Jaussaud Nicolas, Gariboldi Vlad, Giorgi Roch, Grisoli Dominique, Chalvignac Virginie, Thuny Franck, Riberi Alberto, Collart Frederic
Department of Cardiac Surgery, Timone University Hospital, Marseille, France.
J Heart Valve Dis. 2009 May;18(3):256-61.
The risk of reoperative valve replacement for failed aortic bioprosthesis may be overestimated, this being a dominant factor when selecting an initial prosthesis to be implanted in patients aged <70 years. The study aims were, first, to analyze the mortality and morbidity of redo aortic bioprosthesis replacement in the current era, and second, to identify preoperative risk factors and evaluate the EuroSCORE.
A total of 156 consecutive patients (111 men, 45 women; mean age 60.9 years; range: 23-87 years) who underwent reoperation for failed aortic bioprosthesis between 1990 and 2006 was reviewed in this retrospective, single-center study. Surgery was undertaken due to bioprosthesis degeneration (82.7%), bacterial prosthetic endocarditis (14.1%), paravalvular leak (1.3%) and other causes (1.9%). Emergency procedures were performed in 9% of patients. Associated procedures were coronary artery bypass grafting in 7.7% of patients, ascending aortic graft in 7%, and complete aortic root replacement in 6.4%. The predictive mortality was 8% according to the Additive EuroSCORE, and 15% according to the Logistic EuroSCORE.
Overall, the operative mortality was 3.8% (n = 6), and postoperative morbidity was low. The only multivariable predictor was emergency surgery (OR = 15.22, 95% CI = 1.68-86.43; p = 0.02). A mortality trend was associated with atrial fibrillation and NYHA class III/IV, but this was not statistically significant (p = 0.09 and p = 0.06, respectively). Associated procedures were not significant risk factors for mortality.
Reoperation for aortic bioprosthesis dysfunction can be performed with a low risk of mortality. It appears that this risk is overestimated by the EuroSCORE. Those patients who wish to avoid postoperative anticoagulant therapy may choose to receive this type of valve, even if reoperation is foreseeable.
主动脉生物瓣膜置换失败后再次手术的风险可能被高估，这是为年龄小于70岁的患者选择初始植入瓣膜时的一个主导因素。本研究的目的，其一，分析当前时代再次主动脉生物瓣膜置换的死亡率和发病率；其二，识别术前风险因素并评估欧洲心脏手术风险评估系统（EuroSCORE）。
在这项回顾性单中心研究中，对1990年至2006年间因主动脉生物瓣膜置换失败而接受再次手术的156例连续患者（111例男性，45例女性；平均年龄60.9岁；范围：23 - 87岁）进行了回顾。手术原因包括生物瓣膜退变（82.7%）、细菌性人工瓣膜心内膜炎（14.1%）、瓣周漏（1.3%）和其他原因（1.9%）。9%的患者进行了急诊手术。7.7%的患者同时进行了冠状动脉旁路移植术，7%的患者进行了升主动脉移植，6.4%的患者进行了完整主动脉根部置换。根据欧洲心脏手术风险评估系统相加法，预测死亡率为8%；根据逻辑法，预测死亡率为15%。
总体而言，手术死亡率为3.8%（n = 6），术后发病率较低。唯一的多变量预测因素是急诊手术（比值比 = 15.22，95%置信区间 = 1.68 - 86.43；p = 0.02）。房颤和纽约心脏协会（NYHA）心功能III/IV级与死亡率有一定趋势相关，但无统计学意义（p分别为0.09和0.06）。同期手术不是死亡率的显著风险因素。
主动脉生物瓣膜功能障碍的再次手术死亡率较低。欧洲心脏手术风险评估系统似乎高估了这种风险。那些希望避免术后抗凝治疗的患者，即使可预见需要再次手术，也可选择接受这种类型的瓣膜。
