Training the novice to become cardiac surgeon: does the “early learning curve” training compromise surgical outcomes?

Abstract

It is unclear whether novice trainees can be taught safely to perform adult cardiac surgery without any impact on early or late outcomes. All patients (n=1305) data were obtained from an externally validated, mandatory institutional database (2003-2010). 'Novice' is defined as a trainee who required substantial assistance or supervision to perform part or whole of the specified procedure (Intercollegiate Surgical Curriculum Programme UK, Competency Level ≤2). Outcome measures were in-hospital mortality, composite score of in-hospital mortality-morbidities, mid-term survival and revascularisation rate after CABG. Follow-up up to 7 years (median 3.2years) was determined. Some 39% (n=510) of the cases involved novice (28%-part, 11%-whole procedure), 12% (n=157) competent trainees and 49% (n=638) consultant. Median EuroSCORE was higher in consultant group (p<0.001). Without risk adjustment, composite outcome score and mid-term mortality were higher in consultant group (p=0.03). With adjustment using EuroSCORE and propensity scores, EuroSCORE was significantly predictive of in-hospital mortality [odd ratio (OR) 1.38, 95%CI 1.20-1.57, p<0.001], composite outcome (OR 1.26, 95%CI 1.15-1.37, p<0.001) and mid-term mortality (HR 1.24, 95%CI 1.18-1.31, p<0.001) but not the operator categories. Further analysis of subcohort undergoing first-time, isolated CABG (n=1070) showed that EuroSCORE remained predictive of adjusted in-hospital mortality (OR 1.39, 95%CI 1.13-1.71, p=0.002), composite outcome (OR 1.33, 95%CI 1.19-1.49, p<0.001) and mid-term mortality (HR 1.22, 95%CI 1.10-1.35, p<0.001). The operator categories were not associated with adjusted outcome measures including revascularisation rate after CABG. Supervised training in adult cardiac surgery can be achieved safely at the early learning curve phase without compromising both early and mid-term clinical outcomes.