The Learning Curve of Robotic Coronary Arterial Bypass Surgery: A Report
From The STS Database
Abstract
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).