Coronary Artery Bypass Grafting With Mitral Annuloplasty or Replacement for Ischemic Mitral Regurgitation in Medicare Beneficiaries.

IF 3.6 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

Annals of Thoracic Surgery Pub Date : 2025-02-08 DOI:10.1016/j.athoracsur.2025.01.021

Timothy J George, John J Squiers, J Michael DiMaio, Jasjit K Banwait, Paul A Grayburn, Michael J Mack, Justin M Schaffer

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引用次数: 0

Abstract

Background: Retrospective studies of patients with ischemic mitral regurgitation (iMR) undergoing coronary artery bypass grafting (CABG) with concomitant mitral valve surgery frequently report improved survival with mitral valve repair/annuloplasty (MVr) over replacement (MVR). However, the only randomized controlled trial found no survival difference.

Methods: Medicare claims data were queried to identify beneficiaries with iMR undergoing CABG/MVr or CABG/MVR. Kaplan-Meier estimates of survival after CABG/MVr and CABG/MVR were generated, and 20-year restricted mean survival times (RMSTs) were compared. Then, surgeons were stratified by their rate of CABG/MVr into groups with a demonstrated preference for MVr (PA) or MVR (PR). Outcomes were reanalyzed by surgeon preference. Overlap propensity score weighting was used for risk adjustment in all analyses.

Results: Among 10,471 beneficiaries with iMR, 6457 (61.7%) underwent CABG/MVr and 4014 (38.3%) underwent CABG/MVR. Risk-adjusted RMSTs were 6.02 years (95% CI, 5.77-6.26 years) after CABG/MVr and 5.57 years (95% CI, 5.33-5.81 years) after CABG/MVR (difference, 5.4 months; 95% CI, 1.2-9.4 months; P = .01). Among 1118 surgeons, 223 were PA surgeons (performed 2191 operations; 89.5% MVr rate) and 235 were PR surgeons (performed 1930 operations; 23.0% MVr rate). Risk-adjusted RMSTs were 5.76 years (95% CI, 5.36-6.15 years) vs 5.77 years (95% CI, 5.40-6.14 years) among beneficiaries undergoing surgery by PA surgeons and PR surgeons, respectively (difference, 0.1 years; 95% CI, -6.6 to 6.6 months, P = .964).

Conclusions: In Medicare beneficiaries with iMR undergoing CABG/mitral valve surgery, CABG/MVr was associated with improved survival, even after risk adjustment for measured confounders. This may be due to unmeasured confounding variables affecting the decision to perform MVr or MVR, such as valvular pathology and/or severity of regurgitation. After endeavoring to account for unmeasured confounders using surgeon preference as an instrumental variable, surgeons who preferred CABG/MVr or CABG/MVR achieved similar long-term survival for their patients.

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冠状动脉旁路移植术合并二尖瓣环成形术或置换术治疗缺血性二尖瓣返流的医疗保险受益人。

背景：对接受冠状动脉旁路移植术（CABG）合并二尖瓣手术的缺血性二尖瓣返流（iMR）患者的回顾性研究经常报告二尖瓣环成形术（MVr）比置换术（MVr）改善了生存率。然而，唯一的随机对照试验没有发现生存差异。方法：查询医疗保险索赔数据，以确定接受CABG+MVr或CABG+MVr的iMR受益人。生成CABG+MVr和CABG+MVr后的Kaplan-Meier生存估计，并比较20年限制平均生存时间（RMST）。然后，根据CABG/MVr的发生率将外科医生分为MVr（PA）或MVr（PR）两组。根据外科医生的偏好重新分析结果。所有分析均采用重叠倾向评分加权进行风险调整。结果：在10471名iMR受益人中，6457名（61.7%）接受了CABG+MVr， 4014名（38.3%）接受了CABG+MVr。CABG+MVr和CABG+MVr后的风险校正RMSTs分别为6.02[5.77,6.26]年和5.57[5.33,5.81]年（差异5.4[1.2,9.4]个月，p=0.01）。在1118名外科医生中，223名助理医师进行了2191例手术；MVr率89.5%)，PR 235例(1930例；MVr率23.0%)。经风险调整后的rmst分别为5.76[5.36,6.15]和5.77[5.40,6.14]年（差异0.1[-6.6,6.6]个月，p=0.964）。结论：在接受CABG+MVS的iMR医疗保险受益人中，CABG+MVr与生存率的提高相关，即使在测量混杂因素的风险调整后也是如此。这可能是由于影响决定进行MVr或MVr的未测量的混杂变量，例如瓣膜病理和/或反流的严重程度。在尝试将外科医生偏好作为工具变量来解释未测量的混杂因素后，选择CABG+MVr或CABG+MVr的外科医生获得了相似的患者长期生存率。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Annals of Thoracic Surgery 医学-呼吸系统

CiteScore

6.40

自引率

13.00%

发文量

1235

审稿时长

42 days

期刊介绍： The mission of The Annals of Thoracic Surgery is to promote scholarship in cardiothoracic surgery patient care, clinical practice, research, education, and policy. As the official journal of two of the largest American associations in its specialty, this leading monthly enjoys outstanding editorial leadership and maintains rigorous selection standards. The Annals of Thoracic Surgery features: • Full-length original articles on clinical advances, current surgical methods, and controversial topics and techniques • New Technology articles • Case reports • "How-to-do-it" features • Reviews of current literature • Supplements on symposia • Commentary pieces and correspondence • CME • Online-only case reports, "how-to-do-its", and images in cardiothoracic surgery. An authoritative, clinically oriented, comprehensive resource, The Annals of Thoracic Surgery is committed to providing a place for all thoracic surgeons to relate experiences which will help improve patient care.