Although the operative mortality rate decreased over time for patients with aortic dissection, the risk for those with acute aortic dissection during the last 10 years (1983 to 1992) is probably more realistic than that observed in the preceding 5-year interval (1978 to 1982). The operative mortality rates for patients with chronic aortic dissection have remained relatively static. Earlier diagnosis of acute aortic dissection before development of cardiac tamponade and renal impairment is critical to improve the operative salvage rate. Long-term outcome still is not optimal, which emphasizes the need for better serial postoperative aortic imaging surveillance and medical follow-up and blood pressure control.

The incidence of peripheral vascular complications in 272 patients with aortic dissection during a 25-year span was determined, as was outcome after a uniform, aggressive surgical approach directed at repair of the thoracic aorta. One hundred twenty-eight patients (47%) presented with acute type A dissection, 70 (26%) with chronic type A, 40 (15%) with acute type B, and 34 (12%) with chronic type B dissections. Eighty-five patients (31%) sustained one or more peripheral vascular complications: Seven (3%) had a stroke, nine (3%) had paraplegia, 66 (24%) sustained loss of a peripheral pulse, 22 (8%) had impaired renal perfusion, and 14 patients (5%) had compromised visceral perfusion. Following repair of the thoracic aorta, local peripheral vascular procedures were unnecessary in 92% of patients who presented with absence of a peripheral pulse. The operative mortality rate for all patients was 25% +/- 3% (68 of 272 patients). For the subsets of individuals with paraplegia, loss of renal perfusion, and compromised visceral perfusion, the operative mortality rates (+/- 70% confidence limits) were high: 44% +/- 17% (4 of 9 patients), 50% +/- 11% (11 of 22 patients), and 43% +/- 14% (6 of 14 patients), respectively. The mortality rates were lower for patients presenting with stroke (14% +/- 14% [1 of 7 patients]) or loss of peripheral pulse (27% +/- 6% [18 of 66 patients]). Multivariate analysis revealed that impaired renal perfusion was the only peripheral vascular complication that was a significant independent predictor of increased operative mortality risk (p = 0.024); earlier surgical referral (replacement of the appropriate section of the thoracic aorta) or more expeditious diagnosis followed by surgical renal artery revascularization after a thoracic procedure may represent the only way to improve outcome in this high-risk patient subset. Early, aggressive thoracic aortic repair (followed by aortic fenestration and/or abdominal exploration with or without direct visceral or renal vascular reconstruction when necessary) can save some patients with compromised visceral perfusion; however, once visceral infarction develops the prognosis is also poor. Increased awareness of these devastating complications of aortic dissection and the availability of better diagnostic tools today may improve the survival rate for these patients in the future. The initial surgical procedure should include repair of the thoracic aorta in most patients.

Objective We evaluated focused training in coronary artery anastomosis with a porcine heart model and portable task station. Methods At “Boot Camp,” 33 first-year cardiothoracic surgical residents participated in 4-hour coronary anastomosis sessions (6–7 attending surgeons per group of 8–9 residents). At beginning, midpoint, and session end, anastomosis components were assessed on a 3-point rating scale (1 good, 2 average, 3 below average). Performances were video recorded and reviewed by 3 surgeons in a blinded fashion. Participants completed questionnaires at session end, with follow-up surveys at 6 months. Results Ten to 18 end-to-side anastomoses with porcine model and task station were performed. Initial assessments ranged from 2.11 ± 0.58 (forceps use) to 2.44 ± 0.48 (needle angles). Midpoint scores ranged from 1.76 ± 0.63 (forceps use) to 1.91 ± 0.49 (needle angles). Session end scores ranged from 1.29 ± 0.45 (needle holder use) to 1.58 ± 0.50 (needle transfer and suture management and tension; P < .001). Video recordings confirmed improved performance (interrater reliability > 0.5). All respondents agreed that task station and porcine model were good methods of training. At 6 months, respondents noted that the anastomosis session provided a basis for training; however, only slightly more than half continued to practice outside the operating room. Conclusions Four-hour focused training with porcine model and task station resulted in improved ability to perform anastomoses. Boot Camp may be useful in preparing residents for coronary anastomosis in the clinical setting, but emphasis on simulation development and deliberate practice is necessary.

In general, distributed practice with the task station resulted in improvement in the ability to perform an anastomosis, as assessed by times to completion and performance ratings, not only with the task station but also with the beating-heart model. Not all residents improved, which is consistent with a "ceiling effect" with the simulator and a "plateau effect" with the trainee. Simulation can be useful in preparing residents for coronary anastomosis and can provide an opportunity to identify the need and methods for remediation.