Ruel Marc, Rubens Fraser D, Masters Roy G, Pipe Andrew L, Bédard Pierre, Hendry Paul J, Lam B Khanh, Burwash Ian G, Goldstein William G, Brais Maurice P, Keon Wilbert J, Mesana Thierry G
Division of Cardiac Surgery, Department of Epidemiology, University of Ottawa, Ontario, Canada.
J Thorac Cardiovasc Surg. 2004 Jan;127(1):149-59. doi: 10.1016/j.jtcvs.2003.07.043.
We examined factors associated with persistent or recurrent congestive heart failure after aortic valve replacement.
Patients who underwent aortic valve replacement with contemporary prostheses (n = 1563) were followed up with annual clinical assessment and echocardiography. The effect of demographic, comorbid, and valve-related variables on the composite outcome of New York Heart Association class III or IV symptoms or congestive heart failure death after surgery was evaluated with stratified log-rank tests, Cox proportional hazard models, and logistic regression. Factors associated with all-cause death were also examined. Prediction models were bootstrapped 1000 times.
Total follow-up was 6768 patient-years (mean, 4.3 +/- 3.3 years; range, 60 days to 17.1 years). Freedom from congestive heart failure or congestive heart failure death was 98.6% +/- 0.3%, 88.6% +/- 1.0%, 73.9% +/- 2.3%, and 45.2% +/- 8.5% at 1, 5, 10, and 15 years, respectively. Age, preoperative New York Heart Association class, left ventricular grade, atrial fibrillation, coronary artery disease, smoking, and redo status predicted congestive heart failure after surgery (all P <.05). Larger prosthesis size and effective orifice area, both absolute and indexed for body surface area, were independently associated with freedom from congestive heart failure. Increased transprosthesis gradients were predicted by prosthesis-patient mismatch and were associated with congestive heart failure after surgery. Mismatch defined as an effective orifice area/body surface area of 0.80 cm(2)/m(2) or less was a significant predictor of congestive heart failure events after surgery, but mismatch defined as an effective orifice area/body surface area of 0.85 cm(2)/m(2) or less was not. Small prosthesis size and mismatch were not significantly associated with all-cause mortality.
These analyses identify independent predictors of congestive heart failure symptoms and congestive heart failure death late after aortic valve replacement and indicate that prosthesis size has a significant effect on this cardiac end point, but not on overall survival after aortic valve replacement.
我们研究了主动脉瓣置换术后持续性或复发性充血性心力衰竭的相关因素。
对接受当代人工瓣膜主动脉瓣置换术的患者（n = 1563）进行年度临床评估和超声心动图随访。采用分层对数秩检验、Cox比例风险模型和逻辑回归评估人口统计学、合并症和瓣膜相关变量对术后纽约心脏协会III或IV级症状或充血性心力衰竭死亡这一复合结局的影响。还检查了与全因死亡相关的因素。预测模型进行了1000次自抽样。
总随访时间为6768患者年（平均，4.3±3.3年；范围，60天至17.1年）。1年、5年、10年和15年时无充血性心力衰竭或充血性心力衰竭死亡的比例分别为98.6%±0.3%、88.6%±1.0%、73.9%±2.3%和45.2%±8.5%。年龄、术前纽约心脏协会分级、左心室分级、心房颤动、冠状动脉疾病、吸烟和再次手术状态可预测术后充血性心力衰竭（所有P <.05）。更大的人工瓣膜尺寸和有效瓣口面积，无论是绝对值还是根据体表面积计算的指数值，均与无充血性心力衰竭独立相关。人工瓣膜-患者不匹配可预测跨瓣压差增加，并与术后充血性心力衰竭相关。定义为有效瓣口面积/体表面积≤0.80 cm²/m²的不匹配是术后充血性心力衰竭事件的显著预测因素，但定义为有效瓣口面积/体表面积≤0.85 cm²/m²的不匹配则不是。较小的人工瓣膜尺寸和不匹配与全因死亡率无显著相关性。
这些分析确定了主动脉瓣置换术后晚期充血性心力衰竭症状和充血性心力衰竭死亡的独立预测因素，并表明人工瓣膜尺寸对这一心脏终点有显著影响，但对主动脉瓣置换术后的总体生存率无影响。
