左心室功能不全患者主动脉瓣狭窄的主动脉瓣置换术。

Aortic valve replacement for aortic stenosis in patients with left ventricular dysfunction.

作者信息

Halkos Michael E, Chen Edward P, Sarin Eric L, Kilgo Patrick, Thourani Vinod H, Lattouf Omar M, Vega J David, Morris Cullen D, Vassiliades Thomas, Cooper William A, Guyton Robert A, Puskas John D

机构信息

Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia 30308, USA.

出版信息

Ann Thorac Surg. 2009 Sep;88(3):746-51. doi: 10.1016/j.athoracsur.2009.05.078.

DOI:10.1016/j.athoracsur.2009.05.078

PMID:19699891

Abstract

BACKGROUND

The purpose of this study was to assess the impact of left ventricular dysfunction and other risk factors on short- and mid-term outcomes after aortic valve replacement for aortic stenosis.

METHODS

From January 1, 2002, to December 31, 2007, 773 consecutive patients underwent primary aortic valve replacement for aortic stenosis at a single institution; concomitant coronary artery bypass graft surgery (CABG) was performed in 45.4% (351 of 773). Multivariable regression analysis was used to identify predictors of in-hospital mortality, with ejection fraction (EF) as the primary variable of interest. After discharge, survival status was determined using the Social Security Death Index. A Cox proportional hazards regression model was used to identify predictors of mid-term mortality.

RESULTS

On univariable analysis, EF (odds ratio [OR] 0.979, 95% confidence interval [CI]: 0.960 to 0.999, p = 0.044) but not concomitant CABG emerged as a predictor of in-hospital mortality. However, on multivariable analysis, neither EF nor concomitant CABG was associated with increased in-hospital mortality. Multivariable predictors of in-hospital mortality included age, emergent status, and prolonged bypass time. On univariable analysis, mid-term mortality was associated with EF and concomitant CABG (OR 0.979, 95% CI: 0.966 to 0.991, p = 0.001, and OR 1.61, 95% CI: 1.11 to 2.36, p = 0.013, respectively). However, after multivariable adjustment, only EF was associated with mid-term mortality (adjusted OR 0.985, 95% CI: 0.970 to 1.00, p = 0.049). Other multivariable predictors of mid-term mortality included age, dialysis-dependent renal failure, previous stroke, and peripheral vascular disease.

CONCLUSIONS

Left ventricular dysfunction, in addition to other patient comorbidities, may negatively impact survival after aortic valve replacement. Careful consideration of the cumulative effect of these multiple risk factors is necessary to optimize patient outcomes.

摘要

背景

本研究旨在评估左心室功能不全及其他危险因素对主动脉瓣狭窄患者主动脉瓣置换术后短期和中期预后的影响。

方法

2002年1月1日至2007年12月31日，一家机构的773例连续患者接受了主动脉瓣狭窄的初次主动脉瓣置换术；45.4%（773例中的351例）同时进行了冠状动脉旁路移植术（CABG）。多变量回归分析用于确定住院死亡率的预测因素，射血分数（EF）作为主要关注变量。出院后，使用社会保障死亡指数确定生存状态。Cox比例风险回归模型用于确定中期死亡率的预测因素。

结果

单变量分析显示，EF（比值比[OR]0.979，95%置信区间[CI]：0.960至0.999，p = 0.044）是住院死亡率的预测因素，而同时进行CABG不是。然而，多变量分析显示，EF和同时进行CABG均与住院死亡率增加无关。住院死亡率的多变量预测因素包括年龄、急诊状态和体外循环时间延长。单变量分析显示，中期死亡率与EF和同时进行CABG有关（OR分别为0.979，95%CI：0.966至0.991，p = 0.001；OR为1.61，95%CI：1.11至2.36，p = 0.013）。然而，多变量调整后，只有EF与中期死亡率有关（调整后OR 0.985，95%CI：0.970至1.00，p = 0.049）。中期死亡率的其他多变量预测因素包括年龄、依赖透析的肾衰竭、既往中风和外周血管疾病。