William Patrick

and 11 more

Background: There is limited data to inform minimum case requirements for training in robotically-assisted coronary artery bypass grafting (RA-CABG). Current recommendations rely on non-clinical endpoints and expert opinion. Objectives: To determine the minimum number of RA-CABG procedures required to achieve stable clinical outcomes. Methods: We included isolated RA-CABG in The Society of Thoracic Surgeons (STS) registry performed between 2014 and 2019 by surgeons without prior RA-CABG experience. Outcomes were approach conversion, reoperation, major morbidity or mortality, and procedural success. Case sequence number was used as a continuous variable in logistic regression with restricted cubic splines with fixed effects. Outcomes were compared between operations performed earlier versus later in case sequences using unadjusted and adjusted metrics. Results: There were 1195 cases performed by 114 surgeons. A visual inflection point occurs by a surgeon’s 10th procedure for approach conversion, major morbidity or mortality, and overall procedural success after which outcomes stabilize. There was a significant decrease in the rate of approach conversion (7.7% and 2.5%), reoperation (18.9% and 10.8%), and major morbidity or mortality (21.7% and 12.9%), as well as an increase in rate of procedural success (72.9% and 85.3%) with increasing experience between groups. In a multivariable logistic regression model case sequences of >10 was an independent predictor of decreased approach conversion (OR 0.27, 95% CI 0.09 to 0.84) and increased rate procedural success (OR 1.96, 95% CI 1.00 to 3.84).