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Learning Curve Analysis of Minimally Invasive Mitral Valve Repair
Mohsyn Imran Malik1, Brandon Loshusan1, Michael W A Chu1
1Division of Cardiac Surgery, Department of Surgery, Western University, London, ON, Canada.
Objective:
Previous learning curve analyses of minimally invasive mitral valve (MV) repair have focused largely on early safety outcomes without including detailed mitral repair quality outcomes. This study investigates the learning curve of minimally invasive MV repair over a 15-year experience, focused on clinical outcomes and evidence-based technical failure endpoints.
Methods:
All MV repair operations were performed by a single surgeon between May 2008 and February 2023. Patient data were stratified into 3 groups of tertiles. Failure endpoints were defined as postrepair residual mitral regurgitation ≥ mild and a 30-day composite outcome. Cumulative log-likelihood curves were constructed for minimally invasive MV repair using the primary outcomes as technical failure endpoints. Control limits were determined using previous analyses of the Society of Thoracic Surgeons database.
Results:
A total of 362 consecutive patients across 15 years were included. Across tertiles, there was a significant trend toward shorter cross-clamp time (P < 0.001), cardiopulmonary bypass time (P < 0.001), and hospital length of stay (P = 0.005). Learning curve analysis demonstrated crossing of the lower threshold at ~60 patients for postrepair mitral regurgitation ≥ mild and ~85 patients for the 30-day composite outcome. The mean adjusted risk scores for both primary outcomes based on a multivariable logistic model demonstrated no significant differences across tertiles.
Conclusions:
The estimated number of operations to achieve optimal repair outcomes and durability is ~60 to 85 patients. These data can improve the design of surgical training competencies, beyond avoidance of complications, and instead focus the learning curve on what is necessary to achieve optimal mitral repair outcomes.
Insights
This study shows that achieving optimal minimally invasive mitral valve repair outcomes requires approximately 60-85 cases. Focusing surgical training on repair quality, not just safety, is key for better results.
Area of Science:
- Cardiovascular Surgery
- Surgical Education
- Medical Devices
Background:
- Minimally invasive mitral valve (MV) repair learning curves often lack detailed quality outcome analysis.
- This study addresses the need for comprehensive learning curve assessment in MV repair.
Purpose of the Study:
- To investigate the learning curve for minimally invasive MV repair.
- To focus on clinical outcomes and evidence-based technical failure endpoints.
Main Methods:
- A single surgeon performed 362 MV repairs from 2008-2023.
- Patients were stratified into tertiles; failure defined as residual mitral regurgitation ≥ mild or 30-day composite outcome.
- Cumulative log-likelihood curves analyzed technical failure endpoints.
Main Results:
- Significant trends toward shorter cross-clamp time, cardiopulmonary bypass time, and hospital stay were observed across tertiles.
- Learning curve thresholds were identified at ~60 patients for acceptable regurgitation and ~85 patients for the composite outcome.
- No significant differences in adjusted risk scores were found across tertiles.
Conclusions:
- Optimal minimally invasive MV repair outcomes and durability are achieved around 60-85 cases.
- Surgical training should emphasize achieving optimal repair quality, not solely avoiding complications.
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