Analysis Of Surgical Quality And Perioperative Risk Factors In Senior-aged Patients With Valvular Heart Disease In China

Valvular heart disease(VHD)is one of the most important components of structural heart disease and a major cause of heart failure.Worldwide,the mortality rate of valve surgery is improving with advances in valve therapy techniques and successful prevention programs.However,as the global population ages and life expectancy increases,the disease burden of valvular heart disease is increasing exponentially.China also faces huge challenges.According to the China Cardiovascular Disease Report 2021,there are an estimated 25 million patients with valvular heart disease in China,which brings a huge economic burden to society and individuals.In addition,with the increasing degree of aging,the prevalence of valvular heart disease is increasing and the disease spectrum is also changing.Besides,as a risk factor for cardiac valvular surgery,it is necessary to study the senior-aged patients with VHD.However,a summary of current status of senior-aged patients with valve surgery in China is lack.The Chinese Cardiac Surgery Registry(CCSR)database is a national multicenter observational study led by Fuwai Hospital.Based on CCSR,we present the current status of surgical treatment of valvular heart disease in senior-aged patients in China.Besides,in this study,we will have an in-depth discussion of some representative aspects,such as baseline characteristics,perioperative treatment,and etiology,to provide a reference for further improvement of the medical quality in valve surgery.The main results are as follows:Part 1:Analysis of surgical quality and perioperative risk factors in senior-aged patients with valvular heart disease in ChinaObjectives:To analysis the clinical characteristic and surgical treatment status of senior-aged patients with valvular heart disease(VHD)and heart failure in China.Methods:We established the the Chinese Cardiac Surgery Registry(CCSR)database to obtain the demographic,clinical characteristics and treatment patterns of senior-aged patients with heart failure undergoing valve surgery in China.Data were obtained at 7 different regions(North East,North,East,Central,South,South West,and North West)from January 2012 to December 2020.In-hospital mortality were regarded as outcome indexes.We estimated region-level risk standardized in-hospital mortality rates(RSMR)by using hierarchical generalized linear models.Results:From January 2012 to December 2020,data on 2 521 senior-aged patients with VHD with heart failure from 7 regions were registered from 109 participating centers with the adult cardiac surgery volume more than 100 operations per year.Among cases,rheumatic heart disease(RHD)accounted for 37.2%,and degenerative VHD accounted for 34.2%.The number of aortic valve surgeries was 1 597(63.3%),which was slightly higher than that of mitral valve surgeries(n=1 505,59.7%).The number of concurrent aortic and mitral valve surgeries was 609(24.1%).A total of 823 surgical VHD patients(32.6%)also underwent coronary artery bypass grafting(CABG).The overall observed in-hospital mortality rate was 6.98%.The lowest and highest observed in-hospital mortality rates were in the southwest region(2.33%)and the northwest region(10.11%),respectively.The lowest RSMR(3.34%)(95%CI:3.31%～3.38%)was in the southwest region,followed by 5.40%(95%CI:5.36%～5.64%)in the north region and the highest RSMR(10.95%)(95%CI:10.89%～11.01%)was in the northwest region.Conclusions:Based on the CCSR database,a national multi-center database,this study comprehensively presents the current status and clinical characteristics of surgical treatment in elderly patients with valvular heart disease complicated with heart failure in China for the first time.In the senior-aged patients with heart failure who underwent valve surgery in China,RHD was still the major cause of the VHD,with a significant increase in degenerative heart disease.The number of valve surgery in this special population is small and there are marked regional variation in the perioperative mortality of valve surgery.Part 2:An In-Hospital Mortality Risk Model for senior-aged Patients Undergoing Cardiac Valvular Surgery Based on Logistic RegressionBackground:We aimed to develop and validate a prediction model for in-hospital mortality in senior-aged patients with valvular heart diseases(VHD).Methods:Between January 2019 and December 2020,all consecutive senior-aged patients undergoing valvular surgery in the Chinese Cardiac Surgery Registry(CCSR)database were included.Finally,3,367 patients were identified for analysis.As a training group for model derivation,we used patients who had surgery between January 2019 and April 2020(2,484 in total).To validate the model,patients who underwent surgery between May 2020 and December 2020(a total of 883 patients)were included as a testing group.In training group,we constructed a nomogram prediction model to predict in-hospital mortality in senior-aged patients undergoing cardiac valvular surgery by using univariable analysis and multivariable logistic regression.Then we validated the nomogram model in the testing group.Brier score and calibration curves using bootstrapping with 1000 re-samples were used to evaluate the calibration.The area under the receiver operating characteristic curve(AUROC)was used to evaluate the discrimination.The results were also compared to EuroSCORE Ⅱ.Results:A total of 3367 patients were included in this study,with a median age of 68.9 years,and 43.8%were women.Overall,the in-hospital mortality was 4.6%.The final nomogram model included eleven risk factors:ag>70 years;smoking history;peripheral vascular disease;left ventricular ejection fraction(LVEF)<40%;congestive heart failure;New York Heart Association Class(NYHA)Ⅳ;severe tricuspid valve regurgitation;re-operation;combined coronary artery bypass grafting(CABG);estimated glomerular filtration rate(eGFR)<50ml/min/1.73m2;non-elective surgery.Brier scores in the training and testing groups of the nomogram model were 0.042 and 0.041,respectively.Brier scores in the training and testing groups of EuroSCORE Ⅱ were 0.045 and 0.043,respectively.The area under the curve(AUC)values of the nomogram model in the training and testing groups were 0.751 and 0.713,respectively,which was significantly higher than EuroSCORE Ⅱ in both the training(AUC=0.604,p<0.05)and testing(AUC=0.617,p<0.05)groups.Conclusion:The new nomogram model could accurately predict in-hospital mortality rates in senior-aged patients undergoing cardiac valvular surgery.