Minimally Invasive CABG (MICS CABG), performed through a small left thoracotomy, is associated with excellent feasibility and outcomes, high graft patency rates and, when compared to conventional CABG, faster recovery, less transfusions, and lower infection rates. However, it is an advanced technique limited to expert centres; consequently, questions have been raised regarding diffusability. We looked at the outcomes of teaching MICS CABG, including procedural adoption numbers. We retrospectively examined a MICS CABG peer-to-peer (P2P) teaching program, with encounters from 2006 to 2014. At each P2P session, a surgeon-learner with an anesthesiologist, physician assistant, and/or nurse visited an established MICS CABG institution. Each encounter consisted of a didactic lecture, technical briefing, scrubbed surgical attire in-field case observation, and debriefing. Data were collected from institutional records and from Medtronic (Minneapolis, MN, USA). Frequencies were compared by using a Fisher’s exact test, and learning curves by cumulative summation Methods. From 2005 to January 2014, 192 MICS CABG cases were performed as a P2P in North America. In Canada, our training centre performed P2P training in 31 of 276 MICS CABG cases (12%). Amongst these P2P MICS CABG operations, the median number of grafts was 3, and there was 1 (3%) conversion and 1 (3%) reopening, versus 9 (4%) conversions and 5 (2%) reopenings in the remainder 245 (non-P2P) operations (P=0.9). No wound infection occurred after P2P operations. External proctorship of 10 cases at 5 new centres resulted in independent adoption of MICS CABG in all instances. A femoro-femoral on-pump technique for multivessel MICS CABG was associated with lack of a significant learning curve (P=0.7), and no peripheral arterial or venous complications. In the United States, the number of trainers and trainees peaked in 2009, with 9 trainers and 120 trainees (P=0.01 vs. other years). MICS CABG numbers in the USA increased from less than 100 in 2005 to more than 3,100 in 2013 (P<0.001). Data from India, Australia, and China were unavailable, but in Japan, annual MICS CABG adoption increased from 0 to 97 cases since initiating training in 2012. Teaching MICS CABG is feasible and safe, and has been temporally associated with increased adoption of this advanced technique. External proctorship at new centres may increase their likelihood of establishing an independent program. A femoral pump-assistance strategy is not associated with complications, avoids a significant learning curve, and may facilitate the adoption of MICS CABG.
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