Fifteen-Year Outcome Trends for Valve Surgery in North America

doi:10.1016/j.athoracsur.2010.11.009

The Annals of Thoracic Surgery

Volume 91, Issue 3, March 2011, Pages 677-684

Presented at the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25–27, 2010.

https://doi.org/10.1016/j.athoracsur.2010.11.009 Get rights and content

Background

Although results in valvular heart surgery may be improving, too few cases are available in most centers to quantify changes, especially for uncommon procedural categories. This study examined comprehensively national trends in valve surgery outcomes over the past 15 years.

Methods

From 1993 through 2007, 623,039 valve procedures were grouped into single aortic (A), mitral (M), and tricuspid (T) operations, along with AM, MT, AT, and AMT multiple valves ± coronary artery bypass graft surgery. Pulmonary valve surgery was excluded. Trends in baseline characteristics were documented, and logistic regression adjusted for differences in patient profiles. Outcomes were expressed as unadjusted operative mortality, adjusted odds ratios for mortality, and a composite of mortality and major complications.

Results

Single valves comprised 89% of valve surgery and multiple valves, 11%. Preoperative patient risk profiles worsened over time. Mortality rates were higher for multiple valves, but all mortality rates fell significantly over the 15 years (p <0.001). The composite of mortality and major morbidity did not improve, however, largely because of increasing pulmonary/infectious complications. Overall, cardiac etiology accounted for 54% of deaths, and pulmonary/infectious etiologies for 16%. Cardiac etiology of death fell by 16% over time, but pulmonary death and complications increased by 78% and 39%, respectively.

Conclusions

Preoperative patient profiles for cardiac valve procedures have worsened over time. Risk-adjusted mortalities have fallen for all valve surgery, but remain higher for multiple valves. The finding of increasing pulmonary deaths and complications suggests that prevention and improved management of pulmonary and infectious complications could be an important focus for quality improvement.

Section snippets

Material and Methods

This study was performed with a waiver of informed consent by the Duke University Institutional Review Board for the purpose of surgical quality improvement by analysis of deidentified patient cohorts in the STS data set. The STS currently records more than 90% of adult cardiac surgery in North America with well-developed variable sets and certified software systems [20, 21]. Detailed definitions for preoperative risk factors and postoperative complications have can be viewed online (available

Trends in Patient Demographics

Over the 15 years, demographics changed significantly (Table 1). Average age rose slowly from 66.1 to 67.2 years, and percentages of younger patients (50 to 60 years) and older patients (more than 80 years) both increased. Currently, nearly 17% of valve surgery is performed in patients more than 80 years of age. Twelve percent of valve patients have a body mass index above 35, and this incidence has doubled over the last decade. Diabetes has increased by 7%, and hypertension by more than 20%.

Comment

The STS database has the advantage of excellent sample size, but studies can be limited by the detail of variables collected. Recently, the valve data set has been expanded, but many important aspects of patient characteristics and perioperative care are not available in the present analysis. Additionally, the data are viewed from quite a distance from each patient, and undefined confounding variables or treatment selection biases can complicate the interpretation of results. Thus, like most

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Original articleAdult cardiacFifteen-Year Outcome Trends for Valve Surgery in North America

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Trends in Patient Demographics

Comment

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Can J Cardiol

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Clin Chest Med

Original article
Adult cardiac
Fifteen-Year Outcome Trends for Valve Surgery in North America