The Evolving Landscape of Impella Use in the United States Among Patients Undergoing Percutaneous Coronary Intervention With Mechanical Circulatory Support.

BACKGROUND: Impella was approved for mechanical circulatory support (MCS) in 2008, but large-scale, real-world data on its use are lacking. Our objective was to describe trends and variations in Impella use, clinical outcomes, and costs across US hospitals in patients undergoing percutaneous coronary intervention (PCI) treated with MCS (Impella or intra-aortic balloon pump). METHODS: From the Premier Healthcare Database, we analyzed 48 306 patients undergoing PCI with MCS at 432 hospitals between January 2004 and December 2016. Association analyses were performed at 3 levels: time period, hospital, and patient. Hierarchical models with propensity adjustment were used for association analyses. We examined trends and variations in the proportion of Impella use, and associated clinical outcomes (in-hospital mortality, bleeding requiring transfusion, acute kidney injury, stroke, length of stay, and hospital costs). RESULTS: Among patients undergoing PCI treated with MCS, 4782 (9.9%) received Impella; its use increased over time, reaching 31.9% of MCS in 2016. There was wide variation in Impella use across hospitals (>5-fold variation). Specifically, among patients receiving Impella, there was a wide variation in outcomes of bleeding (>2.5-fold variation), and death, acute kidney injury, and stroke (all ≈1.5-fold variation). Adverse outcomes and costs were higher in the Impella era (years 2008-2016) versus the pre-Impella era (years 2004-2007). Hospitals with higher Impella use had higher rates of adverse outcomes and costs. After adjustment for the propensity score, and accounting for clustering of patients by hospitals, Impella use was associated with death: odds ratio, 1.24 (95% CI, 1.13-1.36); bleeding: odds ratio, 1.10 (95% CI, 1.00-1.21); and stroke: odds ratio, 1.34 (95% CI, 1.18-1.53), although a similar, nonsignificant result was observed for acute kidney injury: odds ratio, 1.08 (95% CI, 1.00-1.17). CONCLUSIONS: Impella use is rapidly increasing among patients undergoing PCI treated with MCS, with marked variability in its use and associated outcomes. Although unmeasured confounding cannot be ruled out, when analyzed by time periods, or at the hospital level or the patient level, Impella use was associated with higher rates of adverse events and costs. More data are needed to define the appropriate role of MCS in patients undergoing PCI.

Readmission after inpatient percutaneous coronary intervention in the Medicare population from 2000 to 2012.

BACKGROUND: Since year 2000, reducing hospital readmissions has become a public health priority. In addition, there have been major changes in percutaneous coronary intervention (PCI) during this period. METHODS: The cohort consisted of 3,250,194 patients admitted for PCI from January 2000 through November 2012. RESULTS: Overall, 30-day readmission was 15.8%. Readmission rates declined from 16.1% in 2000 to 15.4% in 2012 (adjusted odds ratio for readmission 1.33 in 2000 compared with 2012). Of all readmissions after PCI, the majority were for cardiovascular-related conditions (>60%); however, only a small percentage (<8%) of total readmissions were for acute myocardial infarction, unstable angina, or cardiac arrest/cardiogenic shock. A much larger percentage of patients were readmitted with chest pain/angina (7.9%), chronic ischemic heart disease (26.6%), and heart failure (12%). A small proportion was due to procedural complications and gastrointestinal (GI) bleeding. The use of PCI with stenting during readmissions was variable, increasing from 14.2% in 2000 to 23.7% in 2006 and then declining to 12.1% in 2012. Hospital mortality during readmission was 2.5% overall and varied over time (2.8% in 2000, decreasing to 2.2% in 2006 and then rising again to 3.1% in 2012). Patients who were readmitted had >4× higher 30-day mortality than those who were not. CONCLUSIONS: Among Medicare beneficiaries, readmission after PCI declined over time despite patients having more comorbidities. This translated into a 33% lower likelihood of readmission in 2012 compared with 2000. A small proportion of readmissions were for acute coronary syndromes.

Hospital Readmission after Aortic Valve Replacement: Impact of Preoperative Heart Failure.

