Trainee exposure to valve surgery in the UK: safety, decline and organisational inequality in a national cohort

Q: What are the key findings of this study?

Trainee-led isolated aortic and mitral valve surgeries were not associated with increased in-hospital mortality compared to consultant-led procedures.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Isolated aortic and mitral valve surgery (n=96907). Intervention: Trainee as primary operator vs. Consultant as primary operator. Primary outcome: In-hospital mortality (propensity-matched isolated AVR cohort) (p=<0.001).

Q: What does this research mean for the field?

Trainee-performed isolated aortic and mitral valve surgeries are not associated with increased in-hospital morbidity or mortality compared to consultant-led procedures, despite marked hospital- and consultant-level variation in trainee operating opportunities. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To evaluate temporal trends, early clinical outcomes, and hospital- and surgeon-level variation in surgical trainees performing isolated aortic valve replacement and mitral valve surgery in the UK.

Jeremy Chan; Maria Comanici; Pradeep Narayan; Tim Dong; Jeremy Chan

doi:10.1136/openhrt-2026-004389

July 1, 2026Open HeartOpen Access

Trainee exposure to valve surgery in the UK: safety, decline and organisational inequality in a national cohort

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Key result

Trainee-led aortic and mitral valve surgeries show no increase in in-hospital mortality vs consultant-led cases.

P<0.001
n=96,907

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Why the study?

Trends, early clinical outcomes, and variation in trainee involvement in isolated aortic and mitral valve surgery in the UK were not well characterized.

Does having a trainee as the primary operator worsen early clinical outcomes in adults undergoing isolated aortic or mitral valve surgery?

Key Points

To evaluate temporal trends, early clinical outcomes, and hospital- and surgeon-level variation in surgical trainees performing isolated aortic valve replacement and mitral valve surgery in the UK.
Analyzed all adults undergoing elective or urgent isolated aortic valve replacement (N=71 710) or isolated mitral valve surgery (N=25 197) in the UK National Adult Cardiac Surgery Audit between 1996 and 2019.
Used propensity score matching (generating cohorts of 13 432 aortic valve replacement, 1223 mitral valve replacement, and 1243 mitral valve repair pairs) to evaluate early postoperative outcomes.
Applied three-level multilevel logistic regression to measure hospital- and consultant-level variation in trainee first-operator status.
Trainees performed 18.7% of isolated aortic valve replacements (13 432 cases) and 9.8% of isolated mitral valve procedures (2472 cases), with exposure lowest in mitral valve repair at 8.1% (1246 cases).
In matched cohorts, trainee-led operations were not associated with increased in-hospital mortality in aortic valve replacement (1.2% vs 1.9%, p<0.001) or mitral valve repair (0.7% vs 1.6%, p=0.040), despite longer bypass time in aortic replacement (90 vs 84 min, p<0.001).
Multilevel models identified substantial provider-level variation in trainee operating opportunities, accounting for 59.6%, 57.1%, and 44.8% of the variation in aortic valve replacement, mitral valve repair, and mitral valve replacement, respectively.

Study Design

Type

Cohort (n=96,907)

Multicenter

Yes

Structured PICO

Does having a trainee as the primary operator worsen early clinical outcomes in adults undergoing isolated aortic or mitral valve surgery?

P

Population

96,907 adults undergoing elective or urgent isolated aortic or mitral valve surgery in the UK between 1996 and 2019.

E

Exposure

Isolated aortic valve replacement (AVR) or mitral valve (MV) surgery performed with a trainee as the primary operator.

C

Comparator

Isolated aortic valve replacement (AVR) or mitral valve (MV) surgery performed with a consultant as the primary operator.

O

Outcome

Annual proportion of isolated AVR, all isolated MVR and MVr recorded with a trainee as the primary operator, and early clinical outcomes (in-hospital mortality).safety

Main Result

Absolute Event Rate: 1.2% vs 1.9%

p-value: p=<0.001

Supervised trainee participation as primary operator in isolated aortic and mitral valve surgery is safe and not associated with worse early clinical outcomes, though trainee exposure is declining and varies significantly by hospital and consultant.

Limitations

Retrospective observational analysis of audit data
First-operator grade does not capture exact proportion of operation performed by trainee or intraoperative takeover
Unmeasured confounding such as valve anatomy, repair complexity, and frailty
Outcomes limited to early postoperative endpoints without long-term survival or valve durability data
Study period ended in April 2019, missing the effects of the COVID-19 pandemic and recent transcatheter valve therapy expansion
First-operator grade does not capture the exact proportion of the operation performed by the trainee, trainee seniority, or consultant scrubbed status
Unmeasured confounding such as valve anatomy, repair complexity, annular calcification, and frailty
Outcomes limited to early postoperative endpoints without long-term survival, valve durability, or patient-reported outcomes
Study period ended in April 2019, missing the effects of the COVID-19 pandemic and recent expansion of transcatheter valve therapies

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Implication

Supports supervised trainee primary operator roles in valve surgery; extends prior observational data but leaves optimal training allocation and long-term outcomes open.

Abstract

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.

Discussion

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Cite This Study

Chan et al. (2026) conducted a cohort in Isolated aortic and mitral valve surgery (n=96,907). Trainee as primary operator vs. Consultant as primary operator was evaluated on In-hospital mortality (propensity-matched isolated AVR cohort) (p=<0.001). Trainee-led isolated aortic and mitral valve surgeries were not associated with increased in-hospital mortality compared to consultant-led procedures.

synapsesocial.com/papers/6ac19d70aeea5716e8c6c6b6 https://doi.org/10.1136/openhrt-2026-004389

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Trainee exposure to valve surgery in the UK: safety, decline and organisational inequality in a national cohort

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Trainee exposure to valve surgery in the UK: safety, decline and organisational inequality in a national cohort

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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