Analysis of learning curve of minimally invasive coronary artery bypass grafting surgery_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIU Jiaji ¹ , KONG Qingyu ¹ , TANG Zhaoli ² , LIANG Lin ¹ , XIAO Wei ¹ , CHEN Xinliang ¹ , MA Xiaolong ¹ , HUANG Yu ¹ , PAN Feng ¹ , GENG Danqing ¹ ,  CHI Liqun ¹

1. Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, P.R.China;
2. China Center for Health Economic Research, Peking University, Beijing, 100871, P.R.China;

Corresponding?author：

CHI Liqun, Email: chiliqun2002@qq.com

Keywords：

Minimal invasive surgery; off-pump coronary artery bypass grafting; learning curve; cumulative summation analysis

DOI：

10.7507/1007-4848.202012110

Video：

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Objective To study the learning curve of minimal invasive coronary artery bypass grafting (MICS CABG) and the influence on the perioperative clinical effects by analyzing operation time.Methods From March 2012 to November 2020, 212 patients underwent MICS CABG by the same surgeon. Among them, 59 patients (52 males and average age of 62.89±8.27 years) with single vessel bypass grafting were as a single-vessel group and 153 patients (138 males, average age of 59.80±9.22 years) with multi-vessel bypass grafting were as a multi-vessel group. Two sets of operation time-operation sequence scatter plots were made and learning curve was analyzed by cumulative summation (CUSUM) and regression method of operation time. The surgical data of each group before and after the inflection point of the learning curve were compared with the main clinical outcome events within 30 days after surgery.Results There was no death, perioperative myocardial infarction and stroke in 212 MICS CABG patients and no transfer to cardiopulmonary bypass or redo thoracotomy. The learning curve conformed to the cubic fitting formula. In the single-vessel group, CUSUM (x operation number)=–1.93+93.45×x–2.33×x²+0.01×x³, P=0.000, R²=0.986, the tipping point was 27 patients. In the multi-vessel group, CUSUM (x)=y=2.87+1.15×x–1.29× x²+3.463×x³, P=0.000, R²=0.993, and the tipping point was 59 patients. The two sets of case data were compared before and after the learning curve and there was no statistical difference in main clinical outcomes within 30 days (mortality, acute myocardial infarction, stroke, perioperative blood transfusion rate), ventilator tube, and intensive care unit retention.Conclusion The learning curve of MICS CABG conforms to the cubic formula, and the process transitions from single to multiple vessels bypass. To enter the mature stage of the learning phase, a certain number of patients need to be done. Reasonable surgical procedures and quality control measures can ensure the safety during the learning phase.

Citation： LIU Jiaji, KONG Qingyu, TANG Zhaoli, LIANG Lin, XIAO Wei, CHEN Xinliang, MA Xiaolong, HUANG Yu, PAN Feng, GENG Danqing, CHI Liqun. Analysis of learning curve of minimally invasive coronary artery bypass grafting surgery. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2021, 28(6): 639-644. doi: 10.7507/1007-4848.202012110 Copy

1.	Choi W, Chang HW, Kang SH, et al. Comparison of minimally invasive direct coronary artery bypass and percutaneous coronary intervention using second-generation drug-eluting stents for coronary artery disease-propensity score-matched analysis. Ann Thorac Surg, 2019, 83(7): 1572-1580.
2.	Xu Y, Li Y, Bao W, et al. MIDCAB versus off-pump CABG: Comparative study. Hellenic J Cardiol, 2020, 61(2): 120-124.
3.	Andrawes PA, Shariff MA, Nabagiez JP, et al. Evolution of minimally invasive coronary artery bypass grafting: Learning curve. Innovations (Phila), 2018, 13(2): 81-90.
4.	楊威, 凌云鵬, 陳彧. 左胸前外側小切口冠狀動脈旁路移植術學習曲線. 中國微創外科雜志, 2015, 15(11): 990-994.
5.	柳佳吉, 遲立群, 孔晴宇, 等. 肋間單一切口直視下微創多支 OPCABG 50 例. 中華胸心血管外科雜志, 2019, 35(3): 159-162.
6.	Halkos ME, Vassiliades TA, Myung RJ, et al. Sternotomy versus nonsternotomy LIMA-LAD grafting for single-vessel disease. Ann Thorac Surg, 2012, 94(5): 1469-1477.
7.	Boodhwani M, Ruel M, Mesana TG, et al. Minimally invasive direct coronary artery bypass for the treatment of isolated disease of the left anterior descending coronary artery. Can J Surg, 2005, 48(4): 307-310.
8.	Puskas JD, Halkos ME, DeRose JJ, et al. Hybrid coronary revascularization for the treatment of multivessel coronary artery disease: A multicenter observational study. J Am Coll Cardiol, 2016, 68(4): 356-365.
9.	張魯鋒, 楊航, 凌云鵬, 等. 微創冠狀動脈搭橋治療多支冠脈病變臨床效果及橋血管通暢率分析. 中國心血管病研究, 2017, 15(9): 818-820.
10.	Une D, Sakaguchi T. Initiation and modification of minimally invasive coronary artery bypass grafting. Gen Thorac Cardiovasc Surg, 2019, 67(4): 349-354.
11.	Une D, Lapierre H, Sohmer B, et al. Can minimally invasive coronary artery bypass grafting be initiated and practiced safely? A learning curve analysis. Innovations (Phila), 2013, 8(6): 403-409.
12.	Rodriguez ML, Lapierre HR, Sohmer B, et al. Mid-term follow-up of minimally invasive multivessel coronary artery bypass grafting: Is the early learning phase detrimental? Innovations (Phila), 2017, 12(2): 116-120.
13.	李欣, 侯純升, 白洋, 等. 單孔腹腔鏡膽囊切除術的學習曲線: 累積求和分析法. 中國微創外科雜志, 2016, 16(3): 241-244.
14.	Wohl H. The cusum plot: Its utility in the analysis of clinical data. N Engl J Med, 1977, 296(18): 1044-1045.
15.	Bergsland J, Lingaas PS, Skulstad H, et al. Intracoronary shunt prevents ischemia in off-pump coronary artery bypass surgery. Ann Thorac Surg, 2009, 87(1): 54-60.

