Jamieson W R, Edwards F H, Schwartz M, Bero J W, Clark R E, Grover F L
Division of Cardiovascular Surgery, University of British Columbia, Vancouver, Canada.
Ann Thorac Surg. 1999 Apr;67(4):943-51. doi: 10.1016/s0003-4975(99)00175-7.
The Society of Thoracic Surgeons National Database Committee is committed to risk stratification and assessment as integral elements in the practice of cardiac operations. The National Cardiac Surgery Database was created to analyze data from subscribing institutions across the country. We analyzed the database for valve replacement procedures with and without coronary artery bypass grafting to determine trends in risk stratification.
The database contains complete records of 86,580 patients who had valve replacement procedures at the participating institutions between 1986 and 1995, inclusive. The 1995 harvest of data was conducted in late 1996 and available for evaluation in 1997. These records were used to conduct an in-depth analysis of risk factors associated with valve replacement and to provide prediction of operative death by using regression analysis. Regression models were made for six subgroups.
Adverse patient risk factors, including diabetes, hypertension and reoperation, but not ventricular function, increased over time. There were trends with regard to increasing age of the various population subsets. The types of prostheses used remained similar over time, with more mechanical prostheses than bioprostheses used for both aortic and mitral valve replacement. There was a trend toward increased use of bioprostheses in aortic replacements and decreased use in mitral replacements between 1991 and 1995 than between 1986 and 1990. The mortality rate was determined by patient subset for primary operation and reoperation and by urgency status. The modeling showed that the predicted and observed mortality correlated for all age groups and within patient subsets.
Risk modeling is a valuable tool for predicting the probability of operative death in any individual patient. This large, multiinstitutional database is capable of determining modern operative risk and should provide standards for acceptable care. The study illustrates the importance of risk stratification for early death both for the patient and the surgeon.
胸外科医师协会国家数据库委员会致力于将风险分层和评估作为心脏手术实践中的重要组成部分。创建国家心脏手术数据库是为了分析来自全国各参与机构的数据。我们分析了该数据库中进行瓣膜置换手术（无论是否同时进行冠状动脉旁路移植术）的数据，以确定风险分层的趋势。
该数据库包含了1986年至1995年（含）期间在参与机构接受瓣膜置换手术的86,580例患者的完整记录。1995年的数据收集工作于1996年末进行，并于1997年可供评估。这些记录用于对与瓣膜置换相关的风险因素进行深入分析，并通过回归分析预测手术死亡率。针对六个亚组建立了回归模型。
不良患者风险因素，包括糖尿病、高血压和再次手术，但不包括心室功能，随时间增加。各人群亚组的年龄呈上升趋势。随着时间的推移，所使用的假体类型保持相似，在主动脉瓣和二尖瓣置换中，使用的机械假体比生物假体更多。1991年至1995年期间与1986年至1990年期间相比，主动脉置换中生物假体的使用有增加趋势，二尖瓣置换中生物假体的使用有减少趋势。死亡率由初次手术和再次手术的患者亚组以及紧急程度决定。模型显示，所有年龄组和患者亚组的预测死亡率与观察到的死亡率相关。
风险建模是预测任何个体患者手术死亡概率的有价值工具。这个大型的多机构数据库能够确定现代手术风险，并应为可接受的医疗提供标准。该研究说明了风险分层对患者和外科医生早期死亡的重要性。