BACKGROUND AND AIM OF THE STUDY: Large-scale data of heart failure (HF) readmission after aortic valve replacement (AVR) are limited. METHODS: A total of 40,751 Medicare beneficiaries >65 years who underwent primary isolated AVR between 2000 and 2004 were included in the study. Preoperative HF was defined using ICD-9-CM diagnostic codes from the index admission and any hospitalization during the preceding year. Cumulative readmission incidences over five years were computed for those patients with and without preoperative HF, while adjusting for propensity scores. RESULTS: The median patient age was 76 years. At 30 days, all-cause readmission was 21.5% and HF readmission was 3.9%. Patients with preoperative HF had higher postoperative HF readmission rates compared to those without (30 days, 6.3% versus 2.2%; one year, 13.9% versus 4.4%; five years, 6.6% versus 10.3%, p = 0.0001). The incremental risk of HF on readmission was >2 following adjustment. In patients with preoperative HF, the number of admissions was associated with increased postoperative HF readmissions. At 30 days, patients with no preoperative HF admissions had a HF readmission rate of 5.3%, while those with one, two, three and four or more preoperative HF admissions had rates of 8.2%, 11.9%, 13.8% and 17.4%, respectively. This trend persisted over the five-year follow up period. CONCLUSIONS: Postoperative HF readmission accounted for about one-fifth of all-cause readmissions after AVR in Medicare beneficiaries. Preoperative HF significantly contributed to postoperative readmission, both all-cause and HF-specific, which likely limits the symptomatic benefit of surgery. These data support early aortic valve intervention prior to the development of clinically apparent HF.

Mitral Valve Surgery in The Elderly: Should We Treat Atrial Fibrillation Too?

BACKGROUND: The study aim was to examine whether concomitant atrial fibrillation (AF) surgery at the time of mitral valve surgery in the elderly results in increased operative mortality (OM). METHODS: Medicare beneficiaries aged ≥65 years undergoing primary mitral valve repair or replacement between 2004 and 2006 were included. The cohort was divided into three groups: Group 1, AF- (n = 2,705); group 2, AF+AF surgery- (n = 2,119), and group 3, AF+AF surgery+ (n = 1,832). The primary outcomes were OM and long-term survival. A secondary outcome was the association between hospital annual mitral procedure volume and OM. RESULTS: The unadjusted OM was 6.4% for group 1 (AF-), 10.3% for group 2 (AF+AF surgery-), and 7.1% for group 3 (AF+AF surgery+) (p = 0.0001). Adjusted OM for AF+AF surgery+ patients was not significantly different from that of AF- patients (OR 1.16, 95% CI 0.90-1.48), or from AF+AF surgery patients (OR 0.83, 95% CI 0.66-1.06). When comparisons were adjusted for differences in baseline characteristics, AF+AF surgery- patients were more likely to experience long-term mortality than AF- patients (HR 1.30, 95% CI 1.17-1.45), as well as AF+AF surgery+ patients (HR 1.17, 95% CI 1.05-1.31). An annual average mitral procedure volume ≤40 was independently predictive of OM (OR 1.42, 95% CI 1.13-1.78). The effect of institutional volume on mortality was strongest in those who received AF surgery (AF+AF surgery+) (HR 1.75, 95% CI 1.15-2.65), compared to those who did not undergo surgery (AF+AF surgery-) (OR 1.20, 95% CI 0.86-1.67). CONCLUSIONS: Elderly patients undergoing mitral valve surgery do not appear to have an increased mortality when clinical judgment favored the performance of concomitant AF surgery.

Long-term survival of patients undergoing mitral valve repair and replacement: a longitudinal analysis of Medicare fee-for-service beneficiaries.

