Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown.
Division of Cardiology, Duke University, Durham, North Carolina.
JAMA Cardiol. 2020 Oct 1;5(10):1092-1101. doi: 10.1001/jamacardio.2020.2221.
Early surgery for severe primary degenerative mitral regurgitation is recommended, provided optimal outcomes are achievable. Contemporary national data defining mitral valve surgery volume and outcomes are lacking.
To assess national 30-day and 1-year outcomes of mitral valve surgery and define the hospital- and surgeon-level volume-outcome association with mitral valve repair or replacement (MVRR) in patients with primary mitral regurgitation.
DESIGN, SETTING, AND PARTICIPANTS: This multicenter cross-sectional observational study used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to identify patients undergoing isolated MVRR for primary mitral regurgitation in the United States. Operative data were collected from July 1, 2011, to December 31, 2016, and analyzed from March 1 to July 1, 2019, with data linked to the Centers for Medicare and Medicaid Services.
The primary outcome was 30-day in-hospital operative mortality after isolated MVRR for primary mitral regurgitation. Secondary outcomes were 30-day composite mortality plus morbidity (any occurrence of bleeding, stroke, prolonged ventilation, renal failure, or deep wound infection), rate of successful mitral valve repair of primary mitral regurgitation (residual mitral regurgitation of mild [1+] or better), and 1-year mortality, reoperation, and rehospitalization for heart failure.
A total of 55 311 patients, 1094 hospitals, and 2410 surgeons were identified. Increasing hospital and surgeon volumes were associated with lower risk-adjusted 30-day mortality, lower 30-day composite mortality plus morbidity, and higher rate of successful repair. The lowest vs highest hospital volume quartile had higher 1-year risk-adjusted mortality (hazard ratio [HR], 1.61, 95% CI, 1.31-1.98), but not mitral reoperation (odds ratio [OR], 1.51; 95% CI, 0.81-2.78) or hospitalization for heart failure (HR, 1.25; 95% CI, 0.96-1.64). The surgeon-level 1-year volume-outcome associations were similar for mortality (HR, 1.60; 95% CI, 1.32-1.94) but not significant for mitral reoperation (HR, 1.14; 95% CI, 0.60-2.18) or hospitalization for heart failure (HR, 1.17; 95% CI, 0.91-1.50).
National hospital- and surgeon-level inverse volume-outcome associations were observed for 30-day and 1-year mortality after mitral valve surgery for primary mitral regurgitation. These findings may help to define access to experienced centers and surgeons for the management of primary mitral regurgitation.
对于严重的原发性退行性二尖瓣反流，建议早期手术，前提是可以实现最佳结果。目前缺乏定义二尖瓣手术量和结果的全国性数据。
评估美国原发性二尖瓣反流患者二尖瓣手术的 30 天和 1 年结局，并定义二尖瓣修复或置换（MVRR）的医院和外科医生水平与容量-结局的关联。
设计、地点和参与者：这项多中心横断面观察性研究使用胸外科医师学会成人心脏手术数据库，在美国识别出接受原发性二尖瓣反流的孤立性 MVRR 的患者。从 2011 年 7 月 1 日至 2016 年 12 月 31 日收集手术数据，并从 2019 年 3 月 1 日至 7 月 1 日进行分析，数据与医疗保险和医疗补助服务中心相关联。
主要结局是原发性二尖瓣反流患者行孤立性 MVRR 后的 30 天院内手术死亡率。次要结局是 30 天复合死亡率加发病率（任何出血、中风、长时间通气、肾衰竭或深部伤口感染的发生）、原发性二尖瓣反流的成功二尖瓣修复率（残余二尖瓣反流为轻度[1+]或更好）以及 1 年死亡率、再次手术和因心力衰竭再次住院。
共确定了 55311 名患者、1094 家医院和 2410 名外科医生。随着医院和外科医生数量的增加，风险调整后的 30 天死亡率、30 天复合死亡率加发病率以及成功修复率降低。最低与最高医院容量四分位数相比，1 年风险调整死亡率更高（风险比[HR]，1.61，95%CI，1.31-1.98），但二尖瓣再次手术（比值比[OR]，1.51；95%CI，0.81-2.78）或因心力衰竭再次住院（HR，1.25；95%CI，0.96-1.64）的发生率并无差异。外科医生水平的 1 年容量-结局关联在死亡率方面相似（HR，1.60；95%CI，1.32-1.94），但二尖瓣再次手术（HR，1.14；95%CI，0.60-2.18）或因心力衰竭再次住院（HR，1.17；95%CI，0.91-1.50）的结果并不显著。
在原发性二尖瓣反流患者行二尖瓣手术后，观察到 30 天和 1 年死亡率的全国性医院和外科医生水平呈负相关。这些发现可能有助于确定获得经验丰富的中心和外科医生治疗原发性二尖瓣反流的机会。
