Is It Safe to Let Trainees Operate on High Risk Cardiac Surgery Cases?

Increasing complexity in cardiac operations has raised the discussion on trainee autonomy and the number of cases required to achieve competency. This study compares outcomes among cases done by trainees vs consultants for high risk patients. 696 (trainee=158 vs consultant=438) major high risk cardiac operations (Euroscore >10) were reviewed at a single center. Observations were propensity matched to consultant or trainee based on several baseline characteristics. Euroscore was: Trainee; 12.3 ± 1.6 versus Consultant; 12.8 ± 2.2, p=.036. Multivariable analysis did not identify trainee as a risk factor for worse in-hospital mortality (OR; 0.95, CI; 0.4-2.2, p=.914) or composite outcome of length of stay >30 days, deep sternal infection, new hemodialysis, new stroke or transient ischemic attack, in-hospital death or reoperation (OR; 0.64, CI; 0.39-1.03, p=.069). NYHA class, diabetes and emergency/salvage surgery were predictors of worse composite outcome. After propensity matching (130 pairs), there was no difference in reoperation rates (3.1% versus 4.6%, p=.727), inhospital death (5.4% versus 7.7%, p=.607) or composite outcome (20.8% versus 29.2%, p=.152). There was no statistical difference in cross clamp times (Trainee; 74.0 ± 32.7 min vs Consultant; 82.6 ± 51.1, p=.229) and bypass times (Trainee; 116.3 ± 52.8 min versus Consultant 135.3 ± 72.6 min, p=.055). The length of stay was similar (18.2 ± 13.2 days versus 19.9 ± 15.6 days, p=.302). It is possible for trainees to perform high risk cardiac surgery without compromising the quality of patient care.

Premature Structural Failure of Trifecta Bioprosthesis in Midterm Follow-up: A Single-Center Study.

BACKGROUND: A cluster of aortic bioprosthetic valve failures, most of which were Trifecta bioprostheses, was observed in Southampton General Hospital, Southampton, United Kingdom. This study was performed to assess whether the cluster represents a significant failure of this valve model or whether there is a selection bias that can explain the failure of these valves. METHODS: This retrospective study evaluated all bioprosthetic aortic valve replacement operations performed between 2011 and 2016 inclusive in our center. The study compared the performance of the Trifecta valve (Abbott, Abbott Park, IL) with that of Perimount (Edwards Lifesciences, Irvine, CA), Perimount Magna Ease, and Mitroflow (LivaNova, London, United Kingdom) bioprostheses. In addition, the study analyzed patient-related and valve-related risk factors for early failure in the failed valves. RESULTS: A total of 2807 bioprosthetic aortic valve replacements were performed. Of these, 836 were Trifecta valves, 1031 were Perimount, 449 were Perimount Magna Ease, and 351 were Mitroflow valves. A total of 24 Trifecta valves had premature structural failure, a number significantly higher than seen with Perimount or Perimount Magna Ease (no failure, P < .001 and P < .005, respectively) valves and the Mitroflow valve (1 failure, P < .05). There was no difference in the incidence of endocarditis or death. At the time of valve failure, 17 (71%) of the failed Trifecta valves had moderate or severe regurgitation, and the average peak gradient was 61 ± 29 mm Hg. The median failed prosthetic size was 23 mm. One failed valve had severe patient-prosthesis mismatch. The mean time to failure was 4.5 ± 1.7 years. CONCLUSIONS: The Trifecta bioprosthesis has an increased incidence of early structural valve failure, which is significantly higher than that of Perimount, Perimount Magna Ease, or Mitroflow. No patient-related or valve-related cause for the failure could be identified.

Outcomes of patients with acute prosthetic aortic valve endocarditis.

BACKGROUND: Prosthetic valve endocarditis is burdened by high mortality and morbidity. We reviewed our experience in the management of patients with acute prosthetic aortic valve infection and studied the implications and outcomes associated with surgical treatment and medical therapy. METHODS: Data of 118 consecutive patients admitted during the period 2008-2018 with definite acute prosthetic aortic valve endocarditis, and presenting a surgical indication, were retrieved from the hospital database. Univariate and multivariate analysis were undertaken to study the association of preoperative characteristics with hospital mortality and the probability of undergoing a reoperation. Survival was assessed with Kaplan-Meier analysis. RESULTS: In the overall population, prosthesis dehiscence was independently associated with the possibility of undergoing surgical reoperation, while presentation with embolic stroke was associated with medical treatment. Hospital mortality was 24%, medical treatment was found to be independently associated with early death. One hundred (85%) patients underwent redo procedures; aortic valve replacement was performed in 53 and full root replacement in 47. Postoperative hospital mortality was 17%. Survival at 1-, 5-, and 8-years was 78%, 74%, and 66%, respectively. Freedom from reoperation and recurrent endocarditis was 95% at 8-year follow-up.Hospital mortality in patients who did not receive a redo operation was 61% with a survival rate of 17% at 1-year follow-up. CONCLUSIONS: Surgical mortality after reoperation for prosthetic aortic valve endocarditis is still high but mid-term outcomes are satisfactory. Failure to undertake surgery when indicated is an independent risk factor for early death.

