Learning Curve for No-Touch Vein Harvesting Technique in Off-Pump Coronary Artery Bypass Grafting.

INTRODUCTION: This study aims to evaluate the learning curve associated with the no-touch vein harvesting technique in off-pump coronary artery bypass grafting (CABG), highlighting its impact on surgical proficiency. METHODS: We employed logarithmic curve fitting to analyze the learning curves of 160 patients undergoing no-touch CABG, with a detailed retrospective examination of 89 patients who received three grafts using Cumulative Sum (CUSUM) analysis. Patients were categorized into two phases: the initial learning phase and the subsequent mastery phase, based on the chronological order of surgeries. We then compared perioperative outcomes between these phases. RESULTS: The learning curve for the no-touch vein harvesting technique was quantitatively established at 51 cases via CUSUM analysis, with supporting evidence from logarithmic curve fitting indicating a significant proficiency milestone. In the mastery phase, median operative times, aorta-saphenous vein graft (SVG) anastomosis, and SVG inspection durations were notably reduced (230 vs. 250 minutes, P = 0.002; 11.5 vs. 13.0 minutes, P = 0.025; 9.0 vs. 11.0 minutes, P = 0.002, respectively), alongside decreased initial 48-hour chest tube drainage, shorter postoperative hospital stays, and fewer incidences of delayed leg incision healing compared to the learning phase [312.6 (140.7) ml vs. 401.0 (233.5) ml, P = 0.029; 11.0 d vs. 12.0 d, P = 0.026; 15.7% vs. 2.6%, P = 0.043)]. CONCLUSION: Cardiac surgeons adopting the full-incision SVG harvesting method for no-touch CABG undergo a discernible learning curve before achieving early proficiency. It is crucial, especially during the initial learning phase, to focus on aorta-SVG anastomosis, the meticulous inspection for bleeding, and the management of wound complications to optimize patient outcomes.

Obesity and acute type A aortic dissection: unraveling surgical outcomes through the lens of the upper hemisternotomy approach.

Background: Acute type A aortic dissection (ATAAD) is a pressing cardiovascular emergency necessitating prompt surgical intervention. Obesity, a pervasive health concern, has been identified as a significant risk factor for ATAAD, introducing unique surgical challenges that can influence postoperative outcomes. This study aimed to investigate the outcomes of ATAAD surgery across various body mass index (BMI) categories, focusing on the implications of the upper hemisternotomy (UHS) approach. Methods: Between April 2017 and October 2023, 229 patients diagnosed with ATAAD underwent aortic arch intervention via UHS at the General Hospital of Northern Theater Command. Based on BMI (WS/T 428-2013), patients were categorized into normal weight, overweight, and obese. The primary outcomes included perioperative parameters, intraoperative details, and postoperative complications, with specific emphasis on hypoxemia, defined by the Berlin criteria as a PaO2/FiO2 ratio of ≤300 mmHg. Results: The average age of the cohort was 50.1 ± 11.2 years with a male predominance (174 males). Preoperatively, 49.0% presented with hypoxemia, with the Obese group exhibiting a significantly elevated rate (77.9%, P < 0.001). Postoperatively, while the Normal group demonstrated a lower thoracic drainage volume 24 h post-surgery [180.0 (140.0) ml; P < 0.001], the Obese group indicated prolonged durations for mechanical ventilation and ICU stay, without statistical significance. Unlike the Normal and Overweight groups, the Obese group showed no notable changes in pre- and postoperative PaO2/FiO2 ratio. No significant difference was observed in severe postoperative complications among the groups. Further ROC curve analysis identifies a BMI cutoff of 25.5 for predicting postoperative hypoxemia, with 76.3% sensitivity and 84.4% specificity. And multivariate analysis reveals BMI and preoperative hypoxemia as independent predictors of postoperative hypoxemia. Conclusion: Obesity, although presenting unique challenges in ATAAD interventions, does not necessarily portend adverse outcomes when managed with meticulous surgical planning and postoperative care. The study emphasizes the significance of individualized patient assessment and tailoring surgical strategies, suggesting the potential of UHS in addressing the surgical intricacies posed by obesity in ATAAD patients. Further research is warranted to consolidate these findings.

The Learning Curve of Total Arch Replacement via Single Upper Hemisternotomy Approach in Aortic Dissection.

Purpose: Upper hemisternotomy (UHS) has benefits over conventional full sternotomy because it ameliorates trauma during cardiac surgery. Owing to its challenging and technically demanding nature, this incision in acute type A aortic dissection (ATAAD) has rarely been reported. This study aimed to analyze the learning curve of total arch replacement (TAR) with moderate hypothermic circulatory arrest via a single UHS approach, which is necessary to guide the training of surgeons in adopting minimally invasive procedures. Patients and Methods: A total of 202 consecutive patients who were definitively diagnosed with ATAAD between July 2016 and June 2021 were enrolled in this retrospective analysis. Patients were divided into three groups based on cumulative sum plots for circulatory arrest time in chronological order. Perioperative characteristics were compared between the groups. Results: There was significant difference in the circulatory arrest time and cross-clamp time respectively among three groups (39.0 min vs 28.0 min vs 15.0 min, P < 0.001; 104.5 min vs 106.2 min vs 84.1 min, P < 0.001). The ventilation time and first 24-h chest tube drainage were statistically different among groups (35.5 h vs 24.0 h vs 19.0 h, P = 0.031; 220.0 mL vs 192.5 mL vs 125.5 mL, P = 0.043). No other clinical outcome was observed as significant difference. Conclusion: A cardiac surgeon can convert a conventional full sternotomy to a single UHS for TAR after experiencing a learning curve, to ensure patient safety. The mastery of this minimally invasive surgical technique may be beneficial for the prognosis of patients with ATAAD.

Mild Hypothermic Circulatory Arrest with Lower Body Perfusion for Total Arch Replacement Via Upper Hemisternotomy in Acute Type A Dissection.

BACKGROUND: Mild hypothermia circulatory arrest combined with lower body perfusion (LBP) might be beneficial for the recovery of patients with acute type A dissection. However, the safety of mild hypothermic circulatory arrest with LBP used in total arch replacement combined with frozen elephant trunk implantation (FET) via single upper hemisternotomy approach is ambiguous. METHODS: We retrospectively analyzed 70 consecutive patients with acute type A dissections who underwent total arch replacement combined with FET between April 2019 to December 2019. These individuals were divided into the moderate (MO) group (N = 39, surgery performed at moderate hypothermic circulatory arrest) and the mild (MI) group (N = 31, surgery conducted at mild hypothermic circulatory arrest with LBP). Perioperative characteristics were recorded. RESULTS: No significant difference in any of the pre- and intraoperative variables was observed between the two groups except for circulatory arrest time, which was significantly shorter in the MI group compared with the MO group [10 (8-11) min vs. 35 (31- 34) min, P = 0.000]. After operation, ventilation times [19 (16 - 24) h vs. 24 (17 - 43) h, P = 0.046] and ICU stay [41 (34 - 58) h vs. 54 (42 - 85) h, P = 0.002] were significantly shorter in the MI group compared with the MO group. CONCLUSIONS: Total arch replacement combined with FET at mild hypothermia circulatory arrest with lower body antegrade perfusion via single upper hemisternotomy approach is safe and feasible with significantly shorter time of circulatory arrest compared with no LBP.