title: Trainees operating on high-risk patients without cardiopulmonary bypass: a high-risk strategy?
abstract: BACKGROUND
  The safety of teaching off-pump coronary artery bypass grafting to trainees is best tested in high-risk patients, who are more likely to experience significant morbidity after surgery. This study compared outcomes of off-pump coronary artery bypass grafting operations performed by consultants and trainees in high-risk patients.
  
  
  METHODS
  Data for consecutive patients undergoing off-pump coronary artery bypass grafting were collected prospectively. Patients satisfying at least one of the following criteria were classified as high-risk: age older than 75 years, ejection fraction less than 0.30, myocardial infarction in the previous month, current congestive heart failure, previous cerebrovascular accident, creatinine greater than 150 micromol/L, respiratory impairment, peripheral vascular disease, previous cardiac surgery, and left main stem stenosis greater than 50%. Early morbidity, 30-day mortality, and late survival were compared.
  
  
  RESULTS
  From April 1996 to December 2002, 686 high-risk patients underwent off-pump coronary artery bypass grafting revascularization. Operations by five consultants (416; 61%) and four trainees (239; 35%) were the focus of subsequent analyses. Nine visiting or research fellows performed the other 31 operations. Prognostic factors were more favorable in trainee-led operations. On average, consultants and trainees grafted the same number of vessels. There were 18 (4.3%) and 5 (1.9%) deaths within 30 days, and 14 (3.4%) and 5 (1.9%) myocardial infarctions in consultant and trainee groups, respectively. After adjusting for imbalances in prognostic factors, odd ratios for almost all adverse outcomes implied no increased risk with trainee operators, although patients operated on by trainees had longer postoperative stays and were more likely to have a red blood cell transfusion. Kaplan-Meier cumulative mortality estimates at 24-month follow-up were 10.5% (95% confidence interval, 7.7% to 14.2%) and 6.4% (95% confidence interval, 3.8% to 10.9%) in consultant and trainee groups, respectively (hazard ratio = 0.60 [95% confidence interval, 0.37 to 0.99]; p = 0.05).
  
  
  CONCLUSIONS
  Off-pump coronary artery bypass grafting surgery in high-risk patients can be safely performed by trainees.
authors.affiliation: Bristol Heart Institute, University of Bristol, Bristol Roayl Infirmary, United Kingdom. r.ascione@bristol.ac.uk
authors.forename: Raimondo
authors.initials: R
authors.lastname: Ascione
authors.forename: Barnaby C
authors.initials: BC
authors.lastname: Reeves
authors.forename: Marco
authors.initials: M
authors.lastname: Pano
authors.forename: Gianni D
authors.initials: GD
authors.lastname: Angelini
mesh_terms: D000368:Aged; D015331:Cohort Studies; D015897:Comorbidity; D047549:Coronary Artery Bypass, Off-Pump / Q000193:education / Q000401:mortality / Q000706:statistics & numerical data*; D023921:Coronary Stenosis / Q000453:epidemiology / Q000601:surgery; D005260:Female; D006331:Heart Diseases / Q000453:epidemiology; D006801:Humans; D007431:Intraoperative Complications / Q000453:epidemiology; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D012017:Referral and Consultation; D012306:Risk; D012720:Severity of Illness Index; D020521:Stroke / Q000453:epidemiology; D013318:Stroke Volume; D016019:Survival Analysis; D014146:Training Support; D016896:Treatment Outcome