Objectives: We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons. Methods: EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. 892 results were obtained, 27 represented best evidence (2-Meta-analyses, 1-RCT and 24 retrospective cohort studies). Results: 474,160 operative outcomes were assessed for 434,535 CABG (431,329 on-pump vs 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital and 4797 thoracic procedures. 398,058 cases were performed by trainees and 75,943 by consultants. 159 cases were indeterminate. There were no statistically significant differences in the patients’ pre-operative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function and re-operation cases that were undertaken by consultants. There were no differences in CPB and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the post-operative outcomes including peri-operative myocardial infarction, resternotomy for bleeding, stroke, renal failure, ITU length of stay and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or mid-term mortality out to five-years. Discussion: Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.

Background: Although concomitant pulmonary vein isolation (PVI) is used more frequently than the Cox-maze procedure, which is currently the gold standard treatment for AF, data on the comparative effectiveness of the two procedures after concomitant mitral valve (MV) surgery are still limited. Objective: We conducted a systematic review to identify randomized controlled trials (RCT) and observational studies comparing the mid-term mortality and recurrence of atrial fibrillation (AF) after concomitant Cox-Maze and PVI in patients with AF undergoing MV surgery based on 12-month follow-up. Methods: Medline, EMBASE databases, and the Cochrane Library were searched from 1987 up to March 2022 for studies comparing concomitant Cox-Maze and PVI. A meta-analysis of RCTs was performed to compare the mid-term clinical outcomes between these two surgical ablation techniques. Results: Three RCTs and 3 observational studies meeting the inclusion criteria were included in this systematic review with 790 patients in total (532 concomitant Cox-Maze and 258 PVI during MV surgery). Most studies reported that concomitant Cox-Maze procedure was associated with a higher freedom from AF at 12-month follow-up than PVI. Regarding AF recurrence, estimate pooled across the 3 RCTs indicated large heterogeneity and high uncertainty. In the largest and highest quality RCT, 12-month AF recurrence was higher in the PVI arm (RR=1.58, 95%CI 0.91-2.73). In 2 out of 3 higher quality observational studies, 12-month AF recurrence was higher in PVI than in Cox-Maze arm (estimated adjusted probabilities 11% vs. 8% and 35% vs. 17%, respectively). RCTs demonstrated comparable 12-month mortality between concomitant Cox-Maze and PVI, while observational studies demonstrated survival benefit of Cox-Maze. Conclusions: Concomitant Cox-Maze in AF patients undergoing MV surgery is associated with better mid-term freedom from AF when compared to PVI with comparable mid-term survival. Large observational studies suggest that there might be a mid-term survival benefit among patients after concomitant Cox-Maze. Further large RCTs with longer standardized follow-up are required in order to clarify benefits of concomitant Cox-Maze in AF patients during MV surgery.

Background: Valve-sparing aortic root replacement such as the re-implantation (David) procedure is becoming increasingly popular. Despite the fact that the procedure is technically more complex, long-term studies demonstrated that excellent clinical outcomes in selected patients with durable repair are achievable. Benefits of minimal access cardiac surgery have stimulated enthusiasm in the use of this approach for valve-sparing aortic root replacement. Methods: We have reviewed available literature on the topic of valve-sparing aortic root replacement (David procedure) via minimally invasive approach through upper hemisternotomy in an attempt to assess current trends and to recognize potential advantages of this technique. Patient selection and preoperative work-up play important role in performing minimally invasive David procedure safely. Surgical technique is similar to the standard David procedure, with several exceptions, and is performed via upper hemisternotomy. Results and Conclusion: Evidence from non-randomized observational and comparative studies demonstrated excellent clinical outcomes of minimally invasive David procedure in selected patients with comparable perioperative mortality to the conventional technique. To date, elective David procedure with a minimal access technique has been performed in low- and intermediate-risk patients. We believe that minimally invasive David procedure could be particularly useful in young patients (Marfan syndrome, bicuspid AV) as it allows faster recovery with improved cosmesis. A decision to perform minimally invasive David procedure should be individualized to each patient and based on the experience of the team. Further large prospective randomized studies with long-term follow-up are still needed to confirm durability of minimal access technique.

Background: Octogenarians are being increasingly referred for coronary artery bypass grafting (CABG). However, there is a paucity of studies reporting impact of choice of surgical revascularization strategy on in-hospital mortality and mid-term survival of octogenarians. We evaluated our institutional experience to determine the impact of off-pump and on-pump CABG on in-hospital mortality and mid-term survival of octogenarians. Methods: We retrospectively analysed prospectively collected data from the Patients Analysis and Tracking System database (Dendrite Clinical Systems, Oxford, UK) for all isolated first-time CABG procedures with at least 2 grafts performed at our institution from January 2000 to September 2017. Over the study period, 566 octogenarians underwent either off-pump (N = 374) or on-pump CABG (N = 192). Short-term outcomes including in-hospital mortality as well as mid-term survival was compared for the two groups. Results: The two groups had similar preoperative demographics and mean number of distal anastomoses (off-pump: 2.7 ± 0.6 [median 3] vs on-pump: 2.7 ± 0.3 [median 3]; P=0.6). However, more bilateral internal mammary artery grafts were performed in the off-pump cohort compared to on-pump cohort (117 [31.3%] vs 22 [11.5%]; P <0.001). In-hospital mortality for the entire cohort was 5.7% with significantly fewer deaths in the off-pump cohort (4.3% vs 8.3%; P=0.04). The remaining in-hospital outcomes were similar. Kaplan-Meier survival at 1 year (89.7% vs 82.9%; P=0.048) and 5 year (71.1% vs 61.3%; P=0.038) was significantly better for the off-pump cohort. Conclusion: Octogenarians experience lower in-hospital mortality and improved mid-term survival after off-pump CABG compared to on-pump CABG.

Several studies have already shown that coronary angiography and PCI can be safely performed after CABG. It is of paramount importance that early graft failure is recognized in a timely manner and that an appropriate treatment is delivered immediately in order to reduce the extent of myocardial damage and improve clinical outcome. Therefore, urgent angiography allows both identification of the underlying cause of early graft failure and immediate treatment according to the findings. So far, recent evidence shows that PCI to native coronary arteries is associated with higher procedural success rate and less complications leading to the better clinical outcome.