Learning Curve of Mitral Valve Replacement through Right Minithoracotomy_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

 WUXian-qiu ¹ , WEIWu-li ¹ , WANGQi ¹ , HEYi ²

1. Department of Cardiothoracic Surgery, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou 545005, Guangxi, P. R. China;
2. Medical Records and Statistical Room, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou 545005, Guangxi, P. R. China;

Corresponding?author：

WUXian-qiu, Email: wxq0546@163.com

Keywords：

Minimally invasive mitral valve replacement; Cumulative sum analysis; Learning curve; Quality control

DOI：

10.7507/1007-4848.20140175

Video：

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Objective To monitor surgical quality and analyze learning curve of minimally invasive mitral valve replacement (MVR)through right minithoracotomy with cumulative sum analysis (CUSUM analysis). Methods Clinical data of 60 consecutive patients who underwent minimally invasive MVR through right minithoracotomy in the Fourth Affiliated Hospital of Guangxi Medical University from June 2011 to April 2013 were retrospectively analyzed. There were 32 male and 28 female patients with their age of 28-53 (34.67±7.11)years and their heart function ranging from NYHA class Ⅱ to Ⅳ. There were 31 patients with mitral stenosis (MS), 19 patients with mitral regurgitation (MR), and 10 patients with MS and MR. According to the surgical sequence, all the patients were divided into 3 groups (group A, B and C)with 20 patients in each group. Surgical outcomes were compared among the 3 groups, and surgical quality was analyzed with descriptive statistics and CUSUM curves. Results Aortic cross-clamp time, cardiopulmonary bypass time and operation time of group C were significantly shorter than those of group A and group B (aortic cross-clamp time of group C vs. group A:50.35±2.30 minutes vs. 66.15±8.38 minutes; operation time of group C vs. group B:167.50±4.63 minutes vs. 178.60±4.49 minutes, P < 0.05). In-hospital mortality was 3.3% (2/60). CUSUM analysis showed a significant learning curve effect, although surgical quality remained in control during the study period. Surgical failure rate was lower than 80% after about 45 operations, indicating that failure rate was 10% lower than expectation. Conclusion Minimally invasive MVR is safe and reliable, and CUSUM analysis is a simple statistical method to monitor surgical quality.

Citation： WUXian-qiu, WEIWu-li, WANGQi, HEYi. Learning Curve of Mitral Valve Replacement through Right Minithoracotomy. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2014, 21(5): 614-618. doi: 10.7507/1007-4848.20140175 Copy

1.	Carpentier A, Loulmet D, Carpentier A, et al. Open heart operation under videosurgery and minithoracotomy. First case (mitral valvulo-plasty)operated with success. CR Acad Sci Ⅲ. 1996, 319(3):219-223.
2.	Chitwood WR, Elbeery JR, Chapman WH, et al. Video-assisted minimally invasive mitral valve surgery:the "micro-mitral" operation.J Thorac Cardiovasc Surg, 1997, 113(2):413-414.
3.	Chitwood WR, Elbeery JR, Moran JF. Minimally invasive mitral valve repair using transthoracic aortic occlusion. Ann Thorac Surg, 1997, 63(5):1477-1479.
4.	Cheng DC, Martin J, Lal A, et al. Minimally invasive versus conven-tional open mitral valve surgery:a meta-analysis and systematic review. Innovations (Phila), 2011, 6(2):84-103.
5.	Modi P, Hassan A, Chitwood WR. Minimally invasive mitral valve surgery:a systematic review and meta-analysis. Eur J Cardiothorac Surg, 2008, 34(5):943-952.
6.	Rogers CA, Reeves BC, Caputo M, et al. Control chart methods for monitoring cardiac surgical performance and their interpretation. J Thorac Cardiovasc Surg, 2004, 128(6):811-819.
7.	Gammie JS, Zhao Y, Peterson ED, et al. Less-Invasive mitral valve operations:trends and outcomes from the society of thoracic surgeons adult cardiac surgery database. Ann Thorac Surg, 2010, 90(5):1401-1410.
8.	Modi P, Rodriguez E, Hargrove WC, et al. Minimally invasive video-assisted mitral valve surgery:a 12-year, 2-center experience in 1178 patients. J Thorac Cardiovasc Surg, 2009, 137(6):1481-1487.
9.	Seeburger J, Borger MA, Falk V, et al. Minimal invasive mitral valve repair for mitral regurgitation:results of 1339 consecutive patients. Eur J Cardiothorac Surg, 2008, 34(4):760-765.
10.	殷亮, 王志農, 王毅峰, 等.微創心臟外科手術與傳統開胸心臟手術術后療效的系統評價.中國循證醫學雜志, 2009, 9(8):849-854.
11.	師恩祎, 谷天祥, 喻磊, 等.微創與常規二尖瓣成形和置換術治療單純二尖瓣病變患者的病例對照研究.中國胸心血管外科臨床雜志, 2013, 20(3):294-297.
12.	Page ES. Continuous inspection schemes. Biometrika, 1954, 41:100-115.
13.	Williams SM, Parry BR, Schlup MM. Quality control:an application of the cusum. BMJ, 1992, 304(6838):1359-1361.
14.	de Leval MR, Fran?ois K, Bull C, et al. Analysis of a cluster of surgical failures. Application to a series of neonatal arterial switch operations. J Thorac Cardiovasc Surg, 1994, 107(3):914-924.
15.	Novick RJ, Fox SA, Kiaii BB, et al. Analysis of the learning curve in telerobotic, beating heart coronary artery bypass grafting:a 90 patient experience. Ann Thorac Surg, 2003, 76(3):749-753.
16.	Holzhey DM, Jacobs S, Walther T, et al. Cumulative sum failure analysis for eight surgeons performing minimally invasive direct coronary artery bypass. J Thorac Cardiovasc Surg, 2007, 134(3):663-669.
17.	Caputo M, Reeves BC, Rogers CA, et al. Monitoring the performance of residents during training in off-pump coronary surgery. J Thorac Cardiovasc Surg, 2004, 128(6):907-915.
18.	Murzi M, Cerillo AG, Bevilacqua S, et al. Traversing the learning curve in minimally invasive heart valve surgery:a cumulative analysis of an individual surgeon's experience with a right minithoracotomy approach for aortic valve replacement. Eur J Cardiothorac Surg, 2012, 41(6):1242-1246.

