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Is It Safe to Let Trainees Operate on High Risk Cardiac Surgery Cases?
Suvitesh Luthra1, Miguel M Leiva-Juarez2, Simon Duggan1
1Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Trust, Southampton, UK.
Insights
Trainees can perform high-risk cardiac surgery safely. This study found no significant difference in outcomes between trainee-performed and consultant-performed complex cardiac operations, ensuring patient care quality.
Area of Science:
- Cardiovascular Surgery
- Surgical Education
- Patient Outcomes
Background:
- Increasing complexity of cardiac operations necessitates a discussion on trainee autonomy and competency.
- Defining the required case volume for trainees to achieve surgical competency is crucial.
- Evaluating patient outcomes based on surgeon experience (trainee vs. consultant) is essential for quality assurance.
Purpose of the Study:
- To compare patient outcomes between high-risk cardiac operations performed by surgical trainees and experienced consultants.
- To assess whether trainee involvement in complex cardiac procedures impacts patient safety and clinical results.
- To investigate the relationship between surgeon experience and key perioperative outcomes in high-risk cardiac surgery.
Main Methods:
- A retrospective review of 696 major high-risk cardiac operations (EuroSCORE >10) at a single institution.
- Propensity score matching was used to balance baseline characteristics between trainee (n=158) and consultant (n=438) cases.
- Outcomes analyzed included in-hospital mortality, composite adverse events, reoperation rates, cross-clamp/bypass times, and length of stay.
Main Results:
- Multivariable analysis and propensity-matched comparisons showed no significant difference in in-hospital mortality or composite adverse outcomes between trainees and consultants.
- Key adverse events such as deep sternal infection, stroke, new hemodialysis, and reoperation rates were similar between groups.
- Operative times (cross-clamp and bypass) and length of stay were comparable, indicating no increased resource utilization or procedural delay with trainees.
Conclusions:
- Surgical trainees can perform high-risk cardiac operations without compromising patient care quality or safety.
- The study supports trainee autonomy in complex cardiac procedures when appropriate supervision and training structures are in place.
- Factors like NYHA class, diabetes, and emergency surgery status were identified as predictors of adverse outcomes, independent of surgeon experience level.
Abstract:
Increasing complexity in cardiac operations has raised the discussion on trainee autonomy and the number of cases required to achieve competency. This study compares outcomes among cases done by trainees vs consultants for high risk patients. 696 (trainee=158 vs consultant=438) major high risk cardiac operations (Euroscore >10) were reviewed at a single center. Observations were propensity matched to consultant or trainee based on several baseline characteristics. Euroscore was: Trainee; 12.3 ± 1.6 versus Consultant; 12.8 ± 2.2, p=.036. Multivariable analysis did not identify trainee as a risk factor for worse in-hospital mortality (OR; 0.95, CI; 0.4-2.2, p=.914) or composite outcome of length of stay >30 days, deep sternal infection, new hemodialysis, new stroke or transient ischemic attack, in-hospital death or reoperation (OR; 0.64, CI; 0.39-1.03, p=.069). NYHA class, diabetes and emergency/salvage surgery were predictors of worse composite outcome. After propensity matching (130 pairs), there was no difference in reoperation rates (3.1% versus 4.6%, p=.727), inhospital death (5.4% versus 7.7%, p=.607) or composite outcome (20.8% versus 29.2%, p=.152). There was no statistical difference in cross clamp times (Trainee; 74.0 ± 32.7 min vs Consultant; 82.6 ± 51.1, p=.229) and bypass times (Trainee; 116.3 ± 52.8 min versus Consultant 135.3 ± 72.6 min, p=.055). The length of stay was similar (18.2 ± 13.2 days versus 19.9 ± 15.6 days, p=.302). It is possible for trainees to perform high risk cardiac surgery without compromising the quality of patient care.
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