72%, respectively, at a concentration of 0.1 mmol/L. The results imply that surgical techniques that avoid preparative injury and vasodilator drugs that act by elevating cyclic adenosine monophosphate or cyclic guanosine monophosphate concentrations may reduce neointima formation in vein grafts. (J Thoracic Cardiovasc Surg 1995;109:2-12

Oxidative Stress after Surgery on the Immature Heart

Paediatric heart surgery is associated with increased inflammation and the production of reactive oxygen species. Use of the extracorporeal cardiopulmonary bypass during correction of congenital heart defects generates reactive oxygen species by various mechanisms: haemolysis, neutrophil activation, ischaemia reperfusion injury, reoxygenation injury, or depletion of the endogenous antioxidants. The immature myocardium is more vulnerable to reactive oxygen species because of developmental differences compared to the adult heart but also because of associated congenital heart diseases that can deplete its antioxidant reserve. Oxidative stress can be manipulated by various interventions: exogenous antioxidants, use of steroids, cardioplegia, blood prime strategies, or miniaturisation of the cardiopulmonary bypass circuit. However, it is unclear if modulation of the redox pathways can alter clinical outcomes. Further studies powered to look at clinical outcomes are needed to define the role of oxidative stress in paediatric patients

Implications of using different methods to characterise anticoagulant control in patients with second generation mechanical heart valve prostheses.

OBJECTIVE:Characterisation of anticoagulant control is fundamental to investigations of its association with clinical outcome. Anticoagulant control depends on several factors. This paper aims to illustrate the implications of different methods for measuring and analysing anticoagulant control in patients with second generation mechanical heart valve prostheses. METHODS:International normalised ratio (INR) data collected during the 10-year follow-up of a randomised controlled trial were analysed. We considered the influence of: 3 different target INR ranges; anticoagulant control expressed as the proportion of INR readings (PoR) vs. anticoagulant control follow-up time (PoT); 3 ways of describing the profile of anticoagulant control over time. RESULTS:Different target INR ranges dramatically influenced derived measures of anticoagulant control; the PoT within the target range varied from 88% for the widest to 28% for narrowest range. Overall distributions of PoR and PoT observations were similar but differed by up to ± 20% for individuals; PoT exceeded PoR when control was good but was less than PoR when control was poor. Classifying PoT outside the target range showed that widely varying combinations of PoT too high and too low are possible across individuals. CONCLUSIONS:Researchers' choices about methods for measuring and quantifying anticoagulant control markedly influence the values derived from INR readings. The use of different methods across studies makes it difficult or impossible to compare findings and to establish an evidence base for clinical practice. Methods for quantifying anticoagulant control should be standardised