The study’s senior author, David H. Adams, MD, with lead author Joanna Chikwe, MD.

Researchers at the Icahn School of Medicine at Mount Sinai have found that patients who undergo mitral valve operations with surgeons who perform more than 25 such procedures annually experience lower one-year mortality and reoperation rates when compared to individuals treated by surgeons who do fewer procedures. Significantly, those high-volume surgeons also were more likely to perform a valve repair—the preferred treatment that offers important clinical advantages, such as better life expectancy and quality of life—over a valve replacement with a mechanical or animal valve.

The findings were presented recently at the American Association for Thoracic Surgery Centennial meeting and simultaneously published online by the Journal of the American College of Cardiology.

In a normal heart, mitral valve leaflets open and close with each heartbeat to allow blood to flow in one direction from the upper collection chamber to the lower pumping chamber. In degenerative mitral valve disease, one or both leaflets prolapse, leading to the backward flow of blood (mitral valve regurgitation).

In the study, Mount Sinai researchers analyzed adult patients who underwent mitral valve surgery in New York State between 2002 and 2013—a population that included a cohort of 5,475 patients with degenerative disease—comparing repair rates, reoperations within 12 months of repair, and survival, based on total annual surgeon volume. In all, 313 surgeons from 41 institutions met the study’s criteria.

The findings showed that among surgeons who performed any mitral valve procedures, the median volume was 10 cases per year, with a mean valve repair rate of 55 percent. In the subgroup of patients with degenerative disease, the mean repair rate ranged from 77 percent for surgeons with total annual volumes of more than 51 cases, to 48 percent for surgeons who performed fewer than 10 cases. Other key results showed that surgeons who performed 25 or more surgeries annually had reoperation rates at 1.3 percent compared to 3.6 percent for surgeons doing fewer surgeries. Additionally, survival improved for every 10 additional cases.

“Our findings add further clarity to the American Heart Association and American College of Cardiology guidelines that already recognize that patients with degenerative mitral valve disease should be referred to experienced mitral surgeons whenever feasible,” says the study’s senior author, David H. Adams, MD, Cardiac Surgeon-in-Chief of the Mount Sinai Health System, and the Marie-Josée and Henry R. Kravis Professor and Chair of the Department of  Cardiovascular Surgery at the Icahn School of Medicine at Mount Sinai. “This is the first study to link individual surgeon volume to survival and freedom from reoperation at one year in patients undergoing operations for degenerative mitral valve disease.”

The study’s lead author, Joanna Chikwe, MD, Clinical Professor of Cardiovascular Surgery at the Icahn School of Medicine at Mount Sinai, and Professor of Surgery, Chief of Cardiothoracic Surgery, and Co-Director of the Heart Institute at Stony Brook School of Medicine, notes, “Considering that there was an incremental improvement in survival and probability of repair with increasing volume over 25 operations, one could make the argument that a minimum volume target of 50, or even more, annual operations would be optimal and particularly beneficial in patients with complex but repairable mitral valve disease.”

Elizabeth A. Howell, MD, MPP, Director of the new Women’s Health Research Institute, right, with Michael Brodman, MD, and Annetine C. Gelijns, PhD, JD.

The Icahn School of Medicine at Mount Sinai has created the Women’s Health Research Institute, with the mission of advancing science in women’s health. The Director of the Institute is a nationally recognized physician-scientist, Elizabeth A. Howell, MD, MPP, System Vice Chair of Research and Professor of Obstetrics, Gynecology and Reproductive Science, and Professor of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai.

“Developing a rigorous research program in women’s health is an essential component of the strategic plan of the Icahn School of Medicine at Mount Sinai, and a natural complement to Mount Sinai’s rapidly growing clinical services and fellowship training programs in this area,” says Eric J. Nestler, MD, PhD, Dean for Academic and Scientific Affairs, Director, The Friedman Brain Institute, and Nash Family Professor of Neuroscience.

Dr. Howell laid the groundwork for the Institute with the close collaboration of Michael Brodman, MD, Ellen and Howard C. Katz Chair and Professor, Obstetrics, Gynecology and Reproductive Science; and Annetine C. Gelijns, PhD, JD, Chair and Edmond A. Guggenheim Professor, Population Health Science and Policy. The two departments are co-sponsors of the new interdisciplinary Institute.

“I think that now is a great time for women’s health research,” says Dr. Howell. “You see a lot of clinical centers of care for women, but you do not see many that are focused on the science of women’s health.”

Two Centers of Excellence will provide the initial platform for achieving the Institute’s goals:

• The Center for Outcomes and Quality Research in Women’s Health

With particular attention to underserved populations, the Center will build upon Mount Sinai’s strong research portfolio on quality of care and outcomes, with a focus on developing and evaluating interventions to improve women’s health and wellness.

• The Center for Early Translational Research in Women’s Health

Drawing on the expertise of multiple departments, institutes, and programs, the Center will develop tools and core resources for translational research in genetics and immunology and build new diagnostic and treatment techniques for gynecologic cancers and other conditions in women’s health.

“The idea is that the same topic areas can be studied at both centers,” Dr. Howell says. “Looking at cervical cancer, for example, you can address screening, treatment practices, and patterns in health services. At the same time, you could be doing advanced work on tumor immunology and trying to find ways to diagnose it earlier and treat it more effectively. The centers will be very integrated, but you need both.”

The Institute is now seeking a director for the Center for Early Translational Research and recruiting senior and junior faculty members with expertise in women’s health, health services research, cancer research, and other complementary fields.  The Institute also hopes to establish the Women’s Health Scholars Program, recruiting residents and fellows to spend an additional year learning research methodology for a career in women’s health.

Dr. Howell sees strong potential for working with the centers across the institution, and she is already working closely with Stephanie V. Blank, MD, Director of Women’s Health at Mount Sinai Chelsea.  Dr. Blank will be the clinical lead for the Center for Early Translational Research in Women’s Health, and because she treats many patients with gynecologic cancer, “she will be one of the key people who can bring both our questions and our learning to the bedside,” Dr. Howell says.  Drs. Blank and Howell aim to build a strong ovarian cancer research program as part of this effort.

The Institute is also expanding and building on Dr. Howell’s work. Supported by grants from the National Institutes of Health, she leads research concerning maternal depression, outcomes for very low birth-weight babies, and the effect of hospital quality on severe complications and death in childbirth, which are persistently higher for black women and other ethnic minorities, compared with white women.

In a 2016 study published in the American Journal of Obstetrics & Gynecology, Dr. Howell’s team looked at 353,773 deliveries in 40 New York City hospitals from 2011 through 2013, and found that some of hospitals had rates of serious complications as low as 1 percent, while others had rates up to 6 percent. The study also found that 65 percent of white women delivered at hospitals with the lowest number of complications, and only 23 percent of black women did. “We need to figure out how to address these disparities, and why some hospitals are doing so much better than others,” Dr. Howell says.

“I am very interested in quality of care in general and how we measure it, how we improve it. Those kinds of issues—particularly in maternal and child health—resonate for me,” Dr. Howell says. The interest was present in her earliest days as at Harvard Medical School, when she had a neonatal rotation, caring for infants who were “so small and fragile” and who faced a lifetime of potential complications. Looking at the bigger picture, she also earned a master’s degree in Public Policy at Harvard’s John F. Kennedy School of Government, writing her thesis on infant mortality.

“I always knew that I love patient care,” Dr. Howell says, “but I also knew that I wanted to have a broader impact if I could.”