Michael E. DeBakey Veterans Affairs Medical Center and Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, and Division of Cardiovascular Surgery, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas 77030, USA.
Ann Thorac Surg. 2012 Aug;94(2):482-8; discussion 488. doi: 10.1016/j.athoracsur.2012.04.039. Epub 2012 Jun 13.
Data are limited regarding the patency of coronary artery bypass grafts performed by residents versus attending surgeons.
We analyzed data from a multicenter, randomized Veterans Affairs Cooperative Study in which the left internal mammary artery was used preferentially to graft the left anterior descending coronary artery, and the best remaining coronary vessel received (per random assignment) either a radial artery or a saphenous vein graft. The study vessel's 1-year graft patency was the primary outcome measure. Secondary outcomes included operative times, operative morbidity, mortality, repeat revascularization, cost, angina symptoms, and quality of life. Multivariate analyses were used to compare patient outcomes for residents versus attendings.
Residents were designated as primary surgeons in 23% of cases (167 of 725). Among the 531 patients who had a 1-year angiogram, study graft patency rates for resident cases (n=122) and attending cases (n=409) were not significantly different (86% versus 90%, p=0.22). Residents' cases had longer perfusion time (119 versus 105 minutes, p<0.0001) and cross-clamp time (84 versus 68 minutes, p<0.0001). After risk adjustment, all outcome measures did not differ between the two groups, and there was no apparent interaction effect between resident/attending designation and radial artery versus saphenous vein use or on-pump versus off-pump approach.
Surgeons in training perform coronary artery bypass surgery without compromising graft patency or patient outcomes. Ongoing evaluation of residents' performance and surgical outcomes is needed, given the major changes that are occurring in residency training.
关于住院医师和主治医生进行冠状动脉旁路移植术的通畅率的数据有限。
我们分析了一项多中心、随机退伍军人事务合作研究的数据，该研究中优先使用左内乳动脉作为左前降支冠状动脉的移植物，而最佳的剩余冠状动脉血管（根据随机分配）接受桡动脉或隐静脉移植物。研究血管的 1 年通畅率是主要的观察结果。次要结果包括手术时间、手术发病率、死亡率、再次血运重建、成本、心绞痛症状和生活质量。采用多变量分析比较住院医师和主治医生的患者结局。
在 725 例患者中，有 23%（167 例）的患者由住院医师担任主刀医生。在 531 例接受 1 年血管造影的患者中，住院医师病例（n=122）和主治医生病例（n=409）的研究移植物通畅率无显著差异（86%与 90%，p=0.22）。住院医师病例的灌注时间（119 分钟与 105 分钟，p<0.0001）和阻断时间（84 分钟与 68 分钟，p<0.0001）更长。在风险调整后，两组间所有结果指标均无差异，且住院医师/主治医生指定与桡动脉与隐静脉使用或体外循环与非体外循环方法之间没有明显的交互作用。
在培训中的外科医生进行冠状动脉旁路手术不会影响移植物通畅率或患者结局。鉴于住院医师培训中正在发生的重大变化，需要对住院医师的表现和手术结果进行持续评估。
