Learning Curve Analysis Of Full Endoscopic Non-rib Spreading Mitral Valve Surgery
Giacomo Bianchi, MD, PhD, Rafik Margaryan, MD, PhD, Marco Solinas, MD, PhD.
Ospedale del Cuore - Fondazione Toscana, Massa, Italy.
Objective:This study aims to elucidate the learning curve of full endoscopic non-rib spreading (eNRS) mitral valve surgery in anInstitution already proficient with standard video-assisted minimally invasive valve surgery (sMIMVS).
Methods: From July 2015 to April 2017 100 patients underwent eNRS mitral valve surgery. A CUSUM curve analysis was performedagainst surgical failure defined as the occurrence of one or more of the following events: 1) perioperative death; 2)intraoperative conversion to sternotomy; 3) perioperative myocardial infarction (new Q-waves >0.04 ms and/or reduction in R-waves >25% in at least two contiguous leads on electrocardiogram); 4) perioperative aortic dissection; 5) stroke (defined as rankin modified scale score >=2); 6) in-hospital reoperation for any cause. Also we considered surgical procedure end-points of failure as the occurrence of one or more of the followings: 1) cardiopulmonary bypass (CPB) time, cross-clamp (X-clamp) and preparation time exceeding 95th percentile of sMIMVS approach from historical database.
Results:Surgical failure criteria were meet in 4 patients (4%) in the early phase; CUSUM curve analysis (fig 1A) confirmed that the process was always in control and crossed the lower boundary at 52 cases. Surgical preparation (fig 1B) as well as CPB time (fig 1C) and cross clamp time (fig 1D) were also always in control and the lower boundary crossed after 45, 50 and 45 patients, respectively.
Conclusions:In a center already proficient with video-assisted minimally invasive mitral valve surgery, switching towards full endoscopic approach is feasible and safe, as showed by CUSUM analysis, with a minimal learning curve and always under control. 
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