Safe evolution towards routine off-pump coronary artery bypass: Negotiating the learning curve

Howard Song, Rebecca J. Petersen, Erez Sharoni, Robert A. Guyton, John D. Puskas

Research output: Contribution to journalArticle

36 Citations (Scopus)

Abstract

Objective: Off-pump coronary artery bypass (OPCAB) hopes to avoid morbidity associated with cardiopulmonary bypass, improving clinical outcomes. Yet its technical difficulty and unfamiliarity raise concern that adoption of OPCAB might be associated with poorer outcomes during each surgeon's 'learning curve'. We examined trends in patient selection over time as a single surgeon's practice evolved to routine OPCAB. Methods: Between 10-1-96 and 12-31-01, 1479 consecutive patients had isolated coronary artery bypass grafting (CABG). Clinical data were gathered prospectively and reviewed retrospectively. Trends in adoption of OPCAB and clinical outcomes were examined. Results: There were 756 OPCAB and 723 CABG/cardiopulmonary bypass patients. The practice evolved from 90% conventional CABG to 93% OPCAB. An abrupt transition coincided with evolution of techniques to expose the obtuse marginal arteries, and improvements in suction-based coronary stabilizers. Mortality was 1.0% for the off-pump group and 2.1% for the on-pump group. Careful patient selection helped maintain acceptable outcomes during the 'learning curve'. Patients with depressed left ventricular ejection fraction, left main disease, and complex three vessel disease were excluded from OPCAB until significant experience (>200 cases) was attained. Presently, all isolated coronary bypass cases are candidates for OPCAB except patients with ischemic ventricular arrhythmias, those in cardiac arrest, and those for whom previous left pneumonectomy or deep pectus excavatum prevent rightward mobilization of heart. Conclusions: Despite a significant learning curve, evolution to routine OPCAB can be achieved while maintaining good patient outcomes. The development of specialized techniques, coronary stabilizers, and apical suction devices allows the application of OPCAB to virtually all coronary bypass patients, as surgeon experience matures.

Original languageEnglish (US)
Pages (from-to)947-952
Number of pages6
JournalEuropean Journal of Cardio-thoracic Surgery
Volume24
Issue number6
DOIs
StatePublished - Dec 2003
Externally publishedYes

Fingerprint

Off-Pump Coronary Artery Bypass
Learning Curve
Negotiating
Coronary Artery Bypass
Suction
Cardiopulmonary Bypass
Patient Selection
Hope
Funnel Chest
Pneumonectomy
Heart Arrest
Stroke Volume
Cardiac Arrhythmias
Arteries
Morbidity

Keywords

  • Coronary artery bypass
  • Coronary artery disease
  • Off-pump coronary artery bypass

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

Safe evolution towards routine off-pump coronary artery bypass : Negotiating the learning curve. / Song, Howard; Petersen, Rebecca J.; Sharoni, Erez; Guyton, Robert A.; Puskas, John D.

In: European Journal of Cardio-thoracic Surgery, Vol. 24, No. 6, 12.2003, p. 947-952.

Research output: Contribution to journalArticle

Song, Howard ; Petersen, Rebecca J. ; Sharoni, Erez ; Guyton, Robert A. ; Puskas, John D. / Safe evolution towards routine off-pump coronary artery bypass : Negotiating the learning curve. In: European Journal of Cardio-thoracic Surgery. 2003 ; Vol. 24, No. 6. pp. 947-952.
@article{4f06d3e726ce426ea502d864ada98d11,
title = "Safe evolution towards routine off-pump coronary artery bypass: Negotiating the learning curve",
abstract = "Objective: Off-pump coronary artery bypass (OPCAB) hopes to avoid morbidity associated with cardiopulmonary bypass, improving clinical outcomes. Yet its technical difficulty and unfamiliarity raise concern that adoption of OPCAB might be associated with poorer outcomes during each surgeon's 'learning curve'. We examined trends in patient selection over time as a single surgeon's practice evolved to routine OPCAB. Methods: Between 10-1-96 and 12-31-01, 1479 consecutive patients had isolated coronary artery bypass grafting (CABG). Clinical data were gathered prospectively and reviewed retrospectively. Trends in adoption of OPCAB and clinical outcomes were examined. Results: There were 756 OPCAB and 723 CABG/cardiopulmonary bypass patients. The practice evolved from 90{\%} conventional CABG to 93{\%} OPCAB. An abrupt transition coincided with evolution of techniques to expose the obtuse marginal arteries, and improvements in suction-based coronary stabilizers. Mortality was 1.0{\%} for the off-pump group and 2.1{\%} for the on-pump group. Careful patient selection helped maintain acceptable outcomes during the 'learning curve'. Patients with depressed left ventricular ejection fraction, left main disease, and complex three vessel disease were excluded from OPCAB until significant experience (>200 cases) was attained. Presently, all isolated coronary bypass cases are candidates for OPCAB except patients with ischemic ventricular arrhythmias, those in cardiac arrest, and those for whom previous left pneumonectomy or deep pectus excavatum prevent rightward mobilization of heart. Conclusions: Despite a significant learning curve, evolution to routine OPCAB can be achieved while maintaining good patient outcomes. The development of specialized techniques, coronary stabilizers, and apical suction devices allows the application of OPCAB to virtually all coronary bypass patients, as surgeon experience matures.",
keywords = "Coronary artery bypass, Coronary artery disease, Off-pump coronary artery bypass",
author = "Howard Song and Petersen, {Rebecca J.} and Erez Sharoni and Guyton, {Robert A.} and Puskas, {John D.}",
year = "2003",
month = "12",
doi = "10.1016/S1010-7940(03)00616-X",
language = "English (US)",
volume = "24",
pages = "947--952",
journal = "European Journal of Cardio-thoracic Surgery",
issn = "1010-7940",
publisher = "Elsevier",
number = "6",

