title: Learning curve of coronary surgery by a cardiac surgeon in Japan with the use of cumulative sum analysis.
abstract: OBJECTIVE
  Case-volume has been believed to be of paramount importance in becoming a good cardiac surgeon. However, for a training cardiac surgeon there is no evidence regarding the specific number of necessary cases to attain the medico-legally acceptable level. We attempted to observe the learning curve in performing coronary surgery with the use of the cumulative sum (CUSUM) method to provide some evidence.
  
  
  METHODS
  From April 2000 to March 2004, a cardiac surgeon, being board-certified but not being on the attending staff, performed 50 coronary artery bypass grafting (CABG) under supervision of three different chief attending surgeons at three different hospitals. His learning curve was analyzed with the use of CUSUM. Mortality and morbidity and the average time of crossclamp and operation at each hospital were examined. Also, the learning curve of 100 left internal mammary artery (LIMA) harvestings were analyzed via CUSUM in terms of harvesting time and injury rate.
  
  
  RESULTS
  The CUSUM curve tended to come closer to the alert line (0.80 confidence) until the 23rd case, but never reached the alert line thereafter until the 50th case. The CUSUM curve never transgressed the alarm line (0.95 confidence) throughout 50 cases. The CUSUM curve of LIMA harvesting approached the alert line in the 38th case and the 59th case, but thereafter never reached the alert line and remained below the reassurance line from the 73rd case.
  
  
  CONCLUSIONS
  Tentatively, it is inferred that approximately 23 cases of CABG may be sufficient to allow for independent practice and that 73 cases of LIMA harvesting are sufficient to allow independent practice.
authors.affiliation: Department of Cardiovascular Surgery, The Japanese Red Cross Nagoya First Hospital, Japan.
authors.forename: Min-Ho
authors.initials: MH
authors.lastname: Song
authors.forename: Kazuyoshi
authors.initials: K
authors.lastname: Tajima
authors.forename: Takashi
authors.initials: T
authors.lastname: Watanabe
authors.forename: Toshiaki
authors.initials: T
authors.lastname: Ito
mesh_terms: D000328:Adult; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000193:education; D002983:Clinical Competence / Q000592:standards*; D001026:Coronary Artery Bypass / Q000401:mortality; D004521:Educational Measurement; D005260:Female; D006801:Humans; D007564:Japan; D007858:Learning; D008297:Male; D008875:Middle Aged