Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia.
Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Ann Thorac Surg. 2024 Feb;117(2):361-368. doi: 10.1016/j.athoracsur.2022.07.036. Epub 2022 Aug 7.
The adoption of transcatheter aortic valve replacement led to the development of appropriate use criteria (AUC) for transcatheter and surgical aortic valve replacement (SAVR) for aortic stenosis in 2017. This study hypothesized that appropriateness of SAVR improved after publication of AUC.
All patients undergoing isolated SAVR for severe aortic stenosis in a regional cardiac surgical quality collaborative were evaluated using data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2021). After excluding endocarditis and emergency cases, appropriateness of SAVR (rarely appropriate, may be appropriate, or appropriate) was assigned to patients by using established criteria. The relationship of appropriateness with publication of AUC was assessed, as was variation in appropriateness over time and by center.
Of 3035 patients across 17 centers, 106 (3.5%) underwent SAVR for an indication identified as rarely appropriate or may be appropriate. Patients who underwent SAVR for rarely or may be appropriate indications were significantly more likely to experience operative mortality (5.7% vs 1.6%, P = .001) as well as major morbidity (21.7% vs 10.5%, P < .001). Performance of rarely or may be appropriate SAVR significantly decreased over time (slope -0.51%/year, P trend < .001), and it was decreased after the release of the AUC (before release, 3.83% vs after release, 2.06%; P = .036). Substantial interhospital variation in appropriateness was observed (range of may be or rarely appropriate SAVR, 0%-10%).
The majority of isolated SAVR for aortic stenosis was appropriate according to the 2017 AUC. Appropriateness improved after publication of AUC, and this improvement was associated with a significant reduction of major morbidity and mortality.
2017 年，经导管主动脉瓣置换术的应用推动了经导管主动脉瓣置换术和外科主动脉瓣置换术（SAVR）治疗主动脉瓣狭窄的适宜性使用标准（AUC）的制定。本研究假设 AUC 公布后，SAVR 的适宜性会提高。
利用胸外科医师学会成人心脏外科学数据库（2011-2021 年）的数据，评估了一个区域性心脏手术质量协作机构中所有接受单纯 SAVR 治疗严重主动脉瓣狭窄的患者。排除心内膜炎和急诊病例后，采用既定标准为患者分配 SAVR 的适宜性（很少适宜、可能适宜或适宜）。评估了适宜性与 AUC 公布的关系，以及随时间和中心的适宜性变化。
在 17 个中心的 3035 例患者中，有 106 例（3.5%）因被认为很少适宜或可能适宜的指征而行 SAVR。因很少或可能适宜的指征而行 SAVR 的患者，其手术死亡率（5.7%比 1.6%，P=.001）和主要发病率（21.7%比 10.5%，P<.001）显著更高。很少或可能适宜的 SAVR 实施率随时间显著下降（斜率为-0.51%/年，P趋势<.001），并且在 AUC 公布后下降（公布前为 3.83%，公布后为 2.06%；P=.036）。适宜性方面存在显著的医院间差异（适宜性 SAVR 的范围为 0%-10%）。
根据 2017 年 AUC，大多数孤立性 SAVR 治疗主动脉瓣狭窄是适宜的。AUC 公布后，适宜性提高，这与主要发病率和死亡率的显著降低有关。