}

TY - JOUR

T1 - Safe evolution towards routine off-pump coronary artery bypass

T2 - Negotiating the learning curve

AU - Song, Howard

AU - Petersen, Rebecca J.

AU - Sharoni, Erez

AU - Guyton, Robert A.

AU - Puskas, John D.

PY - 2003/12

Y1 - 2003/12

N2 - Objective: Off-pump coronary artery bypass (OPCAB) hopes to avoid morbidity associated with cardiopulmonary bypass, improving clinical outcomes. Yet its technical difficulty and unfamiliarity raise concern that adoption of OPCAB might be associated with poorer outcomes during each surgeon's 'learning curve'. We examined trends in patient selection over time as a single surgeon's practice evolved to routine OPCAB. Methods: Between 10-1-96 and 12-31-01, 1479 consecutive patients had isolated coronary artery bypass grafting (CABG). Clinical data were gathered prospectively and reviewed retrospectively. Trends in adoption of OPCAB and clinical outcomes were examined. Results: There were 756 OPCAB and 723 CABG/cardiopulmonary bypass patients. The practice evolved from 90% conventional CABG to 93% OPCAB. An abrupt transition coincided with evolution of techniques to expose the obtuse marginal arteries, and improvements in suction-based coronary stabilizers. Mortality was 1.0% for the off-pump group and 2.1% for the on-pump group. Careful patient selection helped maintain acceptable outcomes during the 'learning curve'. Patients with depressed left ventricular ejection fraction, left main disease, and complex three vessel disease were excluded from OPCAB until significant experience (>200 cases) was attained. Presently, all isolated coronary bypass cases are candidates for OPCAB except patients with ischemic ventricular arrhythmias, those in cardiac arrest, and those for whom previous left pneumonectomy or deep pectus excavatum prevent rightward mobilization of heart. Conclusions: Despite a significant learning curve, evolution to routine OPCAB can be achieved while maintaining good patient outcomes. The development of specialized techniques, coronary stabilizers, and apical suction devices allows the application of OPCAB to virtually all coronary bypass patients, as surgeon experience matures.

AB - Objective: Off-pump coronary artery bypass (OPCAB) hopes to avoid morbidity associated with cardiopulmonary bypass, improving clinical outcomes. Yet its technical difficulty and unfamiliarity raise concern that adoption of OPCAB might be associated with poorer outcomes during each surgeon's 'learning curve'. We examined trends in patient selection over time as a single surgeon's practice evolved to routine OPCAB. Methods: Between 10-1-96 and 12-31-01, 1479 consecutive patients had isolated coronary artery bypass grafting (CABG). Clinical data were gathered prospectively and reviewed retrospectively. Trends in adoption of OPCAB and clinical outcomes were examined. Results: There were 756 OPCAB and 723 CABG/cardiopulmonary bypass patients. The practice evolved from 90% conventional CABG to 93% OPCAB. An abrupt transition coincided with evolution of techniques to expose the obtuse marginal arteries, and improvements in suction-based coronary stabilizers. Mortality was 1.0% for the off-pump group and 2.1% for the on-pump group. Careful patient selection helped maintain acceptable outcomes during the 'learning curve'. Patients with depressed left ventricular ejection fraction, left main disease, and complex three vessel disease were excluded from OPCAB until significant experience (>200 cases) was attained. Presently, all isolated coronary bypass cases are candidates for OPCAB except patients with ischemic ventricular arrhythmias, those in cardiac arrest, and those for whom previous left pneumonectomy or deep pectus excavatum prevent rightward mobilization of heart. Conclusions: Despite a significant learning curve, evolution to routine OPCAB can be achieved while maintaining good patient outcomes. The development of specialized techniques, coronary stabilizers, and apical suction devices allows the application of OPCAB to virtually all coronary bypass patients, as surgeon experience matures.

KW - Coronary artery bypass

KW - Coronary artery disease

KW - Off-pump coronary artery bypass

UR - http://www.scopus.com/inward/record.url?scp=0344825060&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=0344825060&partnerID=8YFLogxK

U2 - 10.1016/S1010-7940(03)00616-X

DO - 10.1016/S1010-7940(03)00616-X

M3 - Article

C2 - 14643813

AN - SCOPUS:0344825060

VL - 24

SP - 947

EP - 952

JO - European Journal of Cardio-thoracic Surgery

JF - European Journal of Cardio-thoracic Surgery

SN - 1010-7940

IS - 6

ER -