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Surgeon volume increased likelihood of mitral valve repair over replacement
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TORONTO — Surgeons who perform at least 20 mitral valve procedures per year are more likely to perform mitral valve repair than replacement, researchers reported here.
“In our study, there was a strong relationship between surgeon volume and the likelihood of mitral [valve] repair,” said Damien LaPar, MD, cardiothoracic fellow in the department of surgery at University of Virginia Health System.
At the American Association for Thoracic Surgery Annual Meeting, LaPar and colleagues presented data on 4,194 patients with moderate or severe mitral regurgitation who underwent mitral valve repair (n=2,516) or replacement (n=1,662) at 17 centers in Virginia from 2001 to 2011. The researchers assessed the association between annual hospital and surgeon volume and the probability for mitral repair.
Damien LaPar
For hospitals, the median annual mitral procedure volume was 54 operations per year (range, 5 to 128). For surgeons, the mean volume was 13 operations per year (range, 0 to 58). Overall mitral valve repair rates were 60%, and the researchers noted significant variation among hospitals (range, 35% to 70%) and surgeons (range, 0% to 90%).
Both average annual hospital volume (P=.04) and surgeon volume (P<.0001) were linked to the probability of mitral valve repair. Repair rates were greater for both higher-annual-volume (≥20) surgeons (73% vs. 26%) and hospitals (62% vs. 37%; P<.001 for both).
“When volume hit [at least] 20 procedures, we started to see a change in the number of performances of mitral repair,” LaPar told Cardiology Today. “Surgeon volume, which we saw as a surrogate for surgeon experience, is a strong predictor for mitral repair.”
The researchers also observed that patients who underwent mitral valve replacement presented with significantly higher Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM; 5.6% vs. 1.7%; P<.001).
LaPar said surgeons must continue to be involved in the decision of whether to repair or replace a mitral valve.
“We are moving into an era where there is increasing access to percutaneous techniques for mitral valve repairs, and surgeons need to play a larger role in deciding whether a valve is repaired by surgical technique, by percutaneous technique, or whether it can be repaired at all and should be replaced,” he said. “It is important for surgeons to work with interventional cardiologists.” – by Louise Gagnon
For more information:
LaPar D. Abstract #79. Presented at: American Association for Thoracic Surgery Annual Meeting; April 26-30, 2014; Toronto.
Disclosure: LaPar reports no relevant financial disclosures.
Perspective
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Faisal G. Bakaeen, MD, FACS
This is a provocative study. Generally, it makes sense that with higher case volume, comes experience and better results that encourage more repair rates.
However, the study's results and conclusions were somewhat of an overreach based on the data analyzed. I agree with W. Randolph Chitwood Jr., MD, a discussant of the presentation, who pointed out that the data are not granular enough to make solid conclusions. There is no information about mitral valve pathology, mechanism or regurgitation, or complexity of the repair. The fact that low-volume mitral surgeons achieved equivalent repair rates to higher-volume surgeons could not be explained. My personal view is that a straightforward posterior leaflet prolapse can be adequately repaired by most competent cardiac surgeons, but more complex pathologies would more likely be repaired by surgeons with a focus on mitral repair. Another important limitation of this study and most of the published work on this subject is the lack of a clear denominator, an intention-to-treat analysis, or reliable long-term durability data. Thus, what we know about mitral repairs, in general, is subject to significant bias, and a randomized controlled trial or a prospective registry would be extremely helpful in that regard.
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