英国瓣膜手术培训：安全、下降及组织不平等

原文

Objective To evaluate trends, early clinical outcomes and surgeon-variation and hospital-variation in trainees performing isolated aortic valve replacement (AVR) and mitral valve (MV) surgery, including replacement (MVR) and MV repair (MVr) in the UK. Methods All adults undergoing elective or urgent isolated AVR or isolated MVr/MVR in the National Adult Cardiac Surgery Audit between 1996 and 2019 were included. Temporal trends and early clinical outcomes were compared between consultants and trainees as primary operators. Three-level multilevel logistic regression was used to quantify hospital-level and consultant-level variation in the proportion of cases performed by trainees. Results Among 71 710 isolated AVR and 25 197 isolated MV surgery cases, 13 432 (18.7%) and 2472 (9.8%) were performed by trainees, respectively. MV surgery included 9893 MVR and 15 292 MVr, of which 1226 (12.4%) and 1246 (8.1%) were performed by trainees, respectively. Propensity matching generated balanced cohorts of 13 432 AVR, 1223 MVR and 1243 MVr pairs. Trainee-led procedures were not associated with higher in-hospital morbidity or mortality. Multilevel modelling demonstrated substantial variation in trainees being the primary operator, with 59.6%, 57.1% and 44.8% of variation at hospital-level and surgeon-level for AVR, MVr and MVR, respectively. Conclusions In this national UK cohort, trainees performed approximately one in five isolated AVR operations and one in ten isolated MV operations. Trainee exposure was the lowest in MVr. Trainee-led procedures were not associated with an increase in in-hospital mortality or early morbidity. There was a marked hospital-level and consultant-level variation in trainees’ operating opportunities. These findings support continued structured exposure to isolated aortic and MV surgery, with particular attention to a specific MVr training pathway.