Northwestern University Medical Center, Chicago, Illinois, USA.
Ann Thorac Surg. 2011 Mar;91(3):677-84; discussion p 684. doi: 10.1016/j.athoracsur.2010.11.009.
Although results in valvular heart surgery may be improving, too few cases are available in most centers to quantify changes, especially for uncommon procedural categories. This study examined comprehensively national trends in valve surgery outcomes over the past 15 years.
From 1993 through 2007, 623,039 valve procedures were grouped into single aortic (A), mitral (M), and tricuspid (T) operations, along with AM, MT, AT, and AMT multiple valves ± coronary artery bypass graft surgery. Pulmonary valve surgery was excluded. Trends in baseline characteristics were documented, and logistic regression adjusted for differences in patient profiles. Outcomes were expressed as unadjusted operative mortality, adjusted odds ratios for mortality, and a composite of mortality and major complications.
Single valves comprised 89% of valve surgery and multiple valves, 11%. Preoperative patient risk profiles worsened over time. Mortality rates were higher for multiple valves, but all mortality rates fell significantly over the 15 years (p <0.001). The composite of mortality and major morbidity did not improve, however, largely because of increasing pulmonary/infectious complications. Overall, cardiac etiology accounted for 54% of deaths, and pulmonary/infectious etiologies for 16%. Cardiac etiology of death fell by 16% over time, but pulmonary death and complications increased by 78% and 39%, respectively.
Preoperative patient profiles for cardiac valve procedures have worsened over time. Risk-adjusted mortalities have fallen for all valve surgery, but remain higher for multiple valves. The finding of increasing pulmonary deaths and complications suggests that prevention and improved management of pulmonary and infectious complications could be an important focus for quality improvement.
尽管心脏瓣膜手术的效果可能在不断提高，但大多数中心的病例数仍然太少，无法量化手术效果的变化，特别是对于罕见的手术类型。本研究全面调查了过去 15 年中全国范围内瓣膜手术结果的变化趋势。
从 1993 年至 2007 年，623039 例瓣膜手术分为单纯主动脉瓣（A）、二尖瓣（M）和三尖瓣（T）手术，以及 A、M、T 和 AM、MT、AT、AMT 多瓣膜手术±冠状动脉旁路移植术。不包括肺动脉瓣手术。记录基线特征的变化趋势，并采用逻辑回归调整患者特征的差异。结果表示为未调整的手术死亡率、死亡率的调整比值比和死亡率与主要并发症的复合结果。
单纯瓣膜手术占瓣膜手术的 89%，多瓣膜手术占 11%。随着时间的推移，术前患者的风险特征逐渐恶化。多瓣膜手术的死亡率更高，但所有死亡率在 15 年内均显著下降（p<0.001）。然而，死亡率和主要发病率的复合结果并没有改善，主要是因为肺部/感染性并发症的增加。总的来说，心脏病因占死亡的 54%，肺部/感染性病因占 16%。心脏病因的死亡率随时间呈下降趋势，但肺部死亡和并发症分别增加了 78%和 39%。
随着时间的推移，心脏瓣膜手术患者的术前特征逐渐恶化。所有瓣膜手术的风险调整死亡率均有所下降，但多瓣膜手术的死亡率仍然较高。肺部死亡和并发症的增加表明，预防和改善肺部和感染性并发症的管理可能是质量改进的一个重要重点。