BACKGROUND: Despite the established superiority of mitral repair over replacement, its adoption in the treatment of elderly patients has not been uniform, partly because of a lack of robust long-term survival data. We present the long-term survival of Medicare fee-for-service beneficiaries undergoing mitral valve repair and replacement over a 10-year period. METHODS AND RESULTS: We used the Medicare database to identify 47 279 fee-for-service beneficiaries ≥65 years of age undergoing primary isolated mitral valve repair or replacement from 2000 to 2009. Operative mortality and long-term survival are presented for repair and replacement. Operative mortality was 3.9% for patients undergoing repair and 8.9% for patients undergoing replacement. The 1-, 5-, and 10-year Kaplan-Meier survival estimates for patients undergoing repair were 90.9%, 77.1%, and 53.6%. The 1-, 5-, and 10-year Kaplan-Meier survival estimates for patients undergoing replacement were 82.6%, 64.7%, and 37.2%. Important predictors of mitral repair included younger age (odds ratio, 1.10; 95% confidence interval, 1.05-1.14), elective admission status (odds ratio, 1.34; 95% confidence interval, 1.27-1.41), and annual mitral procedure volume >40 cases per year (odds ratio, 1.57; 95% confidence interval, 1.36-1.81). Female sex and the presence of comorbidities were associated with a lower likelihood of repair. CONCLUSIONS: Mitral valve surgery in the Medicare population carries less risk than previously reported. Given the favorable outcomes of elderly patients undergoing mitral valve surgery, especially mitral valve repair, an approach of earlier identification and surgical referral appears justified regardless of age.

Acetabular reconstruction in revision total hip arthroplasty: maximizing function and outcomes in protrusio and cavitary defects.

Osteolysis in the periacetabular region is a common long-term complication of total hip arthroplasty that can lead to bone loss, implant loosening, and protrusio. Several systems have been developed for classifying osteolysis and guiding treatment. Options such as bone grafting or augmentation, with exchange of the bearing surface and, in some cases, revision of the acetabular component, can be used for treatment. Most cavitary and protrusio defects can be treated with a cementless revision cup using screw fixation and grafting with morcellized bone. However, structural augmentation, custom components, or cage reconstruction may occasionally be necessary for managing larger defects with severe loss of acetabular bone stock.

The Value of Transradial: Impact on Patient Satisfaction and Health Care Economics.

This review summarizes the impact of transradial access for cardiac catheterization and percutaneous coronary intervention related to patient satisfaction, patient safety, and health care costs. In studies comparing transradial versus transfemoral approach, transradial access causes less bleeding and less vascular access site complications and provides a mortality benefit in patients with acute coronary syndromes. Transradial access improves patient satisfaction related to site tolerability by reducing pain and discomfort, and facilitating early ambulation with reduced length of stay. Taken in total, the existing randomized and observational data strongly support radial access for improved safety, patient satisfaction, and significant cost savings.

Impact of Medicare's Bundled Payments Initiative on Patient Selection, Payments, and Outcomes for Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting.

BACKGROUND: The Center for Medicare and Medicaid Innovation launched the Bundled Payments for Care Initiative (BPCI) in 2013. Its effect on payments and outcomes for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) is unknown. METHODS AND RESULTS: We used Medicare inpatient files to identify index admissions for PCI and CABG from 2013 through 2016 at BPCI hospitals and matched control hospitals and difference in differences models to compare the 2 groups. Our primary outcome was the change in standardized Medicare-allowed payments per 90-day episode. Secondary outcomes included changes in patient selection, discharge to postacute care, length of stay, emergency department use, readmissions, and mortality. Forty-two hospitals joined BPCI for PCI and 46 for CABG. There were no differential changes in patient selection between BPCI and control hospitals. Baseline Medicare payments per episode for PCI were $20 164 at BPCI hospitals and $19 955 at control hospitals. For PCI, payments increased at both BPCI and control hospitals during the intervention period, such that there was no significant difference in differences (BPCI hospitals +$673, P=0.048; control hospitals +$551, P=0.022; difference in differences $122, P=0.768). For CABG, payments at both BPCI and control hospitals decreased during the intervention period (BPCI baseline, $36 925, change -$2918, P<0.001; control baseline, $36 877, change -$2618, P<0.001; difference in differences, $300; P=0.730). For both PCI and CABG, BPCI participation was not associated with changes in mortality, readmissions, or length of stay. Among BPCI hospitals, emergency department use differentially increased for patients undergoing PCI and decreased for patients undergoing CABG. CONCLUSIONS: Participation in episode-based payment for PCI and CABG was not associated with changes in patient selection, payments, length of stay, or clinical outcomes.

Incremental Cost of Acute Kidney Injury after Percutaneous Coronary Intervention in the United States.

