This journal provides a comprehensive report on the status of mitral valve surgery at the VA during a 14-year period.
Reports questioning the quality and access to care at the US Department of Veterans Affairs (VA) have been constantly featured in the national press.1 In this issue of the Journal, Bakaeen and colleagues2 provide a comprehensive report on the status of mitral valve surgery at the VA during a 14-year period. This report, coauthored by some of the most experienced and skillful mitral valve surgeons in the country, supports the notion that veterans receive quality mitral valve surgery at the VA facilities. Mitral valve repair has been the preferred procedure for the surgical treatment of degenerative mitral valve disease. Repair is associated with excellent short- and long-term outcomes that compare very favorably with replacement.3 The superiority of mitral valve repair to replacement for other types of mitral valve pathology has not been as conclusively demonstrated.4 Because degenerative mitral valve disease is the most common form of mitral valve pathology requiring surgery, the rate of mitral valve repair is often use as a surrogate for the quality of the mitral valve surgery and for the expertise of the program and the surgeon.5, 6 Operative mortality, durability of the repair, and long-term survival are other indicators of the quality of mitral valve surgery. The Society of Thoracic Surgeons (STS) database executive summary, which provides a yearly update on the status of mitral valve surgery in the United States, reported 22,562 mitral valve surgeries in 2016.7 Of those, 54% were repairs. In the STS data, approximately one-third of patients undergoing mitral valve repairs and replacements had concomitant coronary artery bypass grafting (CABG). The unadjusted operative mortalities were slightly more than 1% for isolated mitral valve repairs and less than 5% for repairs with concomitant CABG. The operative mortalities for mitral valve replacements were higher: 5% for isolated mitral valve replacement and 9.5% for mitral valve replacement with concomitant CABG. These numbers are a useful, although imperfect, comparator to the results presented in the report of Bakaeen and colleagues.2 Bakaeen and colleagues2 showed that the volume of mitral valve surgery in the VA is low with a median number of 7 surgeries per institution per year. Despite that low volume, the number of mitral valve repairs increased with time, with 63% of patients receiving mitral valve repairs in 2014. Although, the rate of successful to failed repairs is not provided, it is encouraging to note that the overall rate of mitral valve repair at the VA system is greater than the national average. That trend was seen for all types of mitral valve pathologies except for endocarditis. Interestingly, the rate of repair was not associated with the volume of mitral valve surgery at each VA medical center. This observation is at odds with previous reports, which demonstrated an association between surgeon volume and repair rates.5 This discrepancy may be easily explained: surgeries performed at the VA are only part of these surgeons’ practice. Many VA hospitals are affiliated with large academic medical centers, from where experienced mitral valve surgeons bring their non–VA acquired expertise to the VA. Finally, the most absolute of all outcomes is mortality. At the VA, the operative mortalities were 3.5% for mitral valve repair and 4.8% for mitral valve replacement. Although these numbers would be considered very high for isolated mitral valve procedures, they can be compared favorably with the STS database figures, because 45% of the mitral valve surgeries in the report of Bakaeen and colleagues2 were performed concomitantly with CABG. One could infer that the mortality for a comparable group of patients would be somewhere in the middle between isolated procedures with and without CABG. No data are provided on the durability of the repair, the rate of reoperations, or long-term echocardiography, and that is a deficiency of this report. The long-term survival of patients with mitral valve repair, however, was superior to replacement for the overall cohort and for patients with degenerative mitral valve disease. The overall results of this study shows that, despite the low volume of each individual VA hospital, mitral valve surgery is achieved with results that are comparable to those achieved nationally in nongovernment facilities that report to the STS database. These are encouraging results that demonstrate that those who have sacrificed their lives for their country receive quality mitral valve care at the VA. Of course, the quest for quality improvement is never-ending, and there is room for further improvement in the quality of mitral valve surgery both at the VA and at non-VA facilities.
Crestanello, Juan A. (2018). Quality of mitral valve surgery at the United States Department of Veterans Affairs, Journal of thoracic and cardiovascular surgery, Vol: 155 (1), p.80-81.