Traversing the Learning Curve Associated with a New Minimal Access Aortic Valve Replacement Service

OBJECTIVE: Isolated aortic valve replacement is a safe and frequently performed cardiac surgical procedure. Although minimal access approaches including right anterior thoracotomy and partial sternotomy have been adopted by some surgeons in recent years, concerns about additional procedural morbidity and mortality during the early phase of the learning curve persist. The aim of this study was to assess the impact of the learning curve on outcomes for a single surgeon implementing a new minimal access aortic valve replacement service. METHODS: Ninety-three patients undergoing minimal access aortic valve replacement performed by a single surgeon in our institution between October 2014 and March 2019 were analysed. Patients were divided into tertiles according to procedure order. Endpoints included peri-operative mortality and post-operative complications, and these were compared across tertiles to assess the impact of the learning curve on procedural outcomes. RESULTS: Overall in-hospital mortality was 2.15% (n=2). Despite significantly longer cardiopulmonary bypass and cross-clamp duration in the early tertile, there was no significant difference in the rate of post-operative complications, post-operative length of stay or in-hospital mortality between tertiles. CONCLUSIONS: Although our results have demonstrated a significant learning curve effect associated with the introduction of this minimally invasive approach to aortic valve replacement, as demonstrated by the significant reduction in cardiopulmonary bypass and cross-clamp duration over time, our findings suggest that a minimal access aortic valve replacement service can be safely commenced by an experienced surgeon without concerns about the learning curve significantly affecting post-operative morbidity and mortality.