title: What are the barriers to training residents in aortic root surgery?
abstract: OBJECTIVE
  Aortic root surgery is a technically demanding procedure that is performed infrequently by most surgeons, with national mortality rates over 10%. The study aim was to identify the barriers to training residents in this operation.
  
  
  METHODS
  By using univariate and multivariate logistic regression analysis, all consecutive adults (n = 356) undergoing aortic root reconstruction at The Mount Sinai Medical Center between 2007 and 2011 were retrospectively compared according to whether a resident or faculty surgeon performed the procedure. Surveys were then conducted to determine reasons why residents did not perform cases, and to evaluate outcomes of aortic root surgery performed by recent graduates of the program.
  
  
  RESULTS
  Surgical techniques among patients included: root replacement (81%, n = 290) using homograft, composite bioprosthetic or mechanical valved conduits; Ross procedures (17%, n = 53); and other root surgery such as valve-sparing procedures (2%, n = 7). Residents performed 32% (n = 66/204) of cases when they were scrubbed. The incidence of mortality was lower for cases performed by residents (2%, n = 2) compared to faculty (4%, n = 12) (p=0.335), and no significant differences in cardiopulmonary bypass or cross-clamp times, early morbidity or late survival were observed. The most common reasons given why scrubbed residents did not perform cases were a mismatch between the skill of the resident and case complexity (46%, n = 94), followed by the faculty surgeon's preference (41%, n = 83). Recent program graduates had collectively performed 30 aortic root procedures independently as faculty surgeons, and with no mortality; however, most expressed a continued preference for more senior help on such cases.
  
  
  CONCLUSIONS
  Residents can safely perform aortic root surgery under appropriate supervision. The greatest challenge involved in improving resident training in aortic root surgery lies in routinely matching resident skills with case complexity and teaching expertise.
authors.affiliation: Mount Sinai Medical Center, Department of Cardiothoracic Surgery, Fifth Avenue, New York 10029, USA.
authors.forename: Antonio
authors.initials: A
authors.lastname: Polanco
authors.affiliation: Mount Sinai Medical Center, Department of Cardiothoracic Surgery, Fifth Avenue, New York 10029, USA.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Breglio
authors.affiliation: Mount Sinai Medical Center, Department of Cardiothoracic Surgery, Fifth Avenue, New York 10029, USA.
authors.forename: Shinobu
authors.initials: S
authors.lastname: Itagaki
authors.affiliation: Mount Sinai Medical Center, Department of Cardiothoracic Surgery, Fifth Avenue, New York 10029, USA.
authors.forename: Aaron
authors.initials: A
authors.lastname: Weiss
authors.affiliation: Mount Sinai Medical Center, Department of Cardiothoracic Surgery, Fifth Avenue, New York 10029, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Stelzer
authors.affiliation: Mount Sinai Medical Center, Department of Cardiothoracic Surgery, Fifth Avenue, New York 10029, USA.
authors.forename: Joanna
authors.initials: J
authors.lastname: Chikwe
mesh_terms: D000328:Adult; D000368:Aged; D001021:Aortic Valve / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000193:education* / Q000401:mortality; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000193:education* / Q000401:mortality; D016009:Chi-Square Distribution; D002983:Clinical Competence; D003479:Curriculum; D004503:Education, Medical, Graduate; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000193:education; D006801:Humans; D007396:Internship and Residency; D053208:Kaplan-Meier Estimate; D059032:Learning Curve; D016015:Logistic Models; D008297:Male; D008611:Mentors; D008875:Middle Aged; D015999:Multivariate Analysis; D009519:New York City; D016017:Odds Ratio; D011183:Postoperative Complications / Q000401:mortality; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D013647:Task Performance and Analysis; D016896:Treatment Outcome