Learning Minimally Invasive Mitral Valve Surgery: A Cumulative Sum Sequential Probability Analysis of 3895 Operations From a Single High-Volume Center

• Published in: Circulation (New York, N.Y.) Vol. 128; no. 5; pp. 483 - 491
• Main Authors: Holzhey, David M, Seeburger, Joerg, Misfeld, Martin, Borger, Michael A, Mohr, Friedrich W
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD by the American College of Cardiology Foundation and the American Heart Association, Inc 30.07.2013; Lippincott Williams & Wilkins
• Subjects: Aged; Biological and medical sciences; Blood and lymphatic vessels; Cardiology. Vascular system; Clinical Competence - standards; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Female; Heart Valve Prosthesis Implantation - standards; Heart Valve Prosthesis Implantation - trends; Humans; Learning Curve; Male; Medical sciences; Middle Aged; Minimally Invasive Surgical Procedures - standards; Minimally Invasive Surgical Procedures - trends; Mitral Valve - surgery; Physicians - standards; Physicians - trends; Postoperative Complications - diagnosis; Postoperative Complications - epidemiology; Probability; Prospective Studies; Retrospective Studies; Thoracotomy - standards; Thoracotomy - trends; Treatment Outcome; High; Center; Mitral valve; Curve; Probability; Cardiovascular disease; Operation; Learning; Sequential analysis; Minimally invasive surgery; Acquisition process; Volume; Circulatory system; Cardiology; learning curve; surgery; mitral valve
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.112.001402

BACKGROUND—Learning curves are vigorously discussed and viewed as a negative aspect of adopting new procedures. However, very few publications have methodically examined learning curves in cardiac surgery, which could lead to a better understanding and a more meaningful discussion of their consequences. The purpose of this study was to assess the learning process involved in the performance of minimally invasive surgery of the mitral valve using data from a large, single-center experience. METHODS AND RESULTS—All mitral (including tricuspid, or atrial fibrillation ablation) operations performed over a 17-year period through a right lateral mini-thoracotomy with peripheral cannulation for cardiopulmonary bypass (n=3907) were analyzed. Data were obtained from a prospective database. Individual learning curves for operation time and complication rates (using sequential probability cumulative sum failure analysis) and average results were calculated. A total of 3895 operations by 17 surgeons performing their first minimally invasive surgery of the mitral valve operation at our institution could be evaluated. The typical number of operations to overcome the learning curve was between 75 and 125. Furthermore, >1 such operation per week was necessary to maintain good results. Individual learning curves varied markedly, proving the need for good monitoring or mentoring in the initial phase. CONCLUSIONS—A true learning curve exists for minimally invasive surgery of the mitral valve. Although the number of operations required to overcome the learning curve is substantial, marked variation exists between individual surgeons. Such information could be very helpful in structuring future training and maintenance of competence programs for this kind of surgery.