Akar A Ruchan, Szafranek Adam, Alexiou Christos, Janas Robert, Jasinski Marek J, Swanevelder Justiaan, Sosnowski Andrzej W
Department of Cardiothoracic Surgery, University Hospitals of Leicester, Glenfield Hospital, United Kingdom.
Ann Thorac Surg. 2002 Nov;74(5):1450-7; discussion 1457-8. doi: 10.1016/s0003-4975(02)03845-6.
Whether to perform a stentless aortic valve replacement (AVR) is not well established. Our aim was to determine the outcome after AVR with stentless xenograft valves.
Between 1996 and 2001, a total of 404 patients (mean age 70.4 years) underwent a stentless AVR by one surgeon in our unit. Concomitant procedures were performed in 132 patients (33%). Twenty patients (6.4%) had undergone previous AVR. Eleven types of stentless xenograft valves were implanted: Medtronic Freestyle in 221 patients (55%), Shelhigh in 55 (14%), Shelhigh composite conduit in 33 (8%), Sorin in 26 (6%), Cryolife O'Brien in 25 (6%), Aortech-Elan in 17 (4%), Edwards Prima in 14 (4%), Toronto SPV in 7 (2%), and other valves in 6 (1%). A subcoronary implantation technique was used in 302 cases (76%), complete root replacement in 62 (15%), and a modified Bentall-De Bono procedure in 33 (8%). Mean follow-up was 19.4 months (range, 1.2 to 60.6 months).
Overall hospital mortality was 4.2%. This was 2.4% for isolated AVR, 3.6% for AVR and coronary artery bypass grafting, 5.5% for replacement of two or more valves, and 12% for the modified Bentall procedure. On multiple logistic regression redo cardiac operation (p = 0.0006), cardiogenic shock (p = 0.001), left ventricular ejection fraction less than 0.30 (p = 0.01), modified Bentall procedure (p = 0.03), and endocarditis (p = 0.04) were predictors of in-hospital death. Five-year freedom from thromboembolism, hemorrhage, prosthetic endocarditis, structural valve deterioration, and reoperation was 97%, 99%, 99%, 98%, and 96%, respectively. Kaplan-Meier survival at 5 years was 88%. On Cox regression, cardiogenic shock (p = 0.001) and older age (p = 0.03) were adverse predictors of survival. At echocardiographic examination within 6 months from the operation, mean aortic valve gradients were 15 +/- 6 mm Hg, 12.8 +/- 3 mm Hg, 10.8 +/- 4 mm Hg, 9.3 +/- 3 mm Hg, 9.1 +/- 4 mm Hg, and 8.2 +/- 3 mm Hg for valve sizes of 19, 21, 23, 25, 27, and 29 mm, respectively.
The availability of several stentless valve designs facilitates the surgical treatment of diverse aortic valve or root diseases with encouraging early and mid-term results. Patients requiring concomitant procedures may also benefit from the excellent hemodynamic characteristics of a stentless valve. We consider stentless AVR the treatment of choice for patients older than 60 years and those having small aortic roots.
是否进行无支架主动脉瓣置换术（AVR）尚未完全明确。我们的目的是确定使用无支架异种移植瓣膜进行AVR后的结果。
1996年至2001年间，我们单位的一名外科医生共为404例患者（平均年龄70.4岁）实施了无支架AVR。132例患者（33%）同时进行了其他手术。20例患者（6.4%）曾接受过AVR。共植入了11种无支架异种移植瓣膜：美敦力Freestyle瓣膜221例（55%），Shelhigh瓣膜55例（14%），Shelhigh复合管道瓣膜33例（8%），索林瓣膜26例（6%），Cryolife O'Brien瓣膜25例（6%），Aortech-Elan瓣膜17例（4%），爱德华兹Prima瓣膜14例（4%），多伦多SPV瓣膜7例（2%），其他瓣膜6例（1%）。302例（76%）采用了冠状动脉下植入技术，62例（15%）进行了完整根部置换，33例（8%）采用了改良Bentall-De Bono手术。平均随访时间为19.4个月（范围1.2至60.6个月）。
总体医院死亡率为4.2%。单纯AVR的死亡率为2.4%，AVR联合冠状动脉搭桥术的死亡率为3.6%，置换两个或更多瓣膜的死亡率为5.5%，改良Bentall手术的死亡率为12%。多因素logistic回归分析显示，再次心脏手术（p = 0.0006）、心源性休克（p = 0.001）、左心室射血分数低于0.30（p = 0.01）、改良Bentall手术（p = 0.03）和心内膜炎（p = 0.04）是院内死亡的预测因素。血栓栓塞、出血、人工瓣膜心内膜炎、瓣膜结构恶化和再次手术的5年无事件生存率分别为97%、99%、99%、98%和96%。5年Kaplan-Meier生存率为88%。Cox回归分析显示，心源性休克（p = 0.001）和年龄较大（p = 0.03）是生存的不良预测因素。术后6个月内的超声心动图检查显示，如果瓣膜尺寸分别为19、21、23、25、27和29mm，平均主动脉瓣压差分别为15±6mmHg、12.8±3mmHg、10.8±4mmHg、9.3±3mmHg、9.1±4mmHg和8.2±3mmHg。
多种无支架瓣膜设计的出现有助于外科治疗各种主动脉瓣或根部疾病，早期和中期结果令人鼓舞。需要同时进行其他手术的患者也可能受益于无支架瓣膜出色的血流动力学特性。我们认为无支架AVR是60岁以上患者和主动脉根部较小患者的首选治疗方法。
