Akins Cary W, Hilgenberg Alan D, Vlahakes Gus J, MacGillivray Thomas E, Torchiana David F, Madsen Joren C
Department of Surgery, Massachusetts General Hospital, Boston 02114, USA.
Ann Thorac Surg. 2002 Oct;74(4):1098-106. doi: 10.1016/s0003-4975(02)03840-7.
Concomitant coronary artery disease with aortic valve disease is an established risk factor for diminished late survival. This study evaluated the results of bioprosthetic (BAVR) or mechanical aortic valve replacement (MAVR) performed with coronary artery bypass grafting (CABG).
From January 1984 through July 1997, combined AVR + CABG was performed in 750 consecutive patients; 469 received BAVR and 281 received MAVR. BAVR recipients were significantly older (mean age, 75 vs 65 years), and had more nonelective operations, congestive heart failure, peripheral vascular disease, preoperative intraaortic balloons, lower cardiac indices, more severe aortic stenosis, less aortic regurgitation, and more extensive coronary artery disease.
Early complications included operative mortality, 32 patients (4.3% total: 3.8% BAVR and 5.0% MAVR); perioperative infarction, 10 (1.3%); and perioperative stroke, 22 (2.9%). Significant multivariable predictors of early mortality were age, perioperative infarction or stroke, nonelective operation, operative year, ventricular hypertrophy, and need for intraaortic balloon. Ten-year actuarial survival was 41.7% for all patients. Predicted survival for age- and gender-matched cohorts from the general population versus observed survival were BAVR, 45% versus 36%; MAVR, 71% versus 48% (survival differences BAVR 9% vs MAVR 23%, p < 0.007). Significant multivariable predictors of late mortality included age, congestive failure, perioperative stroke, extent of coronary disease, peripheral vascular disease, and diabetes. Valve type was not significant. Ten-year actuarial freedom from valve-related complications were (BAVR vs MAVR) structural deterioration, 95% versus 100%, p = NS; thromboembolism, 86% versus 84%, p = NS; anticoagulant bleeding, 93% versus 88%, p < 0.005; reoperation, 98% versus 98%, p = NS.
AVR + CABG has diminished late survival despite the type of prosthesis inserted. Although valve type did not predict late mortality, mechanical AVR was associated with worse survival compared with predicted and more valve-related complications due to anticoagulation requirements.
冠心病合并主动脉瓣疾病是晚期生存率降低的既定危险因素。本研究评估了冠状动脉旁路移植术（CABG）联合生物瓣主动脉瓣置换术（BAVR）或机械瓣主动脉瓣置换术（MAVR）的结果。
从1984年1月至1997年7月，连续750例患者接受了AVR + CABG联合手术；469例接受BAVR，281例接受MAVR。接受BAVR的患者年龄显著更大（平均年龄75岁对65岁），非择期手术更多，存在充血性心力衰竭、外周血管疾病，术前使用主动脉内球囊，心脏指数更低，主动脉狭窄更严重，主动脉反流更少，冠状动脉疾病更广泛。
早期并发症包括手术死亡率，32例患者（总计4.3%：BAVR为3.8%，MAVR为5.0%）；围手术期心肌梗死，10例（1.3%）；围手术期卒中，22例（2.9%）。早期死亡的显著多变量预测因素为年龄、围手术期心肌梗死或卒中、非择期手术、手术年份、心室肥厚以及是否需要主动脉内球囊。所有患者的10年精算生存率为41.7%。与普通人群年龄和性别匹配队列的预测生存率相比，观察到的生存率为：BAVR，45%对36%；MAVR，71%对48%（生存率差异BAVR为9%对MAVR为23%，p < 0.007）。晚期死亡的显著多变量预测因素包括年龄、充血性心力衰竭、围手术期卒中、冠状动脉疾病范围、外周血管疾病和糖尿病。瓣膜类型不显著。10年无瓣膜相关并发症的精算自由度为（BAVR对MAVR）：结构恶化，95%对100%，p = 无显著性差异；血栓栓塞，86%对84%，p = 无显著性差异；抗凝相关出血，93%对88%，p < 0.005；再次手术，98%对98%，p = 无显著性差异。
尽管植入的假体类型不同，AVR + CABG的晚期生存率仍有所降低。虽然瓣膜类型不能预测晚期死亡率，但与预测生存率相比，机械瓣AVR的生存率更差，且由于抗凝需求，与瓣膜相关的并发症更多。
