Mitral Valve Repair: “An Opportunity for Quality Improvement”

Even in low-volume VA centers, mitral valve repair outcomes best replacement.

A large multi-center study presented at the 96th American Association for Thoracic Surgery Annual Meeting followed trends in mitral valve (MV) surgeries in the Veterans Administration Health System from 2001-2013 and provided further evidence to support the use of mitral valve repair over mitral valve replacement in patients with degenerative MV disease.

"MVRepair has a greater short-term protective effect against mortality than MVReplace has in patients with primary degenerative MR," write the authors. "Despite this survival advantage, the rate of MVRepair is low at some centers; therefore, there is clearly an opportunity for quality improvement."

Beyond a survival advantage, mitral valve repair was also found to result in fewer complications and shorter hospital stays.

Is that success dependent on volume? Not necessarily.

"Other studies have suggested that MV surgery volume is a significant predictor of greater MV repair use and better mitral surgery outcomes," says the AATS press release. "In fact, some reports have specified that 40 MV repairs per year should be the minimum number performed annually to maintain a high level of care."

But in the VA study, annual MV procedural volume varied widely: from 0 to 29, with a median of only 7---well below the 40 case benchmark.

Lower volumes had little effect on both rates of MV repair and outcomes. "Center volume explained only 19 percent of the total variation in facility-level MVRepair rates after adjustment for case mix," write the authors.

But is the VA different? Maybe.

"The shared-faculty model and educational collaboration that exists between some VAs and their academic affiliates may help mitigate these hospitals' low-volume status, which would explain their good MV outcomes," says lead author Faisal G. Bakaeen, MD.

All VA cardiac programs are affiliated with academic centers, according to Dr. Bakaeen.

"Nevertheless, he suggests that determining why MV repair rates are very low in some VA hospitals presents an opportunity for quality improvement," says the press release.

In the VA and beyond, "current clinical practice remains suboptimal for many patients."

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A 2010 review published in the European Heart Journal explores the need for a "best practice revolution" for the care of degenerative mitral valves.

"Despite surgical progress seen in increasing repair rates, lower mortality rates, and less invasive approaches, far too many patients continue to be subjected to unnecessary valve replacement procedures," write the authors.

Are there obstacles to mitral valve repair procedures in your organization? Leave a comment!

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