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

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.

[1]  F. Dagenais Minimally invasive mitral valve surgery: evolution, techniques and outcomes. , 2008, Future cardiology.

[2]  M. Antunes Minimally invasive valve surgery: reality, dream or utopia? , 1998, Journal of Heart Valve Disease.

[3]  N. Doll,et al.  How to establish video assisted, minimally invasive mitral valve surgery , 2012, Heart.

[4]  Volkmar Falk,et al.  Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients. , 2008, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[5]  T Walther,et al.  Minimally invasive port-access mitral valve surgery. , 1998, The Journal of thoracic and cardiovascular surgery.

[6]  Stefan Steiner,et al.  Direct comparison of risk-adjusted and non-risk-adjusted CUSUM analyses of coronary artery bypass surgery outcomes. , 2006, The Journal of thoracic and cardiovascular surgery.

[7]  Ansar Hassan,et al.  Minimally invasive mitral valve surgery: a systematic review and meta-analysis. , 2008, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[8]  M. Caputo,et al.  Control chart methods for monitoring cardiac surgical performance and their interpretation. , 2004, The Journal of thoracic and cardiovascular surgery.

[9]  F. Mohr,et al.  Robot-assisted minimally invasive solo mitral valve operation. , 1998, The Journal of thoracic and cardiovascular surgery.

[10]  N. Doll,et al.  Comparison of outcomes of minimally invasive mitral valve surgery for posterior, anterior and bileaflet prolapse. , 2009, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[11]  W. Boyd,et al.  Assessing the learning curve in off-pump coronary artery surgery via CUSUM failure analysis. , 2002, The Annals of thoracic surgery.

[12]  R. Robbins,et al.  Will minimally invasive valve replacement ever really be important? , 2004, Current opinion in cardiology.

[13]  F. Casselman,et al.  From classical sternotomy to truly endoscopic mitral valve surgery: a step by step procedure. , 2003, Heart, lung & circulation.

[14]  Sean M. O'Brien,et al.  J. Maxwell Chamberlain Memorial Paper for adult cardiac surgery. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. , 2010, The Annals of thoracic surgery.

[15]  W. Chitwood,et al.  Minimally invasive mitral valve repair using transthoracic aortic occlusion. , 1997, The Annals of thoracic surgery.

[16]  Patrick J Charland,et al.  Learning curve analysis of mitral valve repair using telemanipulative technology. , 2011, The Journal of thoracic and cardiovascular surgery.

[17]  Jeevanantham Rajeswaran,et al.  Minimally invasive versus conventional mitral valve surgery: a propensity-matched comparison. , 2010, The Journal of thoracic and cardiovascular surgery.

[18]  F. Mohr,et al.  Minimally invasive versus sternotomy approach for mitral valve surgery in patients greater than 70 years old: a propensity-matched comparison. , 2011, The Annals of thoracic surgery.

[19]  Sean M. O'Brien,et al.  Predictors of mitral valve repair: clinical and surgeon factors. , 2010, The Annals of thoracic surgery.

[20]  R Rayman,et al.  Cumulative sum failure analysis of a policy change from on-pump to off-pump coronary artery bypass grafting. , 2001, The Annals of thoracic surgery.

[21]  V. Fuster,et al.  A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines. , 2012, The Journal of thoracic and cardiovascular surgery.

[22]  J. Gummert,et al.  Cardiac Surgery in Germany during 2010: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery , 2011, The Thoracic and cardiovascular surgeon.

[23]  F. Mohr,et al.  Cumulative sum failure analysis for eight surgeons performing minimally invasive direct coronary artery bypass. , 2007, The Journal of thoracic and cardiovascular surgery.

[24]  F. Casselman,et al.  Mitral Valve Surgery Can Now Routinely Be Performed Endoscopically , 2003, Circulation.