Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Medical Scientist Training Program, Baylor College of Medicine, Houston, Texas; Department of Bioengineering, Rice University, Houston, Texas.
Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
J Surg Res. 2023 Jul;287:124-133. doi: 10.1016/j.jss.2023.01.007. Epub 2023 Mar 16.
Prosthesis choice during aortic valve replacement (AVR) weighs lifelong anticoagulation with mechanical valves (M-AVR) against structural valve degeneration in bioprosthetic valves (B-AVR).
The Nationwide Readmissions Database was queried to identify patients who underwent isolated surgical AVR between January 1, 2016 and December 31, 2018, stratifying by prothesis type. Propensity score matching was used to compare risk-adjusted outcomes. Readmission at 1 y was estimated with Kaplan-Meier (KM) analysis.
Patients (n = 109,744) who underwent AVR (90,574 B-AVR and 19,170 M-AVR) were included. B-AVR patients were older (median 68 versus 57 y; P < 0.001) and had more comorbidities (mean Elixhauser score: 11.8 versus 10.7; P < 0.001) compared to M-AVR patients. After matching (n = 36,951), there was no difference in age (58 versus 57 y; P = 0.6) and Elixhauser score (11.0 versus 10.8; P = 0.3). B-AVR patients had similar in-hospital mortality (2.3% versus 2.3%; P = 0.9) and cost (mean: $50,958 versus $51,200; P = 0.4) compared with M-AVR patients. However, B-AVR patients had shorter length of stay (8.3 versus 8.7 d; P < 0.001) and fewer readmissions at 30 d (10.3% versus 12.6%; P < 0.001) and 90 d (14.8% versus 17.8%; P < 0.001), and 1 y (P < 0.001, KM analysis). Patients undergoing B-AVR were less likely to be readmitted for bleeding or coagulopathy (5.7% versus 9.9%; P < 0.001) and effusions (9.1% versus 11.9%; P < 0.001).
B-AVR patients had similar early outcomes compared to M-AVR patients, but lower rates of readmission. Bleeding, coagulopathy, and effusions are drivers of excess readmissions in M-AVR patients. Readmission reduction strategies targeting bleeding and improved anticoagulation management are warranted in the first year following AVR.
在主动脉瓣置换术（AVR）中选择假体时，需要权衡终身使用机械瓣膜（M-AVR）进行抗凝与生物瓣（B-AVR）的结构性瓣膜退化。
从 2016 年 1 月 1 日至 2018 年 12 月 31 日，通过全国再入院数据库，对接受单纯外科 AVR 的患者进行分层，按假体类型进行分析。采用倾向评分匹配比较风险调整后的结果。通过 Kaplan-Meier（KM）分析估计 1 年时的再入院率。
共纳入 109744 例接受 AVR（90574 例 B-AVR 和 19170 例 M-AVR）的患者。与 M-AVR 患者相比，B-AVR 患者年龄更大（中位数 68 岁 vs. 57 岁；P<0.001），合并症更多（平均 Elixhauser 评分：11.8 分 vs. 10.7 分；P<0.001）。匹配后（n=36951），年龄（58 岁 vs. 57 岁；P=0.6）和 Elixhauser 评分（11.0 分 vs. 10.8 分；P=0.3）无差异。B-AVR 患者的院内死亡率（2.3% vs. 2.3%；P=0.9）和费用（平均：50958 美元 vs. 51200 美元；P=0.4）与 M-AVR 患者相似。然而，B-AVR 患者的住院时间更短（8.3 天 vs. 8.7 天；P<0.001），30 天（10.3% vs. 12.6%；P<0.001）、90 天（14.8% vs. 17.8%；P<0.001）和 1 年（P<0.001，KM 分析）的再入院率更低。B-AVR 患者因出血或凝血障碍（5.7% vs. 9.9%；P<0.001）和胸腔积液（9.1% vs. 11.9%；P<0.001）而再次入院的可能性较小。
与 M-AVR 患者相比，B-AVR 患者的早期结果相似，但再入院率较低。出血、凝血障碍和胸腔积液是 M-AVR 患者再次入院的主要原因。在 AVR 后第一年，应采取降低出血风险和改善抗凝管理的策略来减少再入院。
