Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia.
Eur J Cardiothorac Surg. 2011 Oct;40(4):826-33. doi: 10.1016/j.ejcts.2011.02.003. Epub 2011 Mar 26.
Mitral valve surgery may be regarded as less favourable for training, due to greater mortality risk, technical complexity, and difficulty for the supervisor to observe. We examined this perception by reviewing a multicentre experience.
We analysed a multicentre database over a 7-year period containing 2216 isolated and combined mitral procedures. Of these, 2048 were performed by consultants and 168 by trainees (92% vs 8%) of varying seniority. Preoperative characteristics, early postoperative outcomes and 6-year survival were compared between groups. Propensity-score matching was performed to correct for group differences.
Trainees were less likely to operate on patients, who had previously undergone coronary surgery (consultant 4.3% vs trainee 1.2%, p=0.043) and those with moderate to severe mitral regurgitation (86% vs 81%, p=0.012). There were no other statistically significant differences in preoperative variables, such as urgency, endocarditis and left-ventricular dysfunction. There were similar rates of mitral valve repair (48% vs 51%, p=0.48). Trainees were more likely to operate on rheumatic valve pathology (20% vs 28%, p=0.012). Intra-operatively, trainees had longer aortic cross-clamp times (119 ± 52 vs 136 ± 50 min, p=0.0001). At 30 days, mortality was comparable (4.5% vs 3.6%, p=0.56) with a trend towards higher any mortality/morbidity in consultant procedures (33% vs 26%, p=0.059). At 6 years, survival was similar (79 ± 1.4% vs 78 ± 4.0%, p=0.73). After derivation of 142 propensity-score-matched patient pairs, trainees cases still experienced longer cross-clamp times (121 ± 58 vs 137 ± 52 min, p=0.023), but there was similar 30-day mortality (4.2% vs 3.5%, p>0.99) and any mortality/morbidity (28% vs 24%, p=0.52). Six-year survival between matched pairs was also similar (74 ± 7.2% vs 80 ± 4.4%, p=0.64). Trainee status did not predict early or late adverse events after multivariate Cox regression with and without propensity-score adjustment.
Trainee outcomes are not inferior even when corrected for risk. This suggests that excellent operative training and supervision can be achieved in mitral valve surgery.
由于二尖瓣手术死亡率较高、技术复杂且难以让上级观察，其可能被视为培训效果不佳。我们通过多中心经验回顾来检验这种看法。
我们分析了一个包含 2216 例单纯和联合二尖瓣手术的 7 年多中心数据库。其中 2048 例由顾问完成，168 例由不同级别受训者（92%比 8%）完成。比较两组患者的术前特征、术后早期结局和 6 年生存率。使用倾向评分匹配来纠正组间差异。
受训者较少对之前接受过冠状动脉手术（顾问 4.3%比受训者 1.2%，p=0.043）和中重度二尖瓣反流（顾问 86%比受训者 81%，p=0.012）的患者进行手术。在术前变量方面，如紧急情况、心内膜炎和左心室功能障碍，两组之间没有其他统计学差异。二尖瓣瓣修复率相似（顾问 48%比受训者 51%，p=0.48）。受训者更倾向于对风湿性瓣膜病变进行手术（顾问 20%比受训者 28%，p=0.012）。术中，受训者的主动脉阻断时间更长（119±52比 136±50 分钟，p=0.0001）。术后 30 天死亡率相当（顾问 4.5%比受训者 3.6%，p=0.56），顾问手术中任何死亡率/发病率较高的趋势（顾问 33%比受训者 26%，p=0.059）。6 年生存率相似（顾问 79±1.4%比受训者 78±4.0%，p=0.73）。在得出 142 对倾向评分匹配的患者对后，受训者的手术仍经历更长的主动脉阻断时间（121±58 比 137±52 分钟，p=0.023），但术后 30 天死亡率相似（顾问 4.2%比受训者 3.5%，p＞0.99）和任何死亡率/发病率相似（顾问 28%比受训者 24%，p=0.52）。匹配对之间的 6 年生存率也相似（顾问 74±7.2%比受训者 80±4.4%，p=0.64）。多变量 Cox 回归分析，无论是否进行倾向评分调整，受训者的状态都不能预测早期或晚期不良事件。
即使经过风险校正，受训者的结果也不劣。这表明在二尖瓣手术中可以实现出色的手术培训和监督。
