Association of Volume and Outcomes in 234 556 Patients Undergoing Surgical Aortic Valve Replacement

Vinod H. Thourani, James M. Brennan, J. James Edelman, Dylan Thibault, Oliver K. Jawitz, Joseph E. Bavaria, Robert S.D. Higgins, Joseph F. Sabik, Richard L. Prager, Joseph A. Dearani, Thomas E. MacGillivray, Vinay Badhwar, Lars G. Svensson, Michael J. Reardon, David M. Shahian, Jeffrey P. Jacobs, Gorav Ailawadi, Wilson Y. Szeto, Nimesh Desai, Eric E. RoselliY. Joseph Woo, Sreek Vemulapalli, John D. Carroll, Pradeep Yadav, S. Chris Malaisrie, Mark Russo, Tom C. Nguyen, Tsuyoshi Kaneko, Gilbert Tang, Marc Ruel, Joanna Chikwe, Richard Lee, Robert H. Habib, Isaac George, Martin B. Leon, Michael J. Mack

Research output: Contribution to journalArticlepeer-review

16 Scopus citations


Background: The relationship between institutional volume and operative mortality after surgical aortic valve replacement (SAVR) remains unclear. Methods: From January 2013 to June 2018, 234 556 patients underwent isolated SAVR (n = 144 177) or SAVR with coronary artery bypass grafting (CABG) (n = 90 379) within the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The association between annualized SAVR volume (group 1 [1-25 SAVRs], group 2 [26-50 SAVRs], group 3 [51-100 SAVRs], and group 4 [>100 SAVRs]) and operative mortality and composite major morbidity or mortality was assessed. Random effects models were used to evaluate whether historical (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes. Results: The annualized median number of SAVRs per site was 35 (interquartile range, 22-59; isolated aortic valve replacement [AVR], 20; AVR with CABG, 13). Among isolated SAVR cases, the mean operative mortality and composite morbidity or mortality were 1.5% and 9.7%, respectively, at the highest-volume sites (group 4), with significantly higher rates among progressively lower-volume groups (P trend < .001). After adjustment, lower-volume centers had increased odds of operative mortality (group 1 vs group 4 [reference]: adjusted odds ratio [AOR] for SAVR, 2.24 [95% CI, 1.91-2.64]; AOR for SAVR with CABG, 1.96 [95% CI, 1.67-2.30]) and major morbidity or mortality (AOR for SAVR, 1.53 [95% CI, 1.39-1.69]; AOR for SAVR with CABG, 1.46 [95% CI, 1.32-1.61]) compared with the highest-volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category, and prior outcomes explained a greater proportion of hospital operative outcomes than did prior volume. Conclusions: Operative outcomes after SAVR with or without CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive of future outcomes than is prior volume. Given the excellent outcomes observed at many lower-volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.

Original languageEnglish
Pages (from-to)1299-1306
Number of pages8
JournalAnnals of Thoracic Surgery
Issue number4
StatePublished - Oct 2022


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