A Learning Curve in Bentall and De Bono Procedure with the Use of the Risk-Adjusted Cumulative Sum Analysis Based on the Japan SCORE
Objective: The risk-adjusted cumulative sum analysis of an individual surgical learning curve for the Bentall and De Bono procedure on aortic root pathologies was used to monitor and enhance quality control.
Methods: From April 2004 to March 2009, 20 consecutive patients were operated upon by a single surgeon for aortic root pathologies by means of the Bentall and De Bono procedure. Operative variables, mortality, and major morbidities were analyzed. The learning curve was calculated using descriptive statistics and cumulative sum failure observed minus expected failure rate derived from the Japan SCORE calculator.
Results: In this series, the Japan SCORE calculator expected 3.91% ± 5.14% of 30-day operative mortality rate and 16.74 ± 13.47% of 30-day operative mortality and morbidity. In reality, there was no operative and in-hospital death. Major postoperative morbidity rate was 15.0% (3 patients). The risk-adjusted cumulative sum analysis revealed that the learning curve of mortality was downward below the lower 95% confidence interval throughout all the patients and that of morbidity was upward till the seventh case and remained downward thereafter. The polynomial approximation coefficient analysis revealed a significant negative correlation between aortic cross-clamp time, cardiopulmonary time, and operation time and case load.
Conclusions: The Bentall and De Bono procedure for aortic root pathologies was performed at the professionally permissive level from the beginning, even in a low-volume environment. It showed one good example of a learning curve. The risk-adjusted cumulative sum analysis based on the Japan SCORE was a very useful tool for monitoring the performance.
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