Accola Kevin D, Scott Meredith L, Spector S David, Thompson Paul A, Palmer George J, Sand Mark E, Suarez-Cavalier Jorge E, Ebra George
Florida Hospital Cardiovascular Institute, Cardiovascular Surgeons, P.A., Orlando, Florida 32801, USA.
J Heart Valve Dis. 2006 Jan;15(1):57-66; discussion 66.
The selection of a suitable valve substitute in patients requiring valvular heart surgery is an important element in the preoperative decision-making process between cardiologist, surgeon, and patient. Controversy persists regarding the use of mechanical valves in the elderly. With the population living longer, reoperative risk becomes of paramount importance. Quality of life (QOL) considerations are often as important to the patient as longevity. The influence of mechanical valve replacement on QOL in elderly patients has not been well documented.
Between June 1981 and December 1999, a total of 1,125 consecutive patients aged > or = 65 years (582 men, 543 women; mean age 71.4 +/- 4.9 years) underwent valve replacement with at least one St. Jude Medical (SJM) mechanical valve. Preoperatively, 138 patients (12.3%) were in NYHA class II, 775 (68.9%) in class III, and 212 (18.8%) in class IV. In 535 patients (47.6%), coronary artery disease required surgical intervention. Survivors were administered the Short Form (SF)-36 QOL Survey at follow up, which was 96.1% complete.
Hospital mortality was 7.6% (85/1,125). Mean follow up was 5.9 years (range: 9 months to 18.4 years). Mean (+/- SEM) actuarial survival was 70.6 +/- 1.4% at five years, and 40.6 +/- 2.0% at 10 years. Male patients scored significantly higher on the SF-36 than controls in physical (p = 0.012) and mental health (p = 0.004). Comparing female patients with controls revealed no significant difference in physical health; however, they scored higher in mental health than controls (p = 0.001).
The study results clearly demonstrate that heart surgery in the elderly with the SJM mechanical valve can be accomplished with acceptable hospital mortality, morbidity, and excellent long-term results. Moreover, long-term QOL in elderly patients with a SJM valve can be expected to meet or exceed that of age- and gender-matched controls.
对于需要进行心脏瓣膜手术的患者，选择合适的瓣膜替代品是心脏病专家、外科医生和患者术前决策过程中的重要环节。关于老年患者使用机械瓣膜仍存在争议。随着人口寿命延长，再次手术的风险变得至关重要。生活质量（QOL）考量对患者而言往往与寿命同样重要。机械瓣膜置换对老年患者生活质量的影响尚未得到充分记录。
在1981年6月至1999年12月期间，共有1125例年龄≥65岁的连续患者（582例男性，543例女性；平均年龄71.4±4.9岁）接受了至少一枚圣犹达医疗（SJM）机械瓣膜置换术。术前，138例患者（12.3%）为纽约心脏协会（NYHA）心功能II级，775例（68.9%）为III级，212例（18.8%）为IV级。535例患者（47.6%）因冠状动脉疾病需要手术干预。对幸存者在随访时进行了简短形式（SF）-36生活质量调查，完成率为96.1%。
医院死亡率为7.6%（85/1125）。平均随访时间为5.9年（范围：9个月至18.4年）。五年时的平均（±标准误）精算生存率为70.6±1.4%，十年时为40.6±2.0%。男性患者在SF-36身体（p = 0.012）和心理健康（p = 0.004）方面的得分显著高于对照组。将女性患者与对照组进行比较，发现身体健康方面无显著差异；然而，她们在心理健康方面的得分高于对照组（p = 0.001）。
研究结果清楚地表明，老年患者使用SJM机械瓣膜进行心脏手术可以实现可接受的医院死亡率、发病率，并取得优异的长期效果。此外，使用SJM瓣膜的老年患者的长期生活质量有望达到或超过年龄和性别匹配的对照组。
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