Contrast-induced acute kidney injury (AKI) is a common and severe complication of percutaneous coronary intervention (PCI). Despite its substantial burden, contemporary data on the incremental costs of AKI are lacking. We designed this large, nationally representative study to examine: (1) the independent, incremental costs associated with AKI after PCI and (2) to identify the departmental components of cost contributing to the incremental costs associated with AKI. In this observational cross-sectional study from the Premier database, we analyzed 1,443,297 PCI patients at 518 US hospitals from 1/2006 to 12/2015. Incremental cost of AKI from a hospital perspective obtained by a microcosting approach, was estimated using mixed-effects, multivariable linear regression with hospitals as random effects. Costs were inflation-corrected to 2016 US$. AKI occurred in 82,683 (5.73%) of the PCI patients. Those with AKI had higher hospitalization cost than those without ($38,869, SD 42,583 vs $17,167 SD 13,994, p <0.001). After adjustment, the incremental cost associated with an AKI was $9,448 (95% confidence interval $9,338 to $9,558, p <0.001). AKI was also independently associated with an incremental length of stay of 3.6 days (p <0.001). Room and board costs were the largest driver of AKI costs ($4,841). Extrapolated to the United States, our findings imply an annual AKI cost burden of 411.3 million US$. In conclusion, in this national study of PCI patients, AKI was common and independently associated with ∼$10,000 incremental costs, implying a substantial burden of AKI costs in US hospitals. Successful efforts to prevent AKI in patients who underwent PCI could result in meaningful cost savings.

Improving Care Pathways for Acute Coronary Syndrome: Patients Undergoing Percutaneous Coronary Intervention.

Acute coronary syndrome (ACS) admissions are common and costly. The association between comprehensive ACS care pathways, outcomes, and costs are lacking. From 434,172 low-risk, uncomplicated ACS patients eligible for early discharge (STEMI 35%, UA/NSTEMI 65%) from the Premier database, we identified ACS care pathways, by stratifying low-risk, uncomplicated STEMI and UA/NSTEMI patients by access site for PCI (trans-radial intervention [TRI] vs transfemoral intervention [TFI]) and by length of stay (LOS). Associations with costs and outcomes (death, bleeding, acute kidney injury, and myocardial infarction at 1-year) were tested using hierarchical, mixed-effects regression, and projections of cost savings with change in care pathways were obtained using modeling. In low-risk uncomplicated STEMI patients, compared with TFI and LOS ≥3 days, a strategy of TRI with LOS <3 days and TFI with LOS <3 days were associated with cost savings of $6,206 and $4,802, respectively. Corresponding cost savings for UA/NSTEMI patients were $7,475 and $6,169, respectively. These care-pathways did not show an excess risk of adverse outcomes. We estimated that >$300 million could be saved if prevalence of the TRI with LOS <3 days and TFI with LOS <3 days strategies are modestly increased to 20% and 70%, respectively. In conclusion, we demonstrate the potential opportunity of cost savings by repositioning ACS care pathways in low-risk and uncomplicated ACS patients, toward transradial access and a shorter LOS without an increased risk of adverse outcomes.

Racial Comparisons of the Outcomes of Transcatheter and Surgical Aortic Valve Implantation Using the Medicare Database.

Racial disparities in the outcomes after intervention for aortic valve disease remain understudied. We stratified patients by race who underwent surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) in the Medicare database. The TAVI cohort consisted of 17,973 patients (3.9% were black and 1.0% were Hispanic). The SAVR cohort consisted of 95,078 patients, (4.8% were black and 1.3% were Hispanic). Most comorbidities were more common in blacks. After TAVI, 30-day mortality was not significantly different in races with both unadjusted and adjusted data. There were no significant racial differences in readmission rates or discharge to home after TAVI. After SAVR, black patients had worse unadjusted 30-day and 1-year mortality than whites or Hispanics (30-day mortality, 4.7% vs 6.2% vs 4.7% for whites, blacks, and Hispanics, respectively, p = 0.0001; 1-year mortality 11.7% vs 16.1% vs 12.5%, respectively, p = 0.0001); however, after adjustment, there were no differences in mortality. Black patients had higher 30-day readmission rates after SAVR (20.1% vs 25.2% vs 21.7% for whites, blacks, and Hispanics, respectively, p = 0.0001), which persisted after adjustment for comorbidities. Minorities were underrepresented in both SAVR and TAVI relative to what would be predicted by population prevalence. In conclusion, while blacks have worse outcomes in SAVR compared with whites or Hispanics, race did not impact mortality, readmission, or discharge to home in TAVI. Both blacks and Hispanics were underrepresented compared with what would be predicted by population prevalence.

