Klieverik Loes M A, Noorlander Mariska, Takkenberg Johanna J M, Kappetein A Pieter, Bekkers Jos A, van Herwerden Lex A, Bogers Ad J J C
Department of Cardio-Thoracic Surgery, Erasmus Medical Center Rotterdam, The Netherlands.
J Heart Valve Dis. 2006 Jul;15(4):479-87; discussion 487.
The optimal prosthesis choice in young adults requiring aortic valve replacement (AVR) remains controversial. The study aim was to determine whether implanted prosthesis type is an important determinant of outcome after AVR in young adults.
Between 1991 and 2001, 414 young adults (mean age 40 +/- 11 years; range: 16-55 years) underwent a total of 438 consecutive AVRs using 204 mechanical prostheses (MP), three bioprostheses (BP), 150 allografts (AL), and 81 autografts (AU). The perioperative characteristics, early and late mortality, occurrence of valve-related events and predictors of adverse outcome and prosthesis selection, were evaluated.
Mean patient ages were 45 years for MP, 50 years for BP, 39 years for AL, and 31 years for AU. MP selection was associated with older age, impaired left ventricular function (LVF) and concomitant mitral valve surgery (concMVS); AL selection with ascending aortic aneurysm, active endocarditis, and Marfan's disease; and AU selection with younger age, prior balloon valvuloplasty and isolated valve disease. Hospital mortality was 2.3% (n = 10). During follow up (97% complete) 30 patients died. Ten-year survival was better for AU (96 +/- 2%) compared to MP (84 +/- 4%) and AL (92 +/- 2%). Prosthesis type was not predictive of late mortality; rather, predictors of increased late mortality were prior aortic valve surgery, impaired LVF, concMVS, and older patient age. Ten-year freedom from bleeding and thromboembolism was 89 +/- 3% for MP versus 94 +/- 3% for AL and 99 +/- 1% for AU (p = 0.054). Ten-year freedom from reoperation was 95 +/- 2% for MP versus 79 +/- 5% for AL and 87 +/- 5% for AU (p = 0.003).
Survival after AVR in young adults in Rotterdam was mainly determined by patient-related factors, and not by prosthesis type. A randomized controlled trial is necessary to determine whether valve prosthesis type indeed plays a crucial role in improving survival in young adult patients.
对于需要进行主动脉瓣置换术（AVR）的年轻成年人，最佳的假体选择仍存在争议。本研究的目的是确定植入的假体类型是否是年轻成年人AVR术后结局的重要决定因素。
1991年至2001年间，414名年轻成年人（平均年龄40±11岁；范围：16 - 55岁）连续接受了438次AVR手术，使用了204个机械假体（MP）、3个生物假体（BP）、150个同种异体移植物（AL）和81个自体移植物（AU）。评估了围手术期特征、早期和晚期死亡率、瓣膜相关事件的发生情况以及不良结局和假体选择的预测因素。
MP组患者平均年龄为45岁，BP组为50岁，AL组为39岁，AU组为31岁。选择MP与年龄较大、左心室功能受损（LVF）和同期二尖瓣手术（concMVS）相关；选择AL与升主动脉瘤、活动性心内膜炎和马凡氏综合征相关；选择AU与年龄较小、既往球囊瓣膜成形术和单纯瓣膜疾病相关。医院死亡率为2.3%（n = 10）。在随访期间（97%完整），30名患者死亡。与MP（84±4%）和AL（92±2%）相比，AU的10年生存率更高（96±2%）。假体类型不能预测晚期死亡率；相反，晚期死亡率增加的预测因素是既往主动脉瓣手术、LVF受损、concMVS和患者年龄较大。MP的10年无出血和血栓栓塞率为89±3%，AL为94±3%，AU为99±1%（p = 0.054）。MP的10年再次手术率为95±2%，AL为79±5%，AU为87±5%（p = 0.003）。
鹿特丹年轻成年人AVR术后的生存率主要由患者相关因素决定，而非假体类型。有必要进行一项随机对照试验，以确定瓣膜假体类型是否确实在改善年轻成年患者的生存率方面起关键作用。
