Schelbert E B, Vaughan-Sarrazin M S, Welke K F, Rosenthal G E
Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
Heart. 2008 Sep;94(9):1181-8. doi: 10.1136/hrt.2007.127506. Epub 2007 Dec 10.
To compare outcomes after aortic valve replacement (AVR) according to valve type specifically in older patients since valve-related risks are age-dependent; two randomised trials comparing mechanical and bioprosthetic valves found better outcomes with mechanical valves, but the samples were small and the patients were considerably younger than most who undergo AVR.
Cohort study.
1199 US hospitals.
Patients 65 years and older undergoing AVR during 1991-2003 (n = 307 054) identified through Medicare claims data.
Relative hazard ratios associated with bioprosthetic valves of (1) death (n = 131,719); (2) readmission for haemorrhage (n = 31,186), stroke (n = 25,051) or embolism (n = 5870); (3) reoperation (n = 4216); and (4) death or reoperation (reoperation free survival) in Cox regression analyses adjusting for demographic and clinical factors and hospital-level effects.
Overall, 36% of AVR patients received bioprosthetic valves. Bioprosthetic valve recipients were older (77 vs 75 years, p<0.001) and generally had higher comorbidity. Bioprosthetic valve recipients had a slightly lower adjusted hazard ratios of death (HR = 0.97; 95% CI 0.95 to 0.98); readmission for haemorrhage, stroke or embolism (HR = 0.90, 95% CI 0.88 to 0.92); and death or reoperation (HR = 0.97, 95% CI 0.96 to 0.98), but a higher hazard ratio of reoperation (HR = 1.25, 95% CI 1.16 to 1.35). However, overall mortality and complication rates were more than 20 and 10 times higher, respectively, than the overall reoperation rate.
In older patients undergoing AVR, bioprosthetic valve recipients had slightly lower risks of death and complications, but a higher risk of reoperation. Given the low reoperation rate, these data suggest that bioprosthetic valves may be preferred in older patients.
由于瓣膜相关风险与年龄相关，因此特别针对老年患者比较主动脉瓣置换术（AVR）后不同瓣膜类型的治疗效果；两项比较机械瓣膜和生物瓣膜的随机试验发现机械瓣膜的治疗效果更好，但样本量较小且患者比大多数接受AVR的患者年轻得多。
队列研究。
1199家美国医院。
通过医疗保险理赔数据确定的1991 - 2003年期间接受AVR的65岁及以上患者（n = 307054）。
在调整人口统计学和临床因素以及医院层面效应的Cox回归分析中，与生物瓣膜相关的（1）死亡（n = 131719）；（2）因出血（n = 31186）、中风（n = 25051）或栓塞（n = 5870）再次入院；（3）再次手术（n = 4216）；以及（4）死亡或再次手术（无再次手术生存）的相对风险比。
总体而言，36%的AVR患者接受了生物瓣膜。接受生物瓣膜的患者年龄更大（77岁对75岁，p<0.001），且一般合并症更多。接受生物瓣膜的患者调整后的死亡风险比略低（HR = 0.97；95%CI 0.95至0.98）；因出血、中风或栓塞再次入院的风险比（HR = 0.90，95%CI 0.88至0.92）；以及死亡或再次手术的风险比（HR = 0.97，95%CI 0.96至0.98），但再次手术的风险比更高（HR = 1.25，95%CI 1.16至1.35）。然而，总体死亡率和并发症发生率分别比总体再次手术率高出20倍和10倍以上。
在接受AVR的老年患者中，接受生物瓣膜的患者死亡和并发症风险略低，但再次手术风险较高。鉴于再次手术率较低，这些数据表明生物瓣膜可能更适合老年患者。
