Is Mitral Valve Repair a Specialty?

Is mitral valve repair a specialty? Yes, contend three Cleveland Clinic cardiothoracic surgeons in a recent editorial in the Journal of the American College of Cardiology (JACC).

“The ‘jack of all trades’ cardiac surgeon represents an outmoded, unattainable ideal,” write the editorialists — A. Marc Gillinov, MD; Stephanie Mick, MD; and Rakesh Suri, MD, DPhil. “Excellence requires specialization,” they continue, noting that “[t]oday, trainees often choose to focus on particular areas within cardiac surgery: these include thoracic aortic disease, heart failure, congenital heart surgery, and transcatheter aortic valve replacement. Practicing surgeons should do the same…[and] mitral valve repair should be added to this list of specialties.”

Fueled by a new data analysis

Their editorial comes in the wake of an analysis of a mandatory New York State database published in JACC showing that cardiac surgeons who perform fewer than 25 mitral valve operations a year were significantly more likely to replace, rather than repair, mitral valves in patients with degenerative disease than were their counterparts who do 25 or more mitral valve surgeries a year. Patients of the lower-volume surgeons also had significantly worse survival and significantly higher reoperation rates compared with patients of high-volume surgeons.

The analysis focused on mitral valve repair rates because repair is established as conferring superior outcomes in degenerative mitral valve disease compared with replacement. The investigators, from the Icahn School of Medicine at Mount Sinai and Stony Brook University Hospital, found that operators with 10 or fewer mitral valve cases annually had a mean repair rate of 48 percent while those with more than 50 cases annually had a mean repair rate of 77 percent (P < .001).

The Cleveland Clinic editorialists note that “no examination of this topic has ever found…that surgeons’ volume or experience fails to influence repair rates and results. The weight of these data strongly supports the notion that valve repair for degenerative disease is a specialty.”

Two more key questions

The editorialists go on to observe that this conclusion gives rise to two related questions of great import to patients and providers alike:

1. Which surgeons should operate on patients with degenerative mitral valve disease? Acknowledging that the answer to this question can seem self-serving, the editorialists (all of whom are mitral valve repair specialists) point out that the primary consideration must be improved patient care, regardless of perceptions. They add that there is no barrier to surgeons who desire to develop expertise in mitral valve repair, and that this can be done via numerous opportunities to study with expert mitral valve surgeons around the nation and the world. Once a surgeon has developed mitral valve expertise, they recommend a minimum volume of 25 mitral operations a year (averaged over a three-year period) as “a good threshold” for maintaining and further developing expertise.
2. Does the hospital matter? Yes, according to the editorialists. “In addition to a focused surgeon, the hospital must have cardiologists interested in mitral valve disease and state-of-the-art intraoperative 2- and 3-dimensional transesophageal echocardiography,” they write. They support this conclusion by noting that the new JACC study of the New York State database found that “lower-volume surgeons who operate in the same institution as higher-volume surgeons benefit from this situation and achieve higher repair rates than do surgeons operating in other institutions.”

Bottom line: Volume matters

The Cleveland Clinic editorialists concede that while their recommendation for overt specialization in mitral valve repair will generate controversy, it is fundamentally a data-driven position. “Surgeon volume matters,” they conclude.

Read the full editorial by Drs. Gillinov, Mick and Suri here.