Ruel Marc, Chan Vincent, Bédard Pierre, Kulik Alexander, Ressler Ladislaus, Lam B Khanh, Rubens Fraser D, Goldstein William, Hendry Paul J, Masters Roy G, Mesana Thierry G
Division of Cardiac Surgery, and the Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada.
Circulation. 2007 Sep 11;116(11 Suppl):I294-300. doi: 10.1161/CIRCULATIONAHA.106.681429.
Several centers favor replacing a diseased native heart valve with a tissue rather than a mechanical prosthesis, even in younger adult patients. However, long-term data supporting this approach are lacking. We examined the survival implications of selecting a tissue versus a mechanical prosthesis at initial left-heart valve replacement in a cohort of adults <60 years of age who were followed for over 20 years.
Comorbid and procedural data were available from 6554 patients who underwent valve replacement at our institution over the last 35 years. Of these, 1512 patients contributed follow-up data beyond 20 years, of whom 567 were adults <60 years of age at first left-heart valve operation (mean survivor follow-up, 24.0+/-3.1 years). Late outcomes were examined with Cox regression. Valve reoperation, often for prostheses that are no longer commercially available, occurred in 89% and 84% of patients by 20 years after tissue aortic and mitral valve replacement, respectively, and was associated with a mortality of 4.3%. There was no survival difference between patients implanted with a tissue versus a mechanical prosthesis at initial aortic valve replacement (hazard ratio 0.95; 95% CI: 0.7, 1.3; P=0.7). For mitral valve replacement patients, long-term survival was poorer than after aortic valve replacement (hazard ratio 1.4; 95% CI: 1.1, 1.8; P=0.003), but again no detrimental effect was associated with use of a tissue versus a mechanical prosthesis (hazard ratio 0.9; 95% CI 0.5, 1.4; P=0.5).
In our experience, selecting a tissue prosthesis at initial operation in younger adults does not negatively impact survival into the third decade of follow-up, despite the risk of reoperation.
即使在年轻成年患者中，几个中心也倾向于用组织瓣膜而非机械瓣膜置换病变的天然心脏瓣膜。然而，缺乏支持这种方法的长期数据。我们在一组年龄小于60岁且随访超过20年的成年人中，研究了初次左心瓣膜置换时选择组织瓣膜与机械瓣膜对生存的影响。
可获得过去35年在我们机构接受瓣膜置换的6554例患者的合并症和手术数据。其中，1512例患者有超过20年的随访数据，其中567例在初次左心瓣膜手术时年龄小于60岁（平均存活者随访时间为24.0±3.1年）。采用Cox回归分析晚期结局。组织主动脉瓣和二尖瓣置换术后20年，分别有89%和84%的患者因瓣膜不再有商业供应而进行再次手术，再次手术相关死亡率为4.3%。初次主动脉瓣置换时植入组织瓣膜与机械瓣膜的患者之间生存率无差异（风险比0.95；95%可信区间：0.7，1.3；P = 0.7）。对于二尖瓣置换患者，长期生存率低于主动脉瓣置换患者（风险比1.4；95%可信区间：1.1，1.8；P = 0.003），但同样，使用组织瓣膜与机械瓣膜对生存率无不利影响（风险比0.9；95%可信区间0.5，1.4；P = 0.5）。
根据我们的经验，在年轻成年人初次手术时选择组织瓣膜，尽管有再次手术的风险，但在随访的第三个十年对生存率没有负面影响。
