Dedicated training in advanced coronary surgery: Need and opportunity

Central MessageThere remains a gap between available evidence and common practice in coronary surgery. Focused training is key to creating the specialists of future advancing this discipline.PerspectiveCoronary surgery should be considered well-defined subspecialty within cardiac It an extremely impactful discipline, yet its current implementation below state-of-the-art standards. Expertise performing all aspects, including most technically challenging components, safely effectively on daily basis truly tailor operation each specific patient.See Commentaries pages 2135 2136. There discipline. Coronary patient. See The transition from being trainee becoming autonomous surgeon complex process with many challenges potential pitfalls. Developing niche our specialty, sense true expert management patients similar set problems, such as heart failure or aortic diseases, result years hard work experience. As Drs Vardas Badhwar pointed out Thoracic Surgery Residents Association (TSRA) podcast episode that “must listen to” for every cardiothoracic trainee, “a endgame, not first.”1Vardas P.N. V. podcast: career-early career development.https://soundcloud.com/tsrapodcast/tsra-podcast-career-early-career-development-panos-vardas-vinay-badhwarDate accessed: December 25, 2019Google Scholar attention continued dedication area master facets, it well known there positive volume-to-outcome (or, more appropriately, expertise-to-outcome) relationship field profession. issue whether adult has been matter debate, arguments made both sides.2Mack M. Taggart D. revascularization focus surgery.J Thorac Cardiovasc Surg. September 21, 2018; ([Epub ahead print])Google Scholar,3Chancellor W.Z. Kron I.L. A focused approach: specialization revascularization.J We believe field, advanced discipline advocated create “coronary specialists.” Although literature at scientific meetings addressed mainly senior surgeon's perspective, we would like tackle viewpoint young surgeon, whom think great opportunity wise choice seek formal Indeed, one us (C.M.R.) about complete his Cardiothoracic Fellowship University Michigan will then Advanced Fellow Mount Sinai Morningside (previously St Luke's) New York under mentorship author (J.D.P.), while other among authors editorial (G.T.), after practicing faculty position Luke's, now working second (H.H.B.) totally endoscopic robotic bypass grafting. In Young Surgeon's Note, present reasons, view trainee's standpoint, consider pathway (“why do it”) propose curriculum skills need learned mastered become specialist (“how it”). artery disease (CAD) cause death, represents largest component surgical operations, 55% cases United States involving isolated grafting (CABG).4D'Agostino R.S. Jacobs J.P. Fernandez F.G. Paone G. Wormuth D.W. et al.The Society Surgeons Adult Cardiac database: 2019 update outcomes quality.Ann 2019; 107: 24-32Abstract Full Text PDF PubMed Scopus (126) Google Because commonly performed operation, CABG often simplistically “bread-and-butter” This inappropriate designation, however, against patients' interests trivialize important procedure “commodity.” Despite compelling regarding benefits several components intraoperative perioperative including, instance, multiple arterial (MAG)5Gaudino Bakaeen Benedetto U. Di Franco A. Fremes S. Glineur al.Arterial grafts bypass: critical review publication ART RADIAL.Circulation. 140: 1273-1284Crossref (34) and, high risk patients, no-aortic-touch off-pump techniques,6Zhao D.F. Edelman J.J. Seco Bannon P.G. Wilson M.K. Byrom M.J. al.Coronary without manipulation ascending aorta: network meta-analysis.J Am Coll Cardiol. 2017; 69: 924-936Crossref operations are still using same approach strategy patient: on-pump, cardioplegic arrest through sternotomy left internal mammary (IMA) graft saphenous vein(s) remaining graft(s). conduit used only approximately 11% CABGs States.7Schwann T.A. Habib R.H. Wallace Shahian D.M. O'Brien al.Operative multiple-arterial versus single-arterial grafting.Ann 105: 1109-1119Abstract (83) Minimization manipulation, together assessment epiaortic ultrasound, minimizing stroke. no–aortic touch (OPCAB) technique, particular, dramatically decreases mortality (by 50%), stroke 78%), renal 53%), bleeding 36%), atrial fibrillation 29%) over conventional on-pump CABG6Zhao but rarely due technical complexity. Moreover, advance by offering less invasive procedures capable providing long-term MAG reduced technique minimally able reduce postoperative length stay enhance overall recovery. sense, (TECAB), off-pump, demanding bilateral IMA no sternal wound infection aorta approach. Implementation evidence-based practices beneficial large number year.Figure 2How it: proposed structured IMA, Internal artery; OPCAB, bypass; MAG, grafts; TECAB, bypass.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Consider case OPCAB.8Puskas J.D. Gaudino D.P. Experience crucial grafting.Circulation. 