Kojodjojo P, Gohil N, Barker D, Youssefi P, Salukhe T V, Choong A, Koa-Wing M, Bayliss J, Hackett D R, Khan M A
Department of Cardiology, Hemel Hempstead General Hospital, Hillfield Road, Hertfordshire HP24AD, UK.
QJM. 2008 Jul;101(7):567-73. doi: 10.1093/qjmed/hcn052. Epub 2008 Apr 27.
Aortic valve replacement (AVR) can be performed safely in selected elderly patients with aortic stenosis (AS). However, the survival benefits of AVR over conservative treatment have not been convincingly demonstrated in AS patients aged above 80.
To investigate the outcomes of patients aged 80 and over with symptomatic, severe AS and by analyzing the effects of patient's choice in either agreeing or refusing to undergo AVR, determine the survival benefits afforded by AVR.
Cohort study.
Subjects aged 80 and over with severe symptomatic AS, diagnosed between 2001 and 2006 were segregated into three groups: subjects who underwent AVR (Group A); patients who were fit for AVR but declined surgery due to personal choice (Group B) and those who were not fit for surgery and were managed conservatively (Group C). Follow-up was conducted by out-patient attendances, review of medical records and telephone interviews. The primary endpoint was all-cause mortality.
A total of 103 patients (86.0 +/- 4.2 years, 41% male) were identified and no patient was lost during follow-up. In Group A (n = 17), all 15 patients who underwent AVR were alive after 3.6 +/- 1.4 years follow-up and 2 died whilst awaiting AVR. Seventy-four percent of Group B (n = 24) and 76% of Group C (n = 62) died during follow-up. Group A had significantly better survival than B and C. (P < 0.01) Amongst patients fit for AVR with similar operative risks (Groups A and B), refusal to undergo surgery (hazard ratio 12.61, P = 0.001) was the only predictor of mortality in a multivariate model.
For elderly AS patients fit for surgery, the patient's decision to refuse AVR is associated with a >12-fold increase in mortality risk. These findings have significant implications for informed decision-making when managing the fit, elderly patient with AS.
对于部分患有主动脉瓣狭窄（AS）的老年患者，主动脉瓣置换术（AVR）可安全实施。然而，在80岁以上的AS患者中，AVR相较于保守治疗在生存获益方面尚未得到令人信服的证实。
通过分析80岁及以上有症状的重度AS患者的结局，并探讨患者选择接受或拒绝AVR的影响，确定AVR所带来的生存获益。
队列研究。
将2001年至2006年间确诊的80岁及以上有严重症状的AS患者分为三组：接受AVR的患者（A组）；适合AVR但因个人选择拒绝手术的患者（B组）；不适合手术而接受保守治疗的患者（C组）。通过门诊随访、病历审查和电话访谈进行随访。主要终点是全因死亡率。
共确定了103例患者（86.0±4.2岁，41%为男性），随访期间无患者失访。在A组（n = 17）中，15例接受AVR的患者在3.6±1.4年的随访后均存活，2例在等待AVR期间死亡。B组（n = 24）的74%和C组（n = 62）的76%在随访期间死亡。A组的生存率明显优于B组和C组（P < 0.01）。在具有相似手术风险且适合AVR的患者（A组和B组）中，拒绝手术（风险比12.61，P = 0.001）是多变量模型中死亡率的唯一预测因素。
对于适合手术的老年AS患者，患者拒绝AVR的决定与死亡风险增加12倍以上相关。这些发现对于管理适合手术的老年AS患者时的知情决策具有重要意义。
