John Eisenga, Kyle McCullough, Jasjit Banwait, Timothy George, Kelley Hutcheson, Robert Smith, J Michael DiMaio, Justin Schaffer
{"title":"在二尖瓣手术中通过手术消融心房颤动提高存活率","authors":"John Eisenga, Kyle McCullough, Jasjit Banwait, Timothy George, Kelley Hutcheson, Robert Smith, J Michael DiMaio, Justin Schaffer","doi":"10.1016/j.athoracsur.2025.01.026","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Surgical ablation(SA) at the time of isolated mitral valve surgery(MVS) is recommended in patients with preexisting atrial fibrillation(AF). However, SA remains infrequently utilized during MVS with a poorly quantified impact on stroke and survival.</p><p><strong>Methods: </strong>Medicare claims(2008-2019) were queried to identify beneficiaries with preexisting AF undergoing MVS. All-cause mortality and the post-operative incidence of stroke/transient ischemic attack(TIA) were evaluated as separate endpoints. Overlap propensity score weighting was used to risk-adjust for measured confounding variables. Analyses were repeated using surgeon frequency of SA as an instrumental variable to adjust for unmeasured confounding variables.</p><p><strong>Results: </strong>From 2008-2019, 41,795 Medicare beneficiaries with a preexisting diagnosis of AF underwent MVS. Surgeons were categorized, with 1,326 infrequently(bottom quartile) performing SA(<30%; 10,364 beneficiaries) and 740 frequently(top quartile) performing SA(≥62%; 10,476 beneficiaries) during MVS. Beneficiaries undergoing MVS with SA(\"as-treated\" analysis) had a risk-adjusted median survival advantage of 0.56[0.33-0.81] years (8.85[8.64-9.04] vs 8.29[8.11-8.47] years, P<0.001 for risk-adjusted survival comparison) compared to those without. Beneficiaries undergoing MVS by frequent SA surgeons(\"surgeon-preference\" analysis) had a risk-adjusted median survival advantage of 0.35[0.05-0.71] years (8.59[8.40-8.85] vs 8.24[7.97-8.40] years, P=0.0015 for risk-adjusted survival comparison) compared to surgeons who infrequently performed SA.</p><p><strong>Conclusions: </strong>In Medicare beneficiaries with preexisting AF, concomitant SA during MVS is associated with improved survival, as is undergoing surgery by a frequent SA surgeon. When analyzed based on surgeon preference for SA, the magnitude and time-dependent nature of the treatment effect of SA were substantially different compared to the \"as-treated\" analysis, suggesting that \"as-treated\" analyses may be subject to bias from unmeasured confounding variables.</p>","PeriodicalId":50976,"journal":{"name":"Annals of Thoracic Surgery","volume":" ","pages":""},"PeriodicalIF":3.6000,"publicationDate":"2025-02-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Enhanced Survival With Surgical Ablation of Atrial Fibrillation During Mitral Valve Surgery.\",\"authors\":\"John Eisenga, Kyle McCullough, Jasjit Banwait, Timothy George, Kelley Hutcheson, Robert Smith, J Michael DiMaio, Justin Schaffer\",\"doi\":\"10.1016/j.athoracsur.2025.01.026\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>Surgical ablation(SA) at the time of isolated mitral valve surgery(MVS) is recommended in patients with preexisting atrial fibrillation(AF). However, SA remains infrequently utilized during MVS with a poorly quantified impact on stroke and survival.</p><p><strong>Methods: </strong>Medicare claims(2008-2019) were queried to identify beneficiaries with preexisting AF undergoing MVS. All-cause mortality and the post-operative incidence of stroke/transient ischemic attack(TIA) were evaluated as separate endpoints. Overlap propensity score weighting was used to risk-adjust for measured confounding variables. Analyses were repeated using surgeon frequency of SA as an instrumental variable to adjust for unmeasured confounding variables.</p><p><strong>Results: </strong>From 2008-2019, 41,795 Medicare beneficiaries with a preexisting diagnosis of AF underwent MVS. Surgeons were categorized, with 1,326 infrequently(bottom quartile) performing SA(<30%; 10,364 beneficiaries) and 740 frequently(top quartile) performing SA(≥62%; 10,476 beneficiaries) during MVS. Beneficiaries undergoing MVS with SA(\\\"as-treated\\\" analysis) had a risk-adjusted median survival advantage of 0.56[0.33-0.81] years (8.85[8.64-9.04] vs 8.29[8.11-8.47] years, P<0.001 for risk-adjusted survival comparison) compared to those without. Beneficiaries undergoing MVS by frequent SA surgeons(\\\"surgeon-preference\\\" analysis) had a risk-adjusted median survival advantage of 0.35[0.05-0.71] years (8.59[8.40-8.85] vs 8.24[7.97-8.40] years, P=0.0015 for risk-adjusted survival comparison) compared to surgeons who infrequently performed SA.