Improving coronary artery bypass grafting readmission outcomes from 2000 to 2012 in the Medicare population.

OBJECTIVE: The study objective was to examine trends in 30-day readmission after coronary artery bypass grafting in the Medicare population over 13 years. METHODS: The study included isolated coronary artery bypass grafting procedures in the Medicare population from January 2000 to November 2012. Comorbidities and causes of readmission were determined using Internal Classification of Diseases, 9th Revision, Clinical Modification diagnostic codes. RESULTS: The cohort included 1,116,991 patients. Readmission rates decreased from 19.5% in 2000 to 16.6% in 2012 (P = .0001). There was significant improvement across all categories of admission status, age, race, gender, and hospital annual coronary artery bypass grafting volume that were analyzed. Adjusted odds of readmission in 2000 compared with 2012 was 1.28 (95% confidence interval, 1.24-1.32). Median length of stay for the readmission episode was 5 days, which improved to 4 days by 2012. Hospital mortality during the readmission episode was 2.8% overall and declined to 2.4% in 2012 (P = .0001). The most common primary readmission diagnoses were heart failure (12.6%), postoperative wound infection/nonhealing wound (8.9%), arrhythmias (6.4%), and pleural effusions (3.7%). Readmission for wound infections/nonhealing wounds decreased significantly over time, from 9.8% to 6.5% (P = .0001). CONCLUSIONS: In a large cohort of Medicare patients undergoing coronary artery bypass grafting over 13 years, there was a significant decrease in 30-day readmission rates, a reduction in readmission for wound infections, and reduced mortality during the readmission episode, despite an increase in patient comorbidities. The improvement in readmission rates was seen regardless of patient variables examined.

Outcomes of Early Mitral Valve Reoperation in the Medicare Population.

BACKGROUND: Surgical series on mitral valve reoperation are limited by small numbers and lack of national representation. Large-scale outcomes of reoperation for mitral valve surgery remain uncertain. METHODS: This is a descriptive analysis of 1,627 Medicare beneficiaries who underwent mitral valve reoperation within a 3-year follow-up period after an initial mitral operation (repair or replacement) that took place between 2000 and 2006. The primary outcomes were hospital mortality and long-term survival. RESULTS: The 1,627 patients included in the study comprise 1.6% of patients who underwent operation between 2000 and 2006. The initial surgery was repair in 49.9%, bioprosthetic replacement in 22.0%, and mechanical replacement in 28.1%. Re-repair was performed in 15.4%. Hospital mortality was 12.0% and was similar for repair and bioprosthetic or mechanical replacement. Reoperative mortality was similar for men and women and for patients aged 75 years or less versus more than 75 years; and was significantly higher for nonelective than for elective operations (15.6% versus 5.5%, p = 0.0001), for patients with endocarditis than without endocarditis (21.4% versus 11.0%, p = 0.0001), and for patients with heart failure than without heart failure (14.2% versus 9.9%, p = 0.0080). Cumulative long-term survival rates were 58.6% at 5 years. CONCLUSIONS: The incidence of mitral valve reoperation within 3 years after initial repair or replacement is low but carries high surgical risk, which is significantly increased by certain preoperative characteristics, such as urgent status, endocarditis, and heart failure.

Transcatheter Aortic Valve Replacement Outcomes in Nonagenarians Stratified by Transfemoral and Transapical Approach.

