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Is Minimally-Invasive Coronary Artery Bypass Grafting Teachable?
Marc Ruel1, Maria L. Rodriguez1, Harry Lapierre1, Benjamin Sohmer1, Bridget Cavanagh2, Eric Meyer2, Dai Une3, Keita Kikuchi3, Masood Shariff4, Joseph McGinn4.
1University of Ottawa Heart Institute, Ottawa, ON, Canada, 2Medtronic, Minneapolis, MN, USA, 3Yamato Seiwa Hospital, Yamato City, Japan, 4Staten Island University Hospital, New York, NY, USA.

OBJECTIVE: Minimally Invasive CABG (MICS CABG), performed through a small left thoracotomy, has been associated with excellent feasibility and outcomes, high graft patency, faster recovery, less transfusions, and lower infection rates. However, it is limited to expert centers, and concerns have been raised regarding adoption rates and diffusability
METHODS: We retrospectively examined MICS CABG peer-to-peer (P2P) encounters from 2006 to 2014. At each session, a surgeon-learner with an anesthesiologist, physician assistant, and/or nurse visited an established MICS CABG institution. Each encounter consisted of a didactic lecture, briefing, scrubbed in-field case observation, and debriefing. Frequencies were compared by using a Fisher’s exact test, and learning curves by cumulative summation methods.
RESULTS: From 2011 to 2014, 162 P2P MICS CABG case visits were performed in North America, and 223 centers became new MICS CABG adopters. Our training center performed P2P training in 31 of 276 MICS CABG cases (12%). Amongst these P2P MICS CABG operations, the median number of grafts was 3, and there was 1 (3%) conversion and 1 (3%) reopening, versus 9 (4%) conversions and 5 (2%) reopenings in the remainder 245 (non-P2P) operations (P=0.9). External proctorship at new centers resulted in independent adoption of MICS CABG in all instances. For North America, the number of trainers and trainees peaked in 2009, with 9 trainers and 120 trainees (P=0.01 vs. other years). North American MICS CABG numbers increased from less than 100/year in 2005, to 1,487/year in 2011, to 2,139/year in 2014 (P<0.001); in Japan, annual MICS CABG adoption increased from 0 to more than 150 cases/year since initiating training in 2012. Notably, a femoral on-pump technique for MICS CABG was associated with lack of a significant learning curve (P=0.7), and no peripheral complications.
CONCLUSIONS: Teaching MICS CABG is feasible and safe, and has been associated with increased adoption of this advanced technique. Peer-to-peer visits and proctorship at new centres may increase the likelihood of establishing an independent program. A femoral pump-assistance strategy may facilitate the adoption of MICS CABG.


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