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Mitral Valve Surgery Volume vs. Outcomes
Quick Takes
- Higher hospital volume and higher surgeon volume were associated with lower 30-day and 1-year mortality, lower 30-day composite mortality plus morbidity, and higher rate of successful repair among patients who undergo mitral valve repair or replacement for primary mitral regurgitation.
- A relationship was not demonstrated between volume and mitral reoperation or hospitalization for heart failure.
Study Questions:
Is there a relationship between hospital- and surgeon-level volume and 30-day and 1-year outcomes among patients in the United States who undergo mitral valve repair or replacement (MVRR) for primary mitral regurgitation (MR)?
Methods:
In a multicenter, cross-sectional, observational study, the Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to identify patients undergoing isolated MVRR for primary MR in the United States from July 1, 2011, to December 31, 2016; with data linked to the Centers for Medicare and Medicaid Services. The primary outcome was 30-day in-hospital operative mortality after isolated MVRR for primary MR. Secondary outcomes were 30-day composite mortality plus morbidity (any occurrence of bleeding, stroke, prolonged ventilation, renal failure, or deep wound infection), rate of successful mitral valve repair of primary MR (residual MR ≤ mild [1+]), and 1-year mortality, reoperation, and rehospitalization for heart failure.
Results:
A total of 55,311 patients, 1,094 hospitals, and 2,410 surgeons were identified. Increasing hospital and surgeon volumes were associated with lower risk-adjusted 30-day mortality, lower 30-day composite mortality plus morbidity, and higher rate of successful repair. The lowest vs. highest hospital volume quartile had higher 1-year risk-adjusted mortality (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.31-1.98), but not mitral reoperation (odds ratio [OR], 1.51; 95% CI, 0.81-2.78) or hospitalization for heart failure (HR, 1.25; 95% CI, 0.96-1.64). The surgeon-level 1-year volume-outcome associations were similar for mortality (HR, 1.60; 95% CI, 1.32-1.94), but not significant for mitral reoperation (HR, 1.14; 95% CI, 0.60-2.18) or hospitalization for heart failure (HR, 1.17; 95% CI, 0.91-1.50).
Conclusions:
National hospital- and surgeon-level inverse volume-outcome associations were observed for 30-day and 1-year mortality after mitral valve surgery for primary MR. The authors concluded that these findings may help to define access to experienced centers and surgeons for the management of primary MR.
Perspective:
A relationship between volume and outcome has been demonstrated for multiple complex cardiac procedures, including coronary artery bypass grafting, and both surgical and transcatheter aortic valve replacement; and earlier studies have demonstrated a relationship between higher hospital mitral surgery volume and the likelihood of mitral valve repair, and lower adjusted operative mortality. This large study using the Society of Thoracic Surgeons Adult Cardiac Surgery Database expands the relationship to show that both hospital volume and surgeon volume are associated with lower 30-day and 1-year mortality after intervention for primary MR. A 2019 multisociety expert consensus statement on caring for patients with valvular heart disease makes recommendations regarding levels of experience and patient referrals in order to optimize care for patients with heart valve disease. The present study provides additional data to reinforce that for patients with primary MR, patient care may be improved with referral to centers and surgeons with higher volumes.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease, Mitral Regurgitation
Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Heart Failure, Heart Valve Diseases, Hospital Mortality, Hospitals, High-Volume, Mitral Valve Insufficiency, Quality of Health Care, Renal Insufficiency, Reoperation, Stroke, Ventilation
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