BACKGROUND: Survival and other outcomes of nonagenarians undergoing transcatheter aortic valve replacement (TAVR) in the Medicare population are unclear. METHODS: Patients aged 65 years and older who underwent TAVR from November 2011 through 2013 were considered for inclusion. RESULTS: The study consisted of 18,283 patients and 19.3% were aged 90 years or older. Compared with patients younger than 90 years, patients 90 years or older were less likely to have a number of comorbidities, including previous myocardial infarction (17.5% versus 21.8%), previous coronary artery bypass grafting (20.0% versus 35.0%), and chronic obstructive pulmonary disease (25.4% versus 39.0%) among others. The 30-day and 1-year mortality rates were 8.4% versus 5.9% (p = 0.0001) and 25.4% versus 21.5% (p = 0.0001) in the older and younger groups, respectively (odds ratio [OR] 1.47, 95% confidence interval [CI]: 1.28 to 1.70, p = 0.0001). Patients 90 years and older were more likely to undergo pacemaker insertion (11.1% versus 8.3%, p = 0.0001). Among nonagenarians, compared with the transapical group, patients undergoing transfemoral TAVR had lower 30-day (7.2% versus 13.6%, p = 0.0001) and 1-year (23.8% versus 31.6%, p = 0.0001) mortality rates, were more likely to be discharged home (54.4% versus 34.1%, p = 0.0001), and had lower 30-day readmission rates (23.8% versus 31.8%, p = 0.0001). After adjustment for patient characteristics, transapical TAVR was an independent predictor of 30-day mortality rate (OR 1.94, 95% CI: 1.48 to 2.56, p = 0.0001) and readmission (OR 1.46, 95% CI: 1.19 to 1.80, p = 0.0003). CONCLUSIONS: In patients undergoing TAVR, although 30-day and 1-year mortality rates were slightly worse for nonagenarians than their younger counterparts, long-term survival was still encouraging, with 75% of nonagenarians living to 1 year. Transapical TAVR was associated with worse outcomes in nonagenarians.

Trends in Patient Characteristics and Outcomes of Coronary Artery Bypass Grafting in the 2000 to 2012 Medicare Population.

BACKGROUND: The purpose of this analysis was to examine the trends in patient characteristics and outcomes in patients who underwent coronary artery bypass grafting (CABG) over a 12-year period in the Medicare database. METHODS: The study included 1,264,265 isolated CABG procedures in the Medicare population from January 2000 through November 2012. Comorbidities were determined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes. Trends in patient characteristics and hospital outcomes were assessed with Cochran-Armitage trend tests. Long-term survival was examined with Kaplan-Meier survival curves. RESULTS: The median age was 74 years. Comorbidity profiles increased significantly over time. The number of patients undergoing CABG decreased from 131,385 in 2000 to 71,086 in 2012. The majority of patients underwent multivessel revascularization (13.5% single-vessel CABG, 35.2% 2-vessel CABG, 32.1% 3-vessel CABG, and 15.7% ≥4-vessel CABG). The percentage of patients undergoing 1- and 2-vessel revascularization increased over time, whereas that of ≥3-vessel CABG decreased. Single internal mammary artery (IMA) use increased from 75.6% to 88.6%. Median length of stay (LOS) was 8 days. Thirty-day mortality decreased from 4.2% to 3.0%. Hospital mortality fell from 4.0% in 2000 to 2.7% in 2012 (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.69-0.77). Survival was 93% at 6 months, 91% at 1 year, 84% at 3 years, and 76% at 5 years. Five-year survival changed little over time (range, 75%-77%). CONCLUSIONS: Despite rising comorbidities in Medicare patients undergoing CABG, hospital mortality fell significantly from 2000 to 2012. When adjusted for comorbidities, this signified a 27% reduction in hospital mortality. IMA use increased during the study period, and there was a trend of decreased use of 3 or more grafts.

Effect of Hospital Volume on Prosthesis Use and Mortality in Aortic Valve Operations in the Elderly.

BACKGROUND: This study was designed to examine the effect of hospital procedural volume on outcomes in aortic valve replacement (AVR) in the elderly. METHODS: The study included 277,928 Medicare beneficiaries who underwent AVR from 2000 through 2009 at one of 1,255 participating hospitals. Operative mortality and the use of mechanical prostheses were analyzed according to hospital annual procedural volume. Annual AVR volume was divided into 5 different categories: the smallest volume group with less than 10 AVRs per year to the largest group averaging more than 70 AVRs per year. RESULTS: The overall observed operative mortality rate was 7.3%; for isolated AVR it was 5.5%. Lower-volume hospitals exhibited increased adjusted operative mortality: 10 cases or fewer per year--odds ratio (OR), 1.55; 95% confidence interval (CI), 1.39 to 1.72; 11 to 20 cases per year--OR, 1.35; 95% CI, 1.23 to 1.47; 21 to 40 cases per year--OR, 1.15; 95% CI, 1.06 to 1.25; 41 to 70 cases per year--OR, 1.10; 95% CI, 1.01 to 1.20 relative to those hospitals performing more than 70 cases per year. The discrepancy in operative mortality between low- and high-volume hospitals diverged during the study. Mechanical valve use decreased with increasing hospital volume (p = 0.0001). Mechanical valves were used in 64.5% of AVRs in hospitals with an annual AVR volume less than 10 in contrast to only 25.4% in hospitals with an annual AVR volume more than 70. After adjustment, the use of mechanical valves was independently associated with increased operative mortality (OR, 1.15; 95% CI, 1.11-1.19). CONCLUSIONS: Low-volume centers were characterized by increased adjusted operative mortality and greater use of mechanical prostheses, a trend that persisted during the 10-year course of the study. These data would support the center-of-excellence concept for AVR and may be particularly relevant in the elderly population.

