Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.
Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
Ann Thorac Surg. 2023 Mar;115(3):600-610. doi: 10.1016/j.athoracsur.2022.12.024. Epub 2023 Jan 18.
Risk estimation for surgical intervention is an essential component of heart team shared decision-making. However, current mitral valve (MV) surgery risk models used in practice lack etiologic or procedural specificity. The purpose of this study was to establish a comprehensive method for assessment of operative risk of MV repair of primary mitral regurgitation (MR).
A novel etiology and procedure-specific algorithm identified 53,462 consecutive (July 2014 to June 2020) intention-to-treat MV repair patients with primary MR from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Risk models were fit for 30-day operative mortality, mortality and/or major morbidity, and conversion-to-replacement (CONV). As-treated mortality and morbidity models were derived separately.
Event rates for mortality (n = 619; 1.16%), mortality plus morbidity (n = 4746; 8.88%), and CONV (n = 3399; 6.36%) were low. Mortality was higher in CONV patients vs repair (3.18% vs 1.02%). All event rates were lower with increasing program volumes. The mortality risk model had excellent discrimination (AUC: 0.807) and calibration and confirmed very low mortality risk for isolated MV repair for primary MR, with mean mortality risk of 1.16% and median of 0.55% (interquartile range: 0.30%-1.17%) with 90th and 95th percentiles 2.48% and 3.99%, respectively. The mortality risk was <0.5% in patients <65 years of age, with 97% of the total population across age groups having a risk of <3%. Only 1 in 4 patients age 75 or older had >3% estimated risk of mortality.
This etiologic and procedure-specific risk model establishes that the contemporary mortality risk of MV repair for primary MR is <1% for the vast majority of patients.
手术干预风险评估是心脏团队共同决策的重要组成部分。然而，目前实践中使用的二尖瓣（MV）手术风险模型缺乏病因学或程序特异性。本研究旨在建立一种综合评估原发性二尖瓣反流（MR）MV 修复手术风险的方法。
从胸外科医师学会成人心脏手术数据库中，采用一种新颖的病因和程序特异性算法，确定了 53462 例连续（2014 年 7 月至 2020 年 6 月）原发性 MR 意图治疗的 MV 修复患者。为 30 天手术死亡率、死亡率和/或主要发病率以及转换为置换（CONV）风险模型拟合。分别得出按治疗死亡率和发病率模型。
死亡率（n=619；1.16%）、死亡率加发病率（n=4746；8.88%）和 CONV（n=3399；6.36%）的发生率较低。CONV 患者的死亡率高于修复患者（3.18%比 1.02%）。随着手术量的增加，所有的发生率都降低了。死亡率风险模型具有良好的区分度（AUC：0.807）和校准度，并证实了原发性 MR 的 MV 修复的死亡率风险非常低，平均死亡率风险为 1.16%，中位数为 0.55%（四分位间距：0.30%-1.17%），第 90 和 95 百分位分别为 2.48%和 3.99%。年龄<65 岁的患者死亡率风险<0.5%，97%的总人群在各年龄组中的死亡率风险<3%。年龄 75 岁或以上的患者中，只有 1/4 的患者估计死亡率风险>3%。
这种病因和程序特异性风险模型表明，对于绝大多数患者，原发性 MR 的 MV 修复的当代死亡率风险<1%。
