It is axiomatic that a repair surgeon must be adequately trained and experienced. He or she must also be backed up by a comprehensive and efficient system including intensive treatment units (ITUs), other specialties (renal disease, neurologists) and imaging. A number of studies have retrospectively explored the effect of surgeon and hospital activity as surrogates of these quality measures on mortality and repair rates.
Surgical volume
Bolling et al.22 showed that centre-based repair rates could be explained by individual surgeon volumes. This study involved 28,507 patients undergoing isolated mitral valve surgery by 1,088 surgeons at 639 hospitals in the USA between January 2005 and December 2007. Repair rates averaged 41% (range 0–100%). While substantial variability in repair rates was observed among low-volume surgeons, increased surgeon-level mitral volume above a threshold of 40 cases p.a. was independently associated with an increased probability of mitral repair. It is possible that some low-volume surgeons only accepted easy repairs while some high-volume surgeons were attempting difficult repairs. It is also likely that the expertise of surgeons must differ regardless of volume.
Aortic valve service
The effect of procedural volume is also observed in relation to aortic valve replacement25 with a mortality rate of 9.1% for surgeons with annual volumes of less than 22 cases compared with a rate of 6.5% for those with annual volumes exceeding 42 cases.
Endocarditis service
Mortality remains high, between 11 and 35%26 and is reduced by:
- Early diagnosis.
- Timely recognition of the need for surgery.
- Early surgery once indicated.27
A multidisciplinary specialist approach has also been shown to improve outcome.28–30 Botelho-Nevers et al.29 showed a fall in one year mortality from 18.5% to 8.2% and is widely accepted as best-practice.
It may often be appropriate to transfer cases for specialist assessment at the surgical centre and continuing care to then occur at the referring hospital.
Increasing numbers of cases result from infection of pacing devices (see figure 5) so an electrophysiologist specialising in extractions is essential.31
Courtesy of Professor John Chambers
Education is particularly important for those at high-risk of endocarditis, notably after valve replacement or prior endocarditis. In these patients, the index operation or illness should not be seen as an isolated event but the beginning of a continuum of care including maintenance of good oral hygiene and preventive dental surveillance.
Recent evidence suggests that surgery should be available within 48 hours if there is severe valve disease with large mobile vegetations.32
If surgery is not performed as an inpatient, it is essential to arrange outpatient follow-up, usually at one, three, six and 12 months after discharge.29–30 About 10% of patients initially managed conservatively require surgery in the first year. Repair may be more successful if delayed until the valve has healed.33 Without meticulous surveillance, surgery may be required after readmission in heart failure when the outcome is worse than for elective surgery.
Ideally the possibility of outpatient antibiotic treatment (OPAT) should be available.
There should be an agreed policy on treatment of a second episode of endocarditis in an individual who continues intravenous drug use despite involvement in a rehabilitation programme.34
