Exploring the learning curve for minimally invasive sutureless aortic valve replacement

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 152; no. 6; pp. 1537 - 1546.e1
• Main Authors: Murzi, Michele, MD PhD, Cerillo, Alfredo Giuseppe, MD, Gilmanov, Danyar, MD, Giovanni, Concistrè, MD, Farneti, Pierandrea, MD, Glauber, Mattia, MD, Solinas, Marco, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.12.2016
• Subjects: aortic valve replacement; Cardiothoracic Surgery; performance monitoring; sutureless aortic valve; Aortic Valve Replacement; Sutureless Aortic Valve; Performance Monitoring; RAMT; CUSUM; aortic valve replacement; performance monitoring; sutureless aortic valve; CPB; TAVI; AVR; MIAVR
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2016.04.094

Abstract Objective To assess the learning process and quality of care of right minithoracotomy aortic valve replacement with sutureless bioprosthesis, at a single institution. Methods Analysis of the first 300 consecutive patients (age 76 ± 6 years; Logistic Euroscore 9±6) who underwent sutureless valve implantation through a right minithoracotomy at our institution between 2011 and 2015, by six surgeons. Learning curve was analyzed dividing study population in three tertiles of 100 patients each. Departmental and individual learning curves were calculated, using sequential probability cumulative sum failure analysis. Quality indicators were two composite endoint reflecting the technical success and 30-days complications. Results The overall mortality was 0.7% (2 patients). No significant differences were noted in term of mortality and complications between tertiles. The sutureless valve was implanted succesfully in 99% of cases (298/300). Cusum analysis failed to identify any significant learning effects for technical success. Nevertheless surgeon A, B and C had a small initial learning curve, while surgeon D,E and F did not, reflecting a trend towards a positive effect of cumulative institutional experience on individual learning curve. The 30-days complications analysis revealed a cluster of failures at the beginning of the experience. This cluster prompted an internal audit and modification of the patients selection process. Consecutively the procedure returned in control. Conclusions Right minithoracotomy sutureless valve implantation can be performed safely without learning curve effects. Cusum analysis is a valuable tool to describe and monitor the learning process. They can identify periods of less then expected performance and alert team to react.