</p><p><strong>Conclusions: </strong>In Medicare beneficiaries with preexisting AF, concomitant SA during MVS is associated with improved survival, as is undergoing surgery by a frequent SA surgeon. When analyzed based on surgeon preference for SA, the magnitude and time-dependent nature of the treatment effect of SA were substantially different compared to the \\\"as-treated\\\" analysis, suggesting that \\\"as-treated\\\" analyses may be subject to bias from unmeasured confounding variables.</p>\",\"PeriodicalId\":50976,\"journal\":{\"name\":\"Annals of Thoracic Surgery\",\"volume\":\" \",\"pages\":\"\"},\"PeriodicalIF\":3.6000,\"publicationDate\":\"2025-02-12\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Annals of Thoracic Surgery\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1016/j.athoracsur.2025.01.026\",\"RegionNum\":2,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q1\",\"JCRName\":\"CARDIAC & CARDIOVASCULAR SYSTEMS\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Annals of Thoracic Surgery","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1016/j.athoracsur.2025.01.026","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"CARDIAC & CARDIOVASCULAR SYSTEMS","Score":null,"Total":0}
引用次数: 0
摘要
背景：对于已有心房颤动（房颤）的患者，建议在进行孤立二尖瓣手术（MVS）时进行手术消融（SA）。然而，在二尖瓣置换术中使用手术消融的情况仍不常见，对中风和存活率的影响也很少量化：方法：查询了医疗保险报销单（2008-2019 年），以确定接受 MVS 的原有房颤受益人。将全因死亡率和术后中风/短暂性脑缺血发作（TIA）发生率作为单独的终点进行评估。采用重叠倾向评分加权法对测量的混杂变量进行风险调整。使用外科医生的SA频率作为工具变量重复分析，以调整未测量的混杂变量：2008-2019 年间，41,795 名已有房颤诊断的医疗保险受益人接受了 MVS。对外科医生进行了分类，其中1326名外科医生很少（最低四分位数）进行SA手术：对于已有心房颤动的医保受益人而言，在 MVS 期间同时进行 SA 与生存率的提高有关，由经常进行 SA 的外科医生进行手术也与生存率的提高有关。根据外科医生对 SA 的偏好进行分析时，SA 治疗效果的程度和时间依赖性与 "按治疗 "分析相比有很大不同，这表明 "按治疗 "分析可能会受到未测量混杂变量的影响。
Enhanced Survival With Surgical Ablation of Atrial Fibrillation During Mitral Valve Surgery.
Background: Surgical ablation(SA) at the time of isolated mitral valve surgery(MVS) is recommended in patients with preexisting atrial fibrillation(AF). However, SA remains infrequently utilized during MVS with a poorly quantified impact on stroke and survival.
Methods: Medicare claims(2008-2019) were queried to identify beneficiaries with preexisting AF undergoing MVS. All-cause mortality and the post-operative incidence of stroke/transient ischemic attack(TIA) were evaluated as separate endpoints. Overlap propensity score weighting was used to risk-adjust for measured confounding variables. Analyses were repeated using surgeon frequency of SA as an instrumental variable to adjust for unmeasured confounding variables.
Results: From 2008-2019, 41,795 Medicare beneficiaries with a preexisting diagnosis of AF underwent MVS. Surgeons were categorized, with 1,326 infrequently(bottom quartile) performing SA(<30%; 10,364 beneficiaries) and 740 frequently(top quartile) performing SA(≥62%; 10,476 beneficiaries) during MVS. Beneficiaries undergoing MVS with SA("as-treated" analysis) had a risk-adjusted median survival advantage of 0.56[0.33-0.81] years (8.85[8.64-9.04] vs 8.29[8.11-8.47] years, P<0.001 for risk-adjusted survival comparison) compared to those without. Beneficiaries undergoing MVS by frequent SA surgeons("surgeon-preference" analysis) had a risk-adjusted median survival advantage of 0.35[0.05-0.71] years (8.59[8.40-8.85] vs 8.24[7.97-8.40] years, P=0.0015 for risk-adjusted survival comparison) compared to surgeons who infrequently performed SA.
Conclusions: In Medicare beneficiaries with preexisting AF, concomitant SA during MVS is associated with improved survival, as is undergoing surgery by a frequent SA surgeon. When analyzed based on surgeon preference for SA, the magnitude and time-dependent nature of the treatment effect of SA were substantially different compared to the "as-treated" analysis, suggesting that "as-treated" analyses may be subject to bias from unmeasured confounding variables.
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.
京公网安备 11010802042870号
京ICP备2023020795号-1
分享
求助内容：
应助结果提醒方式：
扫码关注我们
