Dataset Information

Volume-Outcome Association of Mitral Valve Surgery in the United States.

ABSTRACT:

Importance

Early surgery for severe primary degenerative mitral regurgitation is recommended, provided optimal outcomes are achievable. Contemporary national data defining mitral valve surgery volume and outcomes are lacking.

Objective

To assess national 30-day and 1-year outcomes of mitral valve surgery and define the hospital- and surgeon-level volume-outcome association with mitral valve repair or replacement (MVRR) in patients with primary mitral regurgitation.

Design, setting, and participants

This multicenter cross-sectional observational study used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to identify patients undergoing isolated MVRR for primary mitral regurgitation in the United States. Operative data were collected from July 1, 2011, to December 31, 2016, and analyzed from March 1 to July 1, 2019, with data linked to the Centers for Medicare and Medicaid Services.

Main outcomes and measures

The primary outcome was 30-day in-hospital operative mortality after isolated MVRR for primary mitral regurgitation. Secondary outcomes were 30-day composite mortality plus morbidity (any occurrence of bleeding, stroke, prolonged ventilation, renal failure, or deep wound infection), rate of successful mitral valve repair of primary mitral regurgitation (residual mitral regurgitation of mild [1+] or better), and 1-year mortality, reoperation, and rehospitalization for heart failure.

Results

A total of 55 311 patients, 1094 hospitals, and 2410 surgeons were identified. Increasing hospital and surgeon volumes were associated with lower risk-adjusted 30-day mortality, lower 30-day composite mortality plus morbidity, and higher rate of successful repair. The lowest vs highest hospital volume quartile had higher 1-year risk-adjusted mortality (hazard ratio [HR], 1.61, 95% CI, 1.31-1.98), but not mitral reoperation (odds ratio [OR], 1.51; 95% CI, 0.81-2.78) or hospitalization for heart failure (HR, 1.25; 95% CI, 0.96-1.64). The surgeon-level 1-year volume-outcome associations were similar for mortality (HR, 1.60; 95% CI, 1.32-1.94) but not significant for mitral reoperation (HR, 1.14; 95% CI, 0.60-2.18) or hospitalization for heart failure (HR, 1.17; 95% CI, 0.91-1.50).

Conclusions and relevance

National hospital- and surgeon-level inverse volume-outcome associations were observed for 30-day and 1-year mortality after mitral valve surgery for primary mitral regurgitation. These findings may help to define access to experienced centers and surgeons for the management of primary mitral regurgitation.

SUBMITTER: Badhwar V

PROVIDER: S-EPMC7330833 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:Importance:Volume metrics may have relevance in the evaluation of valve center expertise. However, a paucity of data exists regarding the quantity, volume, and geographic location of mitral valve (MV) surgical centers in the United States and the proportion of underserved populations they treat. Objectives:To evaluate the hospital, patient, and procedural characteristics of mitral valve repair or replacement (MVRR) in the United States as a function of hospital procedure volume. Design, Setting, and Participants:This cross-sectional, multicenter observational study was conducted from July 2014 to June 2018. Patients in the Society of Thoracic Surgeons Adult Cardiac Surgery Database undergoing any surgical procedure involving MVRR in the United States were included. Main Outcomes and Measures:Volume distribution of MVRR by hospital and hospital referral region. Results:There were 165?405 MVRRs performed in 1082 centers during the study period, of which 86?488 (52.3%) were MV repairs. There were 575 centers (53.1%) that performed 25 or more MVRRs per year. The geographic distribution of centers performing 25 or more MVRRs per year differed from those performing fewer than 25 MVRRs per year. Of 304 designated hospital referral regions, 235 (77.3%) had at least 1 center performing 25 or more MVRRs per year, representing accessibility to 1 or more such centers for 296.4 million of 320.1 million US residents (92.6% of the US population; Midwest, 60.0 million of 68.0 million [88.4%]; South, 112.6 million of 122.6 million [91.9%]; West, 68.6 million of 72.9 million [94.1%]; and Northeast, 54.9 million of 56.6 million [97.1%]). Of 304 hospital referral regions, 168 (55.3%) had at least 1 center performing 40 or more MVRRs per year, representing accessibility to 1 or more such centers for 259.8 million of 317.90 million (81.7%) of the US population (Midwest, 50.5 million of 67.9 million [74.5%]; South, 94.5 million of 121.1 million [78.1%]; West, 64.0 million of 72.8 million [88.0%]; Northeast, 50.1 million of 56.3 million [90.2%]). More black and Hispanic patients received operations in centers performing 25 or more MVRRs per year (22?984) vs those performing fewer than 25 MVRRs per year (3227), yet the proportion was higher in lower-volume centers (22?984 of 148?385 [15.5%] vs 3227 of 17?020 [19.0%]; P?<?.001). In centers performing 25 or more MVRRs per year vs fewer than 25 MVRRs per year, there was a lower percentage of Medicare and Medicaid patients (47?920 of 148?385 [32.3%] vs 6183 of 17?020 [.3%]; P?<?.001) and patients from rural zip codes (21?208 of 148?385 [14.3%] vs 3146 of 17?020 [18.5%]; P?<?.001). Conclusions and Relevance:Fifty-three percent of all centers performed 25 or more MVRRs per year, and 92.6% of the US population lived in an hospital referral region with at least 1 such center. Disparities in race/ethnicity, rurality, and insurance status exist among patients being treated at centers with different volumes. These data indicate that efforts to centralize care based on volume metrics will need to balance access vs quality.

Project description:BackgroundInitial studies have suggested the familial clustering of mitral valve prolapse, but most of them were either community based among unselected individuals or applied non-specific diagnostic criteria. Therefore little is known about the familial distribution of mitral regurgitation in a referral-type population with a more severe mitral valve prolapse phenotype. The objective of this study was to evaluate the presence of familial mitral regurgitation in patients undergoing surgery for mitral valve prolapse, differentiating patients with Barlow's disease, Barlow forme fruste and fibro-elastic deficiency.MethodsA total of 385 patients (62 ± 12 years, 63% men) who underwent surgery for mitral valve prolapse were contacted to assess cardiac family history systematically. Only the documented presence of mitral regurgitation was considered to define 'familial mitral regurgitation'. In the probands, the aetiology of mitral valve prolapse was defined by surgical observations.ResultsA total of 107 (28%) probands were classified as having Barlow's disease, 85 (22%) as Barlow forme fruste and 193 (50%) patients as fibro-elastic deficiency. In total, 51 patients (13%) reported a clear family history for mitral regurgitation; these patients were significantly younger, more often diagnosed with Barlow's disease and also reported more sudden death in their family as compared with 'sporadic mitral regurgitation'. In particular, 'familial mitral regurgitation' was reported in 28 patients with Barlow's disease (26%), 15 patients (8%) with fibro-elastic deficiency and eight (9%) with Barlow forme fruste (P < 0.001).ConclusionsIn a large cohort of patients operated for mitral valve prolapse, the self-reported prevalence of familial mitral regurgitation was 26% in patients with Barlow's disease and still 8% in patients with fibro-elastic deficiency, highlighting the importance of familial anamnesis and echocardiographic screening in all mitral valve prolapse patients.