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J Thorac Cardiovasc Surg. 2016 Dec;152(6):1537-1546.e1. doi: 10.1016/j.jtcvs.2016.04.094. Epub 2016 May 10.

Exploring the learning curve for minimally invasive sutureless aortic valve replacement.

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Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy. Electronic address:
Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.



The study objective was to assess the learning process and quality of care of right minithoracotomy aortic valve replacement with a sutureless bioprosthesis at a single institution.


We performed an analysis of the first 300 consecutive patients (aged 76 ± 6 years; logistic European System for Cardiac Operative Risk Evaluation 9 ± 6) who underwent sutureless valve implantation via a right minithoracotomy by 6 surgeons at the G. Pasquinucci Heart Hospital between 2011 and 2015. The learning curve was analyzed by dividing the study population into tertiles of 100 patients each. Departmental and individual learning curves were calculated using sequential probability cumulative sum failure analysis. Quality indicators were 2 composite end points reflecting the technical success and 30-day complications.


The overall mortality was 0.7% (2 patients). No significant differences were noted in terms of mortality and complications between tertiles. The sutureless valve was implanted successfully in 99% of patients (298/300). Cumulative sum analysis failed to identify any significant learning effects for technical success. Nevertheless, surgeons A, B, and C had a small initial learning curve, and surgeons D, E, and F did not, reflecting a trend toward a positive effect of cumulative institutional experience on the individual learning curve. The 30-day complications analysis revealed a cluster of failures at the beginning of the experience. This cluster prompted an internal audit and modification of the patients' selection process. Consecutively, the procedure returned in control.


Right minithoracotomy sutureless valve implantation can be performed safely without learning curve effects. Cumulative sum analysis is a valuable tool to describe and monitor the learning process. The analysis can identify periods of less than expected performance and alert the team to react.


aortic valve replacement; performance monitoring; sutureless aortic valve

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