title: Does the surgeon's experience have an impact on outcome after total arterial revascularization with composite T-grafts? A risk factor analysis.
abstract: When composite T-grafting is performed, total arterial revascularization (TAR) can be accomplished with only two grafts. There is the belief that composite grafting poses a risk of graft failure due to its single inflow via the left internal thoracic artery (LITA). High surgical quality is essential for left internal thoracic artery preparation, T-grafting and length estimation. We investigated whether the surgeon's experience influences postoperative outcome.
  
  
  
  We analysed the data of 1080 consecutive patients (88% male, age: 62 ± 9 years) who underwent composite T-grafting between 1996 and 2011 in our institution. Patients were operated on either by experienced surgeons (Group A) or by surgeons early on in their career (Group B). Primary end-points were mortality, myocardial ischaemia, graft dysfunction and low cardiac output syndrome. Secondary end-points were persistent neurologic deficits (PNDs), blood transfusions and re-thoracotomy. Logistic regression analysis was performed to reveal independent risk factors for adverse outcome.
  
  
  
  Patients in Group B had a lower logistic EuroSCORE (2.8 vs 2.3%; P < 0.05), longer operative times (cross-clamp time: 41 ± 11 vs 47 ± 14 min; P < 0.001) and received less anastomoses (3.2 ± 0.7 vs 3.1 ± 0.7, P = 0.005). Mortality was low in both groups (Group A 0.6% vs Group B 0.4%; P = 1.0). Myocardial ischaemia occurred in 2.3% (Group A) and 2.5% (Group B; P = 0.82). Graft dysfunction was seen in 0.6% (Group A) and 1.4% (Group B; P = 0.25). Incidence of postoperative low cardiac output syndrome was comparable (Group A 1.4% vs Group B 0.7%; P = 0.53). Both groups showed similar incidence of secondary end-points (persistent neurologic deficit: Group A 2.9 vs 3.2% in Group B; P = 0.84; re-thoracotomy: 1.6% in Group A vs 1.8% in Group B, P = 1.0). Blood transfusions were more common in Group B (P = 0.005). Less surgical experience could only be identified as an independent risk factor for blood transfusion (P = 0.001).
  
  
  
  Total arterial revascularization with composite T-grafts can be performed safely by surgeons with different surgical experience. Despite differences in surgical performance parameters (e.g. operation times, blood transfusions), complication rates were extremely low, irrespective of the surgeon's operative experience. Surgeons can be introduced to these procedures in an early phase of training.
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Julia
authors.initials: J
authors.lastname: Umminger
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Reitz
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Sebastian V
authors.initials: SV
authors.lastname: Rojas
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Penelope
authors.initials: P
authors.lastname: Stiefel
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Malakh
authors.initials: M
authors.lastname: Shrestha
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Axel
authors.initials: A
authors.lastname: Haverich
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Issam
authors.initials: I
authors.lastname: Ismail
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany martens.andreas@mh-hannover.de.
authors.forename: Andreas
authors.initials: A
authors.lastname: Martens
mesh_terms: D002983:Clinical Competence; D003324:Coronary Artery Disease / Q000601:surgery*; D003331:Coronary Vessels / Q000601:surgery*; D005163:Factor Analysis, Statistical; D005260:Female; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000379:methods*; D059032:Learning Curve; D008297:Male; D008323:Mammary Arteries / Q000601:surgery*; D008875:Middle Aged; D066231:Surgeons / Q000592:standards*; D016896:Treatment Outcome
keywords: Learning curve; Risk factor analysis; Surgical experience; T-graft; Total arterial revascularization