Long-term outcomes of mitral valve repair versus replacement for degenerative disease: a systematic review.

The short-term advantage of mitral valve repair versus replacement for degenerative disease has been extensively documented. These advantages include lower operative mortality, improved survival, better preservation of leftventricular function, shorter post-operative hospital stay, lower total costs, and fewer valve-related complications, including thromboembolism, anticoagulation-related bleeding events and late prosthetic dysfunction. More recent written data are available indicating the long-term advantage of repair versus replacement. While at some institutions, the repair rate for degenerative disease may exceed 90%, the national average in 2007 was only 69%. Making direct comparisons between mitral valve repair and replacement using the available studies does present some challenges however, as there are often differences in baseline characteristics between patient groups as well as other dissimilarities between studies. The purpose of this review is to systematically summarize the long-term survival and reoperation data of mitral valve repair versus replacement for degenerative disease. A PubMed search was done and resulted in 12 studies that met our study criteria for comparing mitral valve repair versus replacement for degenerative disease. A systematic review was then conducted abstracting survival and reoperation data.

Hospital volume, mitral repair rates, and mortality in mitral valve surgery in the elderly: an analysis of US hospitals treating Medicare fee-for-service patients.

BACKGROUND: The volume-outcome relationship has been suggested as a quality metric in mitral valve surgery and would be particularly relevant in the elderly because of their greater burden of comorbidities and higher perioperative risk. METHODS AND RESULTS: The study included 1239 hospitals performing mitral valve surgery on Medicare beneficiaries from 2000 through 2009. Only 9% of hospitals performed more than 40 mitral operations per year, 29% performed 5 or less, and 51% performed 10 or less. Mitral repair rates were low; 22.7% of hospitals performed 1 or less, 65.1% performed 5 or less, and only 5.6% performed more than 20 mitral repairs per year in those aged 65 years or more. Repair rates increased with increasing volume of mitral operations per year: 5 or less, 30.5%; 6 to 10, 32.9%; 11 to 20, 34.9%; 21 to 40, 38.8%; and more than 40, 42.0% (P = .0001). Hospitals with lower volume had significantly higher adjusted operative mortality compared with hospitals performing more than 40 cases per year: 5 or less cases per year, odds ratio (OR) 1.58 (95% confidence interval [CI], 1.40-1.78); 6 to 10 cases per year, OR 1.29 (95% CI, 1.17-1.43); 11 to 20 cases per year, OR 1.17 (95% CI, 1.07-1.28); 21 to 40 cases per year, OR 1.15 (95% CI, 1.05-1.26). Hospitals with lower mitral repair rates had an increased likelihood of operative mortality relative to the top quartile: lowest quartile, OR 1.31 (95% CI, 1.20-1.44); second quartile, OR 1.18 (95% CI, 1.09-1.29); and third quartile, OR 1.14 (95% CI, 1.05-1.24). Long-term mortality beyond 6 months was also higher in low-volume hospitals: 5 or less cases year, hazard ratio (HR) 1.11 (95% CI, 1.06-1.18); 6 to 10 cases per year, OR 1.06 (95% CI, 1.02-1.10) compared with hospitals performing more than 40 cases per year. CONCLUSIONS: Most hospitals perform few mitral valve operations on elderly patients. Greater volume of mitral procedures was associated with higher repair rates. Both greater volume of mitral procedures and increasing mitral repair rates were associated with decreased mortality.