1. Carpentier A, Loulmet D, Carpentier A, et al. Open heart operation under videosurgery and minithoracotomy. First case (mitral valvulo-plasty)operated with success. CR Acad Sci Ⅲ. 1996, 319(3):219-223.
2. Chitwood WR, Elbeery JR, Chapman WH, et al. Video-assisted minimally invasive mitral valve surgery:the "micro-mitral" operation.J Thorac Cardiovasc Surg, 1997, 113(2):413-414.
3. Chitwood WR, Elbeery JR, Moran JF. Minimally invasive mitral valve repair using transthoracic aortic occlusion. Ann Thorac Surg, 1997, 63(5):1477-1479.
4. Cheng DC, Martin J, Lal A, et al. Minimally invasive versus conven-tional open mitral valve surgery:a meta-analysis and systematic review. Innovations (Phila), 2011, 6(2):84-103.
5. Modi P, Hassan A, Chitwood WR. Minimally invasive mitral valve surgery:a systematic review and meta-analysis. Eur J Cardiothorac Surg, 2008, 34(5):943-952.
6. Rogers CA, Reeves BC, Caputo M, et al. Control chart methods for monitoring cardiac surgical performance and their interpretation. J Thorac Cardiovasc Surg, 2004, 128(6):811-819.
7. Gammie JS, Zhao Y, Peterson ED, et al. Less-Invasive mitral valve operations:trends and outcomes from the society of thoracic surgeons adult cardiac surgery database. Ann Thorac Surg, 2010, 90(5):1401-1410.
8. Modi P, Rodriguez E, Hargrove WC, et al. Minimally invasive video-assisted mitral valve surgery:a 12-year, 2-center experience in 1178 patients. J Thorac Cardiovasc Surg, 2009, 137(6):1481-1487.
9. Seeburger J, Borger MA, Falk V, et al. Minimal invasive mitral valve repair for mitral regurgitation:results of 1339 consecutive patients. Eur J Cardiothorac Surg, 2008, 34(4):760-765.
10. 殷亮, 王志農, 王毅峰, 等.微創心臟外科手術與傳統開胸心臟手術術后療效的系統評價.中國循證醫學雜志, 2009, 9(8):849-854.
11. 師恩祎, 谷天祥, 喻磊, 等.微創與常規二尖瓣成形和置換術治療單純二尖瓣病變患者的病例對照研究.中國胸心血管外科臨床雜志, 2013, 20(3):294-297.
12. Page ES. Continuous inspection schemes. Biometrika, 1954, 41:100-115.
13. Williams SM, Parry BR, Schlup MM. Quality control:an application of the cusum. BMJ, 1992, 304(6838):1359-1361.
14. de Leval MR, Fran?ois K, Bull C, et al. Analysis of a cluster of surgical failures. Application to a series of neonatal arterial switch operations. J Thorac Cardiovasc Surg, 1994, 107(3):914-924.
15. Novick RJ, Fox SA, Kiaii BB, et al. Analysis of the learning curve in telerobotic, beating heart coronary artery bypass grafting:a 90 patient experience. Ann Thorac Surg, 2003, 76(3):749-753.
16. Holzhey DM, Jacobs S, Walther T, et al. Cumulative sum failure analysis for eight surgeons performing minimally invasive direct coronary artery bypass. J Thorac Cardiovasc Surg, 2007, 134(3):663-669.
17. Caputo M, Reeves BC, Rogers CA, et al. Monitoring the performance of residents during training in off-pump coronary surgery. J Thorac Cardiovasc Surg, 2004, 128(6):907-915.
18. Murzi M, Cerillo AG, Bevilacqua S, et al. Traversing the learning curve in minimally invasive heart valve surgery:a cumulative analysis of an individual surgeon's experience with a right minithoracotomy approach for aortic valve replacement. Eur J Cardiothorac Surg, 2012, 41(6):1242-1246.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Learning Curve of Mitral Valve Replacement through Right Minithoracotomy

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