Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Institute for Aging Research, Hebrew Senior Life, Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
JACC Cardiovasc Interv. 2020 Feb 10;13(3):335-343. doi: 10.1016/j.jcin.2019.09.048.
The aim of this study was to examine whether hospital surgical aortic valve replacement (SAVR) volume was associated with corresponding transcatheter aortic valve replacement (TAVR) outcomes.
Recent studies have demonstrated a volume-outcome relationship for TAVR.
In total, 208,400 fee-for-service Medicare beneficiaries were analyzed for all aortic valve replacement procedures from 2012 to 2015. Claims for patients <65 years of age, concomitant coronary artery bypass grafting surgery, other heart valve procedures, or other major open heart procedures were excluded, as were secondary admissions for aortic valve replacement. Hospital SAVR volumes were stratified on the basis of mean annual SAVR procedures during the study period. The primary outcomes were 30-day and 1-year post-operative TAVR survival. Adjusted survival following TAVR was assessed using multivariate Cox regression.
A total of 65,757 SAVR and 42,967 TAVR admissions were evaluated. Among TAVR procedures, 21.7% (n = 9,324) were performed at hospitals with <100 (group 1), 35.6% (n = 15,298) at centers with 100 to 199 (group 2), 22.9% (n = 9,828) at centers with 200 to 299 (group 3), and 19.8% (n = 8,517) at hospitals with ≥300 SAVR cases/year (group 4). Compared with group 4, 30-day TAVR mortality risk-adjusted odds ratios were 1.32 (95% confidence interval: 1.18 to 1.47) for group 1, 1.25 (95% confidence interval: 1.12 to 1.39) for group 2, and 1.08 (95% confidence interval: 0.82 to 1.25) for group 3. These adjusted survival differences in TAVR outcomes persisted at 1 year post-procedure.
Total hospital SAVR volume appears to be correlated with TAVR outcomes, with higher 30-day and 1-year mortality observed at low-volume centers. These data support the importance of a viable surgical program within the heart team, and the use of minimum SAVR hospital thresholds may be considered as an additional metric for TAVR performance.
本研究旨在探讨医院外科主动脉瓣置换术（SAVR）量与相应经导管主动脉瓣置换术（TAVR）结果之间的关系。
最近的研究表明 TAVR 存在量效关系。
2012 年至 2015 年，对所有主动脉瓣置换手术的 208400 名福利受益人均进行了分析。排除了年龄<65 岁、同时行冠状动脉旁路移植术、其他心脏瓣膜手术或其他大型心脏直视手术的患者，以及因主动脉瓣置换而再次入院的患者。根据研究期间平均每年 SAVR 手术量对医院 SAVR 量进行分层。主要结局是 30 天和 1 年 TAVR 术后生存率。采用多变量 Cox 回归评估 TAVR 后调整后的生存情况。
共评估了 65757 例 SAVR 和 42967 例 TAVR 入院患者。在 TAVR 手术中，21.7%（n=9324）在 SAVR 量<100 的医院进行（第 1 组），35.6%（n=15298）在 SAVR 量 100-199 的中心进行（第 2 组），22.9%（n=9828）在 SAVR 量 200-299 的中心进行（第 3 组），19.8%（n=8517）在 SAVR 量≥300 例/年的医院进行（第 4 组）。与第 4 组相比，第 1 组的 30 天 TAVR 死亡率风险调整比值比为 1.32（95%置信区间：1.18-1.47），第 2 组为 1.25（95%置信区间：1.12-1.39），第 3 组为 1.08（95%置信区间：0.82-1.25）。术后 1 年时，TAVR 结果的这些调整后生存差异仍然存在。
医院总 SAVR 量似乎与 TAVR 结果相关，低容量中心的 30 天和 1 年死亡率更高。这些数据支持心脏团队内可行的外科手术计划的重要性，并且可以考虑使用最低的 SAVR 医院阈值作为 TAVR 性能的附加指标。