Is Resident Training Safe in Cardiac Surgery?

BACKGROUND: There exists a knowledge gap regarding the safety of training in cardiac surgery. The purpose of this analysis was to establish the safety of resident training in cardiac surgery and compare the results of the trainee cases to those performed by consultants. METHODS: In all, 5894 (trainee, 3343; consultant, 2551) major cardiac operations (European System for Cardiac Operative Risk Evaluation less than 10) from 2013 to 2018 were reviewed. Multivariate analysis was performed for inhospital mortality and composite outcome of length of stay longer than 30 days, deep sternal infection, new hemodialysis, new stroke or transient ischemic attack, inhospital death, or reoperation. Observations were propensity matched to consultant or trainee with the 16 covariates. RESULTS: Trainees performed 56.7% of cases. Multivariate analysis identified renal disease (odds ratio [OR] 2.93; 95% confidence interval [CI], 1.3 to 6.7; P < .02), peripheral vascular disease (OR 4.62; 95% CI, 1.82 to 11.71; P < .01), and emergency/salvage procedure (OR 7.23; 95% CI, 2.00 to 26.11; P < .01) as predictors of inhospital mortality. Emergency/salvage procedure was the only predictor of worse composite outcomes (OR 2.65; 95% CI, 1.54 to 4.55; P < .001). Trainee cases had similar inhospital mortality and composite outcomes. After propensity matching (1842 observations), bypass time and cross-clamp time were significantly longer for trainees for isolated coronary artery bypass graft surgery and aortic valve replacement. There was no difference between deep sternal infection, new hemodialysis, new stroke/transient ischemic attack, inhospital death, or reoperation. Overall composite outcome differed between groups (trainee 9% vs consultant 16.6%, P = .001) owing to difference in the length of stay longer than 30 days (trainee 4.2% vs consultant 9.9%, P = .001). CONCLUSIONS: Resident training is safe in cardiac surgery without compromising the quality of patient care.

Early Hemodynamic Performance of the Crown PRT Aortic Prosthesis: A Prospective Study.

BACKGROUND: Currently, only limited data are available on the rate of hemodynamic progression with clinical outcome in patients receiving the latest Crown PRT aortic prosthesis. The study aim was to report clinical and hemodynamic outcomes in 55 consecutive patients for a follow up of up to one year after Crown PRT implantation. METHODS: Between February and September 2015, a total of 55 patients (34 males, 21 females; mean age 77.3 ± 1.2 years) underwent aortic valve replacement (AVR) with the latest LivaNova Crown PRT bioprosthesis at the authors' institution. Left ventricular function was preserved in 79% of patients. Data relating to the patients' clinical, echocardiographic and functional capacities were obtained prospectively. RESULTS: There were no in-hospital deaths. Significant perioperative complications included stroke (3.6%), atrial fibrillation (27%), and permanent pacemaker insertion (1.8%). Pre-discharge echocardiography demonstrated peak (PG) and mean (MG) transprosthetic gradients of 24.4 ± 10.4 mmHg and 12.9 ± 6.2 mmHg, respectively. The Doppler velocity index (DVI) was 0.49 ± 0.13, and the effective orifice area index (EOAi) 0.89 ± 0.12 cm2/m2. At a mean follow up of 1.3 ± 0.3 years, the transprosthetic gradients, DVI and EOAi were not significantly different from postoperative or pre-discharge values. The patients' NYHA status was I or II in 95% of cases, and the mean left ventricular mass had decreased by 36% at the end of follow up. CONCLUSIONS: The Crown PRT is an effective bioprosthesis, with a low incidence of valve-related complications comparable to those of other current bioprostheses. The bioprosthesis demonstrated satisfactory results in terms of hemodynamics and freedom from reoperation.