Is Single LIMA-LAD Bypass Appropriate for OPCAB Training?

Abstract

Background A significant impact of surgeons' experience on outcomes of off-pump coronary artery bypass (OPCAB) has been recognized through previous large-scale studies. However, a safe, effective, and concrete OPCAB training was yet to be identified. We evaluate a safety of our OPCAB training model with single left internal mammary artery (LIMA)–left anterior descending artery (LAD) as a reasonable first step.

Methods Between January 2010 and June 2019, 180 patients with an isolated single coronary bypass of the LAD using LIMA as an in situ graft via median sternotomy fulfilled the inclusion criteria. Coronary arterial bypass under cardiopulmonary bypass (CPB), utilizing other graft material, minimal invasive direct coronary arterial bypass through left-sided thoracotomy, and multiple diseased coronary artery disease were excluded. The primary outcome is an early postoperative outcome (major adverse cardiac and cerebrovascular events [MACCEs]: myocardial infarction, coronary re-revascularization, stroke, acute renal failure, and all causes of death) between residents in training under supervision (group 1: n = 63) and experienced surgeons (group 2: n = 117). Trainees were already experienced in on-pump coronary artery bypass grafting.

Results Preoperative variables were comparable. There was no significant difference in the rate of MACCEs between the two groups including hospital mortality (p = 1.000), perioperative myocardial infarction (p = 0.246), stroke (p = 0.655), and acute renal failure (p = 0.175).

Conclusion The early postoperative outcome of off-pump LIMA to the LAD performed by trainees was comparable to those by experienced surgeons. Single LIMA-LAD was safely performed by trainees under supervision without CPB. In order to master OPCAB technique, single LAD bypass might be a reasonable first step to get into touch with the technical characteristics of this special procedure.

Keywords

off-pump coronary artery bypass - training - LIMA-LAD

Authors' Contribution

S.N. and B.S. contributed to the conception of the project. S.N. created the figure, performed the statistical analysis, interpreted the data, and wrote the text. H.R. and B.S. revised the latest version of the manuscript.

Publication History

Received: 05 September 2023

Accepted: 31 January 2024

Accepted Manuscript online:
02 February 2024

Article published online:
23 February 2024

• References

• 1 Bowdish ME, D'Agostino RS, Thourani VH. et al. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2020 update on outcomes and research. Ann Thorac Surg 2020; 109 (06) 1646-1655
• 2 Rosati CM, Torregrossa G, Balkhy HH, Puskas JD. Dedicated training in advanced coronary surgery: need and opportunity. J Thorac Cardiovasc Surg 2021; 161 (06) 2130-2134
• 3 Mack M, Taggart D. Coronary revascularization should be a subspecialty focus in cardiac surgery. J Thorac Cardiovasc Surg 2019; 157 (03) 945-947
• 4 Ohri SK, Benedetto U, Luthra S. et al. Coronary artery bypass surgery in the UK, trends in activity and outcomes from a 15-year complete national series. Eur J Cardiothoracic Surg 2022; 61 (02) 449-456
• 5 Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract 2012; 120 (04) c179-c184
• 6 Thygesen K, Alpert JS, Jaffe AS. et al; Joint ESC/ACCF/AHA/WHF Task Force for Universal Definition of Myocardial Infarction, Authors/Task Force Members Chairpersons, Biomarker Subcommittee, ECG Subcommittee, Imaging Subcommittee, Classification Subcommittee, Intervention Subcommittee, Trials & Registries Subcommittee, Trials & Registries Subcommittee, Trials & Registries Subcommittee, Trials & Registries Subcommittee, ESC Committee for Practice Guidelines (CPG), Document Reviewers. Third universal definition of myocardial infarction. J Am Coll Cardiol 2012; 60 (16) 1581-1598
• 7 Murzi M, Caputo M, Aresu G, Duggan S, Angelini GD. Training residents in off-pump coronary artery bypass surgery: a 14-year experience. J Thorac Cardiovasc Surg 2012; 143 (06) 1247-1253
• 8 Pal S, Hartley P, Salmasi Y, Asimakopoulos G. Establishing the safety of training in off-pump coronary artery bypass surgery: a retrospective comparison of outcomes between trainees and a consultant surgeon. Thorac Cardiovasc Surg 2020; 68 (08) 674-678
• 9 Neumann FJ, Sousa-Uva M, Ahlsson A. et al. ESC/EACTS guidelines on myocardial revascularization. Vol. 40. Eur Heart J 2018; 2019: 87-165
• 10 Caplan LR, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol 1998; 55 (11) 1475-1482
• 11 Ueki C, Miyata H, Motomura N, Sakaguchi G, Akimoto T, Takamoto S. Off-pump versus on-pump coronary artery bypass grafting in patients with left ventricular dysfunction. J Thorac Cardiovasc Surg 2016; 151 (04) 1092-1098
• 12 Guan Z, Guan X, Gu K. et al. Short-term outcomes of on- vs off-pump coronary artery bypass grafting in patients with left ventricular dysfunction: a systematic review and meta-analysis. J Cardiothorac Surg 2020; 15 (01) 84
• 13 Shroyer AL, Hattler B, Wagner TH. et al; Veterans Affairs ROOBY-FS Group. Five-year outcomes after on-pump and off-pump coronary-artery bypass. N Engl J Med 2017; 377 (07) 623-632
• 14 Wu S, Ling Y-P, Zhao H. Experience with porcine beating heart simulator for coronary artery bypass surgery residency training. J Thorac Cardiovasc Surg 2021; 161 (05) 1878-1885
• 15 Ito J, Shimamoto T, Sakaguchi G, Komiya T. Impact of novel off-pump coronary artery bypass simulator on the surgical training. Gen Thorac Cardiovasc Surg 2013; 61 (05) 270-273