Outcomes of Mitral Valve Repair Among High-Volume and Low-Volume Surgeons within a High-Volume Institution
Edward Percy1, Sameer Hirji1, Morgan Harloff1, Siobhan McGurk1, Akash Premkumar2, Alexandra Malarczyk1, Muntasir Chowdhury1, Farhang Yazdchi1, Tsuyoshi Kaneko1
1Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 2Harvard Medical School, Boston, MA
Background: Volume-outcome relationships in mitral valve repair are well established and currently there is consideration of reimbursement-linked volume requirements. We aimed to examine whether low-volume (LV) surgeons can perform similarly to high-volume (HV) surgeons within the context of a high-volume mitral repair institution.
Methods: All mitral valve repair cases at a high-volume center from 1992 to 2019 were considered. Cases with concomitant procedures were excluded. The distinction between HV and LV surgeons was 20 mitral repair cases/year, based on previous literature. Outcomes of interest included operative mortality and observed-to-expected (O/E) ratio, adjusted using the Society of Thoracic Surgeons (STS) predicted risk of mortality score.
Results: In total, 2530 isolated mitral valve repairs were included. Four surgeons made up the HV group and 7 were in the LV group. Baseline patient characteristics were similar between groups, however STS scores were slightly higher among the HV group (1.4% vs. 1.2%, p=0.009). HV surgeons had shorter aortic cross-clamp and total bypass times compared to LV surgeons (Panel A). However, there were no differences in morbidity and both operative mortality (1.0% vs. 1.4%, p=0.167) and O/E mortality ratio (0.5 vs. 0.8, p=0.167) were similar for HV and LV surgeons (Panel B).
Conclusion: Volume-outcome relationships for mitral valve repair may be mitigated in experienced centers. Decisions regarding volume limits for reimbursmenet should consider both institutional and individual minimum case thresholds.
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