Baskett Roger J F, Nanton Maurice A, Warren Andrew E, Ross David B
Maritime Heart Centre & Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
J Thorac Cardiovasc Surg. 2003 Jul;126(1):232-9. doi: 10.1016/s0022-5223(03)00210-1.
This study examines the incidence and factors associated with the failure of homograft valves and identifies those factors that are modifiable.
From 1990 to 2001, 96 homograft valves were implanted in the right ventricular outflow tract of 83 children (mean age 5.1 +/- 5.6 years). Clinical and blinded serial echocardiographic follow-up was performed on all 90 valves in the 77 survivors.
Eighteen homograft valves were replaced as the result of pulmonary insufficiency (3), stenosis (9), or both (6). Freedom from reoperation was 71% at 9 years (95% confidence interval, 58%-84%). Forty-eight valves developed progressive pulmonary insufficiency of at least 2 grades, 26 valves developed transvalvular gradients of 50 mm Hg or greater, and 14 of these valves were also insufficient. The freedom from echocardiographic failure (progressive pulmonary insufficiency >or=2 grades or >or=50 mm Hg gradient) was only 27% at 5 years (95% confidence interval, 17%-37%). In a multivariate analysis (Cox regression), use of an aortic homograft (P =.001) and short antibiotic preservation time (P =.04) were associated with reoperation. Younger age (P =.01), ABO mismatch (P =.04), and diagnosis (P =.005) were associated with echocardiographic failure. In the subanalysis of patients with human leukocyte antigen typing, age (P =.002), aortic homograft (P =.04), and human leukocyte antigen-DR mismatch (P =.03) were associated with echocardiographic valve failure.
Many homografts rapidly become insufficient and require replacement. In our analysis of both reoperation and echocardiographic failure, several immunologic factors are consistently associated with homograft failure. Matching for human leukocyte antigen-DR, blood group, and avoiding short preservation times (thus minimizing antigenicity) offers the potential to extend the life of these valves.
本研究探讨同种异体移植瓣膜失败的发生率及相关因素，并确定那些可改变的因素。
1990年至2001年期间，83名儿童（平均年龄5.1±5.6岁）的右心室流出道植入了96个同种异体移植瓣膜。对77名存活者的所有90个瓣膜进行了临床及盲法系列超声心动图随访。
18个同种异体移植瓣膜因肺动脉瓣关闭不全（3个）、狭窄（9个）或两者皆有（6个）而被置换。9年时再次手术的免手术率为71%（95%置信区间，58%-84%）。48个瓣膜出现至少2级的进行性肺动脉瓣关闭不全，26个瓣膜出现跨瓣压差达50mmHg或更高，其中14个瓣膜同时存在关闭不全。5年时超声心动图检查无失败（进行性肺动脉瓣关闭不全≥2级或压差≥50mmHg）的免发生率仅为27%（95%置信区间，17%-37%）。多因素分析（Cox回归）显示，使用主动脉同种异体移植瓣膜（P = 0.001）和抗生素保存时间短（P = 0.04）与再次手术相关。年龄较小（P = 0.01）、ABO血型不匹配（P = 0.04）和诊断（P = 0.005）与超声心动图检查失败相关。在进行人类白细胞抗原分型的患者亚分析中，年龄（P = 0.002）、主动脉同种异体移植瓣膜（P = 0.04）和人类白细胞抗原-DR不匹配（P = 0.03）与超声心动图瓣膜失败相关。
许多同种异体移植瓣膜很快出现功能不全并需要置换。在我们对再次手术和超声心动图检查失败的分析中，几个免疫因素始终与同种异体移植瓣膜失败相关。进行人类白细胞抗原-DR、血型匹配并避免短保存时间（从而将抗原性降至最低）有可能延长这些瓣膜的使用寿命。
