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J Thorac Cardiovasc Surg 2008;135:1259-1260
© 2008 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr Ludwig Karl von Segesser (Lausanne, Switzerland). I wish to congratulate Dr Carey and colleagues for providing the manuscript and for bringing up a very important issue, which might become even more critical if CABG numbers are decreasing in the future.

I believe that most of us are happy to learn that the high-volume surgeon in a low-volume environment does like others in that environment. The main concern is, of course, that if a problem occurs, the surgeon gets most of the blame, and much less goes to the other team members. I am wondering whether further subgroup analysis is possible and whether there is a difference between the high-volume generalist cardiac surgeon compared with the high-volume CABG specialist? For the future, it might be important not to be focused on CABG alone. I am also wondering whether the low-volume surgeons are treated unfavorably in the statistical analysis here. If you have a surgeon doing 10 CABG procedures a year and he loses 1 patient, his mortality will be 10%, and if he does not lose a patient in the second year, it will be 0%, and therefore the mean will be 5%. Even if he loses no patient in the following 8 years, his mortality in this analysis will be 5% compared with that of others who lose 1 of 100 patients, where the mortality will be 1%.

I have the following questions. How does a high-volume CABG surgeon perform when he does a few procedures in another high-volume program compared with those who do a lot in the other high-volume program? How does a high-volume surgeon do in CABG, valve, and other procedures compared with a high-volume surgeon doing CABG alone in a high-volume environment, and what about the same for . . . [Full Text of this Article]

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