无支架与带支架异种移植主动脉瓣置换术后的生存率：一项同期对照试验。

Survival after stentless and stented xenograft aortic valve replacement: a concurrent, controlled trial.

作者信息

Luciani Giovanni Battista, Casali Gianluca, Auriemma Stefano, Santini Francesco, Mazzucco Alessandro

机构信息

Division of Cardiac Surgery, University of Verona, Italy.

出版信息

Ann Thorac Surg. 2002 Nov;74(5):1443-9. doi: 10.1016/s0003-4975(02)03954-1.

DOI:10.1016/s0003-4975(02)03954-1

PMID:12440591

Abstract

BACKGROUND

To define the impact of stentless versus stented valve design on survival late after xenograft aortic valve replacement, a retrospective analysis of all consecutive patients operated on between January 1992 and April 2000 was undertaken.

METHODS

Two hundred ninety-two patients had stented (group 1) and 376 stentless (group 2) xenograft aortic valve replacements. Age was older in group 1 (75 +/- 4 vs 70 +/- 7 years, p = 0.01), whereas male gender and aortic stenosis were equally prevalent. Advanced New York Heart Association class III-IV (85% vs 78%, p = 0.03) and associated procedures (53% vs 41%, p = 0.01) were more common in group 1. Aortic cross-clamp (80 +/- 28 vs 96 +/- 23 minutes, p = 0.01) and bypass (91 +/- 56 vs 129 +/- 34 minutes, p = 0.01) times were shorter in group 1. Logistic regression and Cox proportional hazard methods were used to define the role of demographic and operative variables on hospital and late survival, freedom from valve-related mortality, and reintervention.

RESULTS

Early mortality was higher in group 1 (6.2% vs 2.6%, p = 0.02). Smaller aortic anulus (p = 0.008), aortic cross-clamp (p = 0.03), and coronary disease requiring bypass (p = 0.03) were associated with hospital mortality. During follow-up (37 +/- 30 vs 43 +/- 35 months, p = NS), 66 late deaths were recorded (12% vs 9%, p = NS). At 8 years, survival (70 +/- 5% vs 81 +/- 3%, p = 0.01), freedom from cardiac- (85 +/- 1% vs 92 +/- 3%, p = 0.02), and valve-related death (79 +/- 5% vs 95 +/- 2%, p = 0.004) were higher in group 2. Freedom from structural deterioration was similar (92 +/- 5% vs 93 +/- 3%, p = NS), but freedom from reoperation was lower in group 2 (99 +/- 1% vs 90 +/- 4%, p = 0.009). Multivariate analysis showed female gender (p = 0.02), age (p = 0.03), and smaller valve size (p = 0.05) to be associated with late mortality; age (p = 0.06) and diagnosis of aortic stenosis (p = 0.008) with cardiac mortality; longer intensive care unit stay (p = 0.001) and stented xenografts (p = 0.05) with valve-related mortality; and younger age (p = 0.01) and stentless xenograft (p = 0.05) with reoperation.

CONCLUSIONS

Use of stentless xenografts correlates with better survival and freedom from cardiac- and valve-related mortality than stented valves. However, bias favoring stented valves in older and sicker patients exists. Selective survival advantage of stentless xenograft is confined to valve-related mortality. Stentless valves are more likely to be replaced for dysfunction.

摘要

背景

为了确定无支架与有支架瓣膜设计对异种移植主动脉瓣置换术后晚期生存率的影响，我们对1992年1月至2000年4月间所有连续接受手术的患者进行了回顾性分析。

方法

292例患者接受了有支架（第1组）异种移植主动脉瓣置换术，376例患者接受了无支架（第2组）异种移植主动脉瓣置换术。第1组患者年龄较大（75±4岁对70±7岁，p = 0.01），而男性性别和主动脉瓣狭窄的发生率相当。纽约心脏协会心功能Ⅲ - Ⅳ级晚期患者（85%对78%，p = 0.03）和相关手术（53%对41%，p = 0.01）在第1组中更为常见。第1组的主动脉阻断时间（80±28分钟对96±23分钟，p = 0.01）和体外循环时间（91±56分钟对129±34分钟，p = 0.01）较短。采用逻辑回归和Cox比例风险方法来确定人口统计学和手术变量对住院生存率和晚期生存率、瓣膜相关死亡率和再次干预的作用。

结果

第1组的早期死亡率较高（6.2%对2.6%，p = 0.02）。较小的主动脉瓣环（p = 0.008）、主动脉阻断（p = 0.03）以及需要行旁路移植术的冠状动脉疾病（p = 0.03）与住院死亡率相关。在随访期间（37±30个月对43±35个月，p =无显著性差异），记录到66例晚期死亡（12%对9%，p =无显著性差异）。在8年时，第2组的生存率（70±5%对81±3%，p = 0.01）、无心脏相关（85±1%对92±3%，p = 0.02）和瓣膜相关死亡（79±5%对95±2%，p = 0.004）的比例更高。无结构恶化的比例相似（92±5%对93±3%，p =无显著性差异），但第2组再次手术率较低（99±1%对90±4%，p = 0.009）。多因素分析显示女性性别（p = 0.02）、年龄（p = 0.03）和较小的瓣膜尺寸（p = 0.05）与晚期死亡率相关；年龄（p = 0.06）和主动脉瓣狭窄诊断（p = 0.008）与心脏死亡率相关；较长的重症监护病房住院时间（p = 0.001）和有支架异种移植瓣膜（p = 0.05）与瓣膜相关死亡率相关；较年轻的年龄（p = 0.01）和无支架异种移植瓣膜（p = 0.05）与再次手术相关。