Burt Bryan M, ElBardissi Andrew W, Huckman Robert S, Cohn Lawrence H, Cevasco Marisa W, Rawn James D, Aranki Sary F, Byrne John G
Division of Thoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex.
Division of Cardiac Surgery, Department of Surgery, The Brigham and Women's Hospital, Boston, Mass.
J Thorac Cardiovasc Surg. 2015 Nov;150(5):1061-7, 1068.e1-3. doi: 10.1016/j.jtcvs.2015.07.068. Epub 2015 Aug 1.
We hypothesized that increased postgraduate surgical experience correlates with improved operative efficiency and long-term survival in standard cardiac surgery procedures.
Utilizing a prospectively collected retrospective database, we identified patients who underwent isolated coronary artery bypass grafting (CABG) (n = 3726), aortic valve replacement (AVR) (n = 1626), mitral valve repair (n = 731), mitral valve replacement (MVR) (n = 324), and MVR + AVR (n = 184) from January 2002 through June 2012. After adjusting for patient risk and surgeon variability, we evaluated the influence of surgeon experience on cardiopulmonary bypass and crossclamp times, and long-term survival.
Mean surgeon experience after fellowship graduation was 16.0 ± 11.7 years (range, 1.0-35.2 years). After adjusting for patient risk and surgeon-level fixed effects, learning curve analyses demonstrated improvements in cardiopulmonary bypass and crossclamp times with increased surgeon experience. There was marginal improvement in the predictability (R(2) value) of cardiopulmonary bypass and crossclamp time for CABG with the addition of surgeon experience; however, all other procedures had marked increases in the R(2) following addition of surgeon experience. Cox proportional hazard models revealed that increased surgeon experience was associated with improved long-term survival in AVR (hazard ratio [HR], 0.85; P < .0001), mitral valve repair (HR, 0.73; P < .0001), and MVR + AVR (HR, 0.95; P = .006) but not in CABG (HR, 0.80; P = .15), and a trend toward significance in MVR (HR, 0.87; P = .09).
In cardiac surgery, not including CABG, surgeon experience is an important determinant of operative efficiency and of long-term survival.
我们推测，在标准心脏外科手术中，研究生阶段手术经验的增加与手术效率的提高及长期生存率的改善相关。
利用前瞻性收集的回顾性数据库，我们确定了2002年1月至2012年6月期间接受单纯冠状动脉旁路移植术（CABG）（n = 3726）、主动脉瓣置换术（AVR）（n = 1626）、二尖瓣修复术（n = 731）、二尖瓣置换术（MVR）（n = 324）以及二尖瓣置换术+主动脉瓣置换术（MVR + AVR）（n = 184）的患者。在调整患者风险和外科医生差异后，我们评估了外科医生经验对体外循环时间、主动脉阻断时间和长期生存率的影响。
fellowship毕业后外科医生的平均经验为16.0±11.7年（范围为1.0 - 35.2年）。在调整患者风险和外科医生水平的固定效应后，学习曲线分析表明，随着外科医生经验的增加，体外循环时间和主动脉阻断时间有所改善。在CABG中，增加外科医生经验后，体外循环时间和主动脉阻断时间的可预测性（R²值）略有改善；然而，在添加外科医生经验后，所有其他手术的R²值均显著增加。Cox比例风险模型显示，外科医生经验的增加与AVR（风险比[HR]，0.85；P <.0001）、二尖瓣修复术（HR，0.73；P <.0001）和MVR + AVR（HR，0.95；P =.006）的长期生存率改善相关，但与CABG（HR，0.80；P =.15）无关，在MVR中存在显著趋势（HR，0.87；P =.09）。
在心脏外科手术中，不包括CABG，外科医生经验是手术效率和长期生存率的重要决定因素。
