Li Jun, Zhao Yun, Zhou Tianyu, Zhu Kai, Zhai Junyu, Sun Yongxin, Wei Lai, Ding Wenjun, Hong Tao, Lai Hao, Wang Chunsheng
Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.
J Thorac Dis. 2020 Nov;12(11):6563-6572. doi: 10.21037/jtd-20-1960.
Mitral valve (MV) repair has become the gold standard for treating degenerative mitral regurgitation (MR), yet the success rate of MV repair is still low in clinical practice. While studies focused on the learning process of MV repair are scarce, fully understanding the learning curve could provide valuable information for education and the quality control of MV repair, thus benefiting patients. This observational study aimed to evaluate the learning process and performances of individual surgeon for MV repair for degenerative mitral disease using data from a single high-volume center.
Profiles of patients who underwent MV repair for degenerative MR at our institution from January 2003 to December 2016 were analyzed retrospectively. Overall and individual learning curves for the repair rate and major adverse events were calculated using sequential probability cumulative sum failure analysis. Average learning curves for major adverse events and operative time were also analyzed, by calculating the average incidence of adverse events and operative time of all operations stratified by accumulated operation numbers of individual surgeon. Altogether, we evaluated 2,482 operations performed by 14 surgeons.
There was an obvious learning curve for the repair rate at the institution and individual surgeon levels. Altogether, 50 to 200 operations were needed to overcome the repair rate learning curve, yet wide variation was observed among individual surgeons. The learning process for individual surgeons became faster after the turning point in the institutional learning curve appeared. No obvious learning curve was observed at the institution or individual level for major adverse events and in-hospital mortality.
The number of cases required to overcome the learning curve for repair rate is substantial, although there is marked variation among surgeons. Individuals' learning curves accelerate as the institution accumulates experience. MV repair is safe in experienced high-volume center. Close monitoring is necessary when surgeons begin to practice new techniques.
二尖瓣修复已成为治疗退行性二尖瓣反流（MR）的金标准，但在临床实践中二尖瓣修复的成功率仍然较低。虽然专注于二尖瓣修复学习过程的研究很少，但充分了解学习曲线可为二尖瓣修复的教育和质量控制提供有价值的信息，从而使患者受益。本观察性研究旨在利用来自单一高容量中心的数据，评估个体外科医生进行退行性二尖瓣疾病二尖瓣修复的学习过程和表现。
回顾性分析2003年1月至2016年12月在我院接受退行性MR二尖瓣修复的患者资料。使用序贯概率累积和失败分析计算修复率和主要不良事件的总体及个体学习曲线。还通过计算按个体外科医生累积手术数量分层的所有手术的不良事件平均发生率和手术时间，分析主要不良事件和手术时间的平均学习曲线。我们总共评估了14位外科医生进行的2482例手术。
在机构和个体外科医生层面，修复率均存在明显的学习曲线。总共需要50至200例手术才能克服修复率学习曲线，但个体外科医生之间存在很大差异。在机构学习曲线出现转折点后，个体外科医生的学习过程加快。在机构或个体层面，未观察到主要不良事件和院内死亡率的明显学习曲线。
尽管外科医生之间存在显著差异，但克服修复率学习曲线所需的病例数仍然较多。随着机构积累经验，个体的学习曲线会加速。在经验丰富的高容量中心，二尖瓣修复是安全的。当外科医生开始实践新技术时，需要密切监测。
