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Enhancing Departmental Quality Control in Minimally Invasive Aortic Valve Surgery: a Single Institution Experience
Michele Murzi, Alfredo G. Cerillo, Antonio Miceli, Stefano Bevilacqua, Marco Solinas, Pierandrea Farneti, Mattia Glauber.
G. Pasquinucci Heart Hospital, Massa, Italy.

OBJECTIVE: In recent years, there has been an increasing interest in monitoring the quality of cardiac surgical performance. The aim of the present study was to apply control charts (CUSUM curves) to monitor the performance of minimally invasive aortic valve procedures
to enhance quality control for that operation.
METHODS: A total of 586 minimally invasive aortic valve replacement (370 right minithoracotomy and 219 ministernotomy) were performed from 2006 to 2012 by six
surgeons (range 31-294 procedures) at a single institution. Institutional and individual surgeons’ performances were monitored using descriptive statistics and control charts, with a predetermined acceptable failure rate of 10% and calculated 80% alert and 95% alarm lines. Perioperative death or one or more of seven adverse events constituted failure.
RESULTS: The incidence of in-hospital mortality was 0.7% (4/586) and compared favourably with the predicted mortality (logistic EuroSCORE 5.3%). The incidence of stroke was 1.2% (7/586). Institutional CUSUM analysis revealed an initial learning curve and then the surgical process remained in control for all the study period. There were differences between surgeons with regard to the learning curves and perioperative complications (5.3-9.3%, P = 0.9). Five surgeons crossed the 95% reassurance boundary between operations 13 and 28 (figure). One surgeon crossed the 95% reassurance boundary after 57 operations. No surgeon crossed the 95% alarm line, which indicates unacceptably high failure rates.
CONCLUSIONS: Minimally invasive aortic valve surgery can be safely performed with low morbidity and mortality. CUSUM curve analysis is a simple statistical method to implement continuous individual and departmental performance monitoring.


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