目的:多瓣膜心脏手术后的长期结局仍未得到充分评价。
方法:2008-2019年的Medicare行政索赔确定了接受多瓣膜手术的受益人。使用国际疾病分类和当前程序技术代码双重裁定手术特征。多变量灵活参数模型评估了生存的预测因子;进行回归标准化以预测年瓣膜体积的不同百分位数的标准化生存概率(SSP)。
结果:在涉及主动脉(AVS)的476,092例心脏手术中,二尖瓣(MVS),或三尖瓣(TVS)瓣膜,63,083(13.3%)被确定为涉及多瓣膜手术:22,884MVSTVS,30,697AVS+MVS,3443AVS+TVS和6059AVS+MVS+TVS。手术由2,922名外科医生在1,157家医院进行。为外科医生和医院计算年瓣膜体积(总AVS+MVS+TVS)。中位生存期因多瓣膜手术类型而异:MVS/TVS为8.09[7.90-8.24]年,在AVS/MVS中6.65[6.49-6.81]年,AVS/TVS中的5.77[5.37-6.13],和6.02[5.64-6.38]在AVS/MVS/TVS中。在合并的医院/外科医生体积百分位数之间计算SSP;随着合并的医院/外科医生体积百分位数的增加,SSP中位数增加:5%tile:5.77[5.58,5.98],25%瓷砖:6.18[6.07,6.28],50%瓷砖:6.56[6.44,6.68],75%瓷砖:6.86[6.75,6.97],和95%瓷砖:7.58[7.34,7.83]年,分别。
结论:多瓣膜手术类型不同,生存率差异显著,随着伴随干预措施的增加,情况恶化,随着每年医院和外科医生数量的增加,情况有了很大改善。医院容量与手术后3个月后死亡的早期危险改善相关),而外科医生的数量与死亡风险的改善相关,甚至持续到术后第一年。应考虑将多瓣膜病例转诊给高容量的医院和外科医生。
OBJECTIVE: Long-term outcomes after multi-valve cardiac surgery remain under-evaluated.
METHODS: Medicare administrative claims from 2008-2019 identified beneficiaries undergoing multi-valve surgery. Operative characteristics were doubly-adjudicated using International Classification of Diseases and Current Procedural Technology codes. A multivariable flexible parametric model evaluated predictors of survival; regression standardization was performed to predict standardized survival probabilities (SSP) at varying percentiles of annual valvar volume.
RESULTS: Of 476,092 cardiac surgeries involving the aortic (AVS), mitral (MVS), or tricuspid (TVS) valve, 63,083 (13.3%) were identified as involving multi-valve surgery: 22,884 MVS+TVS, 30,697 AVS+MVS, 3,443 AVS+TVS and 6,059 AVS+MVS+TVS. Surgery occurred at 1,157 hospitals by 2,922 surgeons. Annual valvar volume (total AVS+MVS+TVS) was tallied for surgeons and hospitals. Median survival varied substantially by type of multi-valve surgery: 8.09 [7.90-8.24] years in MVS/TVS, 6.65 [6.49-6.81] years in AVS/MVS, 5.77 [5.37-6.13] in AVS/TVS, and 6.02 [5.64-6.38] in AVS/MVS/TVS. SSPs were calculated across combined hospital/surgeon volume percentiles; the median SSP increased with increasing percentile of combined hospital/surgeon volume: 5%tile: 5.77 [5.58,5.98], 25%tile: 6.18 [6.07,6.28], 50%tile: 6.56 [6.44,6.68], 75%tile: 6.86 [6.75,6.97], and 95%tile: 7.58 [7.34,7.83] years, respectively.
CONCLUSIONS: Survival varied significantly by type of multi-valve surgery, worsened with addition of concomitant interventions and improved substantially with increasing annual hospital and surgeon volume. Hospital volume was associated with an improved early hazard for death that abated beyond 3 months post-surgery), while surgeon volume was associated with an improved hazard for death that persisted even beyond the first post-operative year. Consideration should be given to referring multi-valve cases to high-volume hospitals and surgeons.