139: 1872-1875Crossref (14) widely held belief OPCAB provides benefit, also associated higher rates incomplete inferior patency rates. Such overly simplistic, does take into consideration importance experience expertise OPCAB. documented avoiding deleterious effects (eg, neurologic, respiratory, dysfunction, coagulopathy) cardiopulmonary bypass, disproportionally high-risk patients.9Puskas Thourani V.H. Kilgo P. Cooper W. Vassiliades T. Vega al.Off-pump disproportionately patients.Ann 2009; 88: 1142-1147Abstract (205) However, occasionally occasional patients. Reviewing data (Nationwide Inpatient Sample) than 2 million who underwent 2003 2011, al10Benedetto Lau C. Caputo Kim L. Feldman D.N. Ohmes L.B. al.Comparison low-volume high-volume centers surgeons.Am J 121: 552-557Abstract (44) clearly showed volume-to-outcomes OPCAB: hospital level, risk-adjusted in-hospital was lower those hospitals highest-volume quartile (≥164 cases/year); surgeons 3 lowest quartiles (ie, <48 cases/year), (odds ratio, 0.6) high–OPCAB volume (≥48 cases/year). applies results randomized clinical trials. For example, Arterial Revascularization Trial, intention-to-treat analysis failed show any benefit single strategy. Thus finding inconsistent body observational showing superiority may attributed rate crossover use radial arm. when considering enrolled trial (a reasonable proxy expertise), terms composite mortality, stroke, myocardial infarction evident ≥50 trial.11Gaudino role CABG.in: Presented 33rd Annual Meeting European Cardio-Thoracic Surgery; October 3-5. Therefore, derived studies trials, plays “Hot topics” studied keeping mind. Only can aspect option To perform (such TECAB) successfully basis, commitment part their entire team mandatory. Complex scenarios major comorbidities/high risk, diffuse severe CAD, poor targets, previous interventions) discussed managed multidisciplinary experts. interest aspects surgery, paramount collaboration interventional cardiologists offer best treatment hybrid, touch, multiarterial, endarterectomy) individual patient effectively. “generalist” surgeons, address educate cardiovascular professional community. Yes, personal opinion data-supported statement, honestly none beauty technique. see different “phenotypes” justify/motivate decision pursue subspecialty. “heart failure/transplant surgeon,” passionate idea replacing supporting function very weak (“failed”) treating sick (oftentimes) multisystem organ failure. “aortic excited macroscopic reconstructive endovascular affect central/largest blood vessel also, consequentially, system (brain, spinal cord, viscera, extremities), “whole-body” scale. view, phenotype surgeon” characterized passion precise, challenging, elegant (true microsurgery heart, where everything must done perfectly <0.1-mm scale, efficiently safely). Technical perfection mandatory requirement eventual success nowhere exemplified better operations. quality depth, distance, harmony, pace efficiency stitch, gesture, step) consequences durability thus quantity life inextricable interrelationship (“what looks beautiful works better”), which eternal theme art philosophy, kalós kai agathós ancient Greek aesthetic moral ideals Michelangelo Renaissance own days, finds highest embodiments If you love operate nothing exciting Dealing circulation, focuses studying understanding flow requirements developing implementing strategic plan meant optimize energy supply-to-demand balance heart. endless opportunities specialty pertains pathophysiology disease, noninvasive steps management. wonderful wants academic career. International Congress (ICC), annual 3-day-long meeting engages participation experts around world, unique venue learn discuss emerging topics trainees. fifth ICC City 6–8, 2019, next scheduled 4–6, 2020, Tokyo. From knowledge understand diagnostic therapeutic proficiently members dedicated team, enthusiastically involved research endeavors beyond basic wishes expert. following list progression (transitioning easier complex) master. Of course, adapted situation trainee.•Routine skeletonization IMAs. pedicle established increase length, infection, facilitate performance Y T anastomoses conduits. Harmonic scalpel (Ethicon Endo-Surgery, Minneapolis, Minn) user-friendly tool proficient IMA. Its helps minimize trauma veins soft tissues surrounding decreasing even further. pedal activator good train hand/foot coordination required platform revascularization.•Endoscopic harvest artery. Endoscopic always perceived skill One limiting factors adopting standard care lack skilled operators harvesting techniques. establish center excellence vested step physician assistants residents arteries.•Routine MAG. facilitated skeletonized thoracic arteries arteries. routine default revascularization.•OPCAB sternotomy. abundant indicating complications heart-lung machine allows entirely avoid during revascularization. requires reengineering conduct whole cannot casual, infrequent occurrence. Given epicardial given availability stabilizers positioners wealth successfully, perfected takes time field.•Proximal clamp using, HeartString device (Heartstring III Proximal Seal System; Getinge, Wayne, NJ) shot PAS-Port (PAS-Port Anastomosis AesDex/Aesculap, Palo Alto, Calif). avoidance clamping shown dreaded complication goal cases.•Composite Y/T, I, K grafts, alternative configurations conduits efficiently•Total perhaps gold via sternotomy•Coronary endarterectomy stentectomy. These difficult suitable in-stent restenosis, and/or chronic total occlusion. indications these era stenting.•Robotic sternal-sparing successful, advantage systems provide 3-dimensional vision manual dexterity execute bypass. first toward followed Skeletonization sternotomy, tackled, finally crossing midline right pleural space exact maneuvers IMA.•Minimally direct (MIDCAB) though nonsternotomy approaches anterior small thoracotomy)•On-pump TECAB•Off-pump TECAB. form significant learning curve perfect. period necessary mastering OPCAB/MIDCAB begin handle full beating environment. Familiarity stabilization distal anastomotic devices important, demonstration engagement help secure industry support development devices. summary, survival immense Nonetheless, considerable practice. elevate key, OPCAB) inexperienced only. is, opinion, research/academic standpoints. structured, golden surgeons.