1. Choi W, Chang HW, Kang SH, et al. Comparison of minimally invasive direct coronary artery bypass and percutaneous coronary intervention using second-generation drug-eluting stents for coronary artery disease-propensity score-matched analysis. Ann Thorac Surg, 2019, 83(7): 1572-1580.
2. Xu Y, Li Y, Bao W, et al. MIDCAB versus off-pump CABG: Comparative study. Hellenic J Cardiol, 2020, 61(2): 120-124.
3. Andrawes PA, Shariff MA, Nabagiez JP, et al. Evolution of minimally invasive coronary artery bypass grafting: Learning curve. Innovations (Phila), 2018, 13(2): 81-90.
4. 楊威, 凌云鵬, 陳彧. 左胸前外側小切口冠狀動脈旁路移植術學習曲線. 中國微創外科雜志, 2015, 15(11): 990-994.
5. 柳佳吉, 遲立群, 孔晴宇, 等. 肋間單一切口直視下微創多支 OPCABG 50 例. 中華胸心血管外科雜志, 2019, 35(3): 159-162.
6. Halkos ME, Vassiliades TA, Myung RJ, et al. Sternotomy versus nonsternotomy LIMA-LAD grafting for single-vessel disease. Ann Thorac Surg, 2012, 94(5): 1469-1477.
7. Boodhwani M, Ruel M, Mesana TG, et al. Minimally invasive direct coronary artery bypass for the treatment of isolated disease of the left anterior descending coronary artery. Can J Surg, 2005, 48(4): 307-310.
8. Puskas JD, Halkos ME, DeRose JJ, et al. Hybrid coronary revascularization for the treatment of multivessel coronary artery disease: A multicenter observational study. J Am Coll Cardiol, 2016, 68(4): 356-365.
9. 張魯鋒, 楊航, 凌云鵬, 等. 微創冠狀動脈搭橋治療多支冠脈病變臨床效果及橋血管通暢率分析. 中國心血管病研究, 2017, 15(9): 818-820.
10. Une D, Sakaguchi T. Initiation and modification of minimally invasive coronary artery bypass grafting. Gen Thorac Cardiovasc Surg, 2019, 67(4): 349-354.
11. Une D, Lapierre H, Sohmer B, et al. Can minimally invasive coronary artery bypass grafting be initiated and practiced safely? A learning curve analysis. Innovations (Phila), 2013, 8(6): 403-409.
12. Rodriguez ML, Lapierre HR, Sohmer B, et al. Mid-term follow-up of minimally invasive multivessel coronary artery bypass grafting: Is the early learning phase detrimental? Innovations (Phila), 2017, 12(2): 116-120.
13. 李欣, 侯純升, 白洋, 等. 單孔腹腔鏡膽囊切除術的學習曲線: 累積求和分析法. 中國微創外科雜志, 2016, 16(3): 241-244.
14. Wohl H. The cusum plot: Its utility in the analysis of clinical data. N Engl J Med, 1977, 296(18): 1044-1045.
15. Bergsland J, Lingaas PS, Skulstad H, et al. Intracoronary shunt prevents ischemia in off-pump coronary artery bypass surgery. Ann Thorac Surg, 2009, 87(1): 54-60.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Analysis of learning curve of minimally invasive coronary artery bypass grafting surgery

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