Katholieke Universiteit

“OPCAB was and still is considered a minor variation of a mature surgical technology. In most hands this has failed. In reality, OPCAB demands a complete re-engineering of the operational procedures [by the] surgeon and anesthetist. The [KU Leuven OPCAB Centre] addresses this issue…”-Dr. Paul Sergeant

For over a decade, the Katholieke Universiteit Leuven Off-Pump Coronary Artery Bypass Centre (KU Leuven OPCAB Centre) has focused on a progressive approach to surgical education for both experienced surgeons as well as young residents. Surgeons and anesthesiologists are taught the principles and intricacies of OPCAB through multiple modalities. By offering this very specific training, Dr. Paul Sergeant, the Centre’s director, feels many of the vital yet subtle details of the procedure can be instilled. The recent publication of the randomized OPCAB versus on-pump CABG trial (Shroyer AL et al. NEJM 2009;361:1827-37) with the inferiority result of the OPCAB technique underscores the need for appropriate training. As an important limitation in this study the majority of procedures were carried out by trainees under the supervison of surgeon who were inexperienced in OPCAB technique (see letter to the Editor of Puskas, Mack and Smiths in NEJM 2010; 362:851-854). As a consequence the conversion to on-pump was much higher (12.4%) than in experienced OPCAB centers.

Much of a cardiothoracic surgeon’s training in Belgium and other European countries is a part of a pre-described process, which differs from education in the United States.

For example, in the United States:

1. College/University (4 years)
2. Medical School (4 years)
3. Residency (5-8 years)
4. Specialty Fellowship training (2+ years)

Or as in Belgium, where the KU Leuven OPCAB Centre resides:

1. University/Medical School (7-years)
2. Postgraduate surgical training (3-6 years)
3. Specialty training(3+ years)

Though many of KU Leuven OPCAB Centre trainees are visiting residents and fellows incorporating this experience as a supplement to the aforementioned training process, many more of the Centre’s trainees are fully board-certified surgeons and anesthesiologists seeking retraining. There are also some full-time residents and fellows who call the KU Leuven Centre their home institution and participate in the OPCAB Centre training as a part of their standard surgical training. Whether they are Gasthuisberg University natives or visiting scholars, all trainees are respected equally.

Training (or re-training) very purposefully implements what Dr Sergeant calls “the science of adult learning” by breaking down surgical procedures first into the conceptually and the virtually taught components. Conceptual discussions cover a wide range of crucial points leading to practice of stabilization, enucleation, shunt insertion, position refinement, and apical suction on virtual models. Simulation is one key element of this training program as the teachable components of the procedure can be easily simulated in a low-cost, low fidelity simulator. Participants then scrub into approximately 2 surgeries per day to integrate the new information in operational training experiences. Anastomoses are typically performed by trainees who stay at least six-months or those rotating through the general surgical training. The active learning processes achieved through multimodal training such as this have been shown to create optimal teaching for adults and certainly many of the KU Leuven OPCAB program alumni would agree:

“For me, the most useful aspect was to learn how Professor Sergeant taught his residents to do OPCAB... Although I attended this as a fully converted OPCAB surgeon already, I was still able to come away with a number of useful ideas which I am planning to incorporate into my practice…”-Dr. Augustine Tang

“The training for OPCAB surgery held by Dr. Sergeant was excellent and I learned a lot in a short period. There were some good tricks which I took home and put into practice. I would suggest everybody who plans to start [using] OPCAB surgery to visit Dr. Sergeant first.”-Dr. Ali Falsafi

Diligently applying the science of learning to every objective set by the Centre sets this training apart from many of the more traditional training experiences.

Strides have been made to explicitly document how re-training affects surgeons' bypass practices. In the January 2006 edition of The Journal of Thoracic and Cardiovascular Surgery, Dr Alexander Albert and colleagues (including Dr. Sergeant) followed fifty surgical teams and compared their attitude toward OPCAB, rating of complexity and frequency of application of OPCAB before and after participating in two days at the KU Leuven Centre. Their statistically significant results at 3 months post-training were as follows:

1. Teams predominantly viewed OPCAB beneficial for at least as many, if not more, patients than prior to re-training.
2. Perceived complexity of OPCAB procedures significantly decreased.
3. OPCAB was used more frequently by the re-trained teams (absolute increase= 26% and relative increase= 110%).
4. Conversion of OPCAB to Cardiopulmonary bypass-dependent decreased relatively by more than 50%.

(A Albert, EA Peck, P Wouters, et. al. Performance analysis of interactive multimodal CME retraining on attitude toward and application of OPCAB. The Journal of Thoracic and Cardiovascular Surgery. January 2006. pg.154-162.)

The Centre’s website explicitly shares the program’s training outline. Self-quizzing modules, journal articles, videos and descriptions of surgical and anesthetist protocols help the website also act as a training tool itself. The Centre’s trainees boasts hundreds of OPCAB surgeries each year and over 840 scholars from more than 48 countries between 2000-2009.

It is important to note that this way of OPCAB-training does not allow a learning curve in a way that patients are put at harm. To ensure the accuracy of the outcome, every OPCAB training program needs to go along with an appropriate quality control (Murphy et al Ann Thorac Surg 2005; 80:1965-70). The KU Leuven Centre has implemented this in an exemplary way.

Though dedicated scholarships are not currently available to support visiting scholars, Dr Sergeant is said to be very accommodating and makes great efforts to help visits affordable. Several recent applicants have used European Association for Cardio-Thoracic Surgery scholarships to help cover costs as well while many others have been given funding from their home institutions, medical device companies or pharmaceutical companies (no affiliation with the Centre). For those licensed European students staying more than a year, paid positions are typically offered.

The Centre is located at the Gasthuisberg University Hospital where the program’s scholars meet in staff rooms and surgical suites with no more than two anesthetists and up to two surgeons. Such small groups allow for teaching to be highly individualized and effective. Scholars are grouped according to the language spoken and the procedure is taught in one of the five languages offered.

The KU Leuven OPCAB Centre’s dedication to surgical re-training and assiduous use of the science of learning has contributed much to OPCAB proliferation. The work being done at the Centre does much to support the urgent call for evidence. More evidence about OPCAB outcomes will certainly help surgeons form judicious opinions about this technique’s use but the Centre’s practices also provide the surgical community with evidence about how to potentially better surgical training and re-training. Dr Sergeant and the KU Leuven Centre staff assuredly look forward to continuing on this quest.

Acknowledgments

Special Thanks to the Katholieke Universiteit Leuven Off-Pump Coronary Artery Bypass Centre, Dr. Paul Sergeant, Dr. Augustine Tang, Dr. Ali Falsafi, and Dr. Boris Chernyak for their assistance in this article.

Program contact information