Bach David S, Siao Derrick, Girard Steven E, Duvernoy Claire, McCallister Benjamin D, Gualano Sarah K
Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan 48109-5853, USA.
Circ Cardiovasc Qual Outcomes. 2009 Nov;2(6):533-9. doi: 10.1161/CIRCOUTCOMES.109.848259. Epub 2009 Oct 27.
Some patients with severe symptomatic aortic stenosis (AS) do not undergo aortic valve replacement (AVR) despite demonstrated symptomatic and survival advantages and despite unequivocal guideline recommendations for surgical evaluation.
In 3 large tertiary care institutions (university, Veterans Affairs, and private practice) in Washtenaw County, Mich, patients were identified with unrefuted echocardiography/Doppler evidence of severe AS during calendar year 2005. Medical records were retrospectively reviewed for symptoms, referral for AVR, calculated operative risk for AVR, and rationale as to why patients did not undergo valve replacement. Of 369 patients with severe AS, 191 (52%) did not undergo AVR. Of these, 126 (66%, 34% of total) had symptoms consistent with AS. The most common reasons cited for absent intervention were comorbidities with high operative risk (61 patients [48%]), patent refusal (24 patients [19%]), and symptoms unrelated to AS (24 patients [19%]). Operated patients had a lower Society of Thoracic Surgery-calculated perioperative mortality risk than unoperated patients (1.8% [interquartile range, 1.0 to 3.0%] versus 2.7% [interquartile range, 1.6 to 5.5%], P<0.001). However, 28 (24%) of 126 unoperated symptomatic patients had a calculated perioperative risk less than the median risk for patients who underwent AVR. Only 57 (30%) of 191 unoperated patients were evaluated by a cardiac surgeon. There were similar rates of intervention across practice settings, and similar rates of unoperated patients despite symptoms and low operative risk.
One third of patients with severe AS are symptomatic but do not undergo AVR, with similar findings in multiple practice environments. For most unoperated patients, objectively calculated operative risks did not appear prohibitive. Despite this, a minority of unoperated patients were referred for surgical consultation. Some patients with severe symptomatic AS may be inappropriately denied access to potentially life-saving therapy.
一些有严重症状性主动脉瓣狭窄（AS）的患者尽管有证据表明手术治疗在改善症状和提高生存率方面具有优势，且明确的指南也推荐进行手术评估，但仍未接受主动脉瓣置换术（AVR）。
在密歇根州沃什特瑙县的3家大型三级医疗机构（大学附属医院、退伍军人事务部医院和私立医疗机构）中，确定了2005年经超声心动图/多普勒检查确诊为严重AS的患者。对这些患者的病历进行回顾性分析，记录其症状、是否被转诊进行AVR、计算得出的AVR手术风险以及未接受瓣膜置换术的原因。在369例严重AS患者中，191例（52%）未接受AVR。其中，126例（66%，占总数的34%）有与AS相符的症状。未进行干预的最常见原因是合并症导致手术风险高（61例[48%]）、患者拒绝（24例[19%]）以及与AS无关的症状（24例[19%]）。接受手术的患者经胸外科协会计算的围手术期死亡风险低于未接受手术的患者（1.8%[四分位间距，1.0%至3.0%]对2.7%[四分位间距，1.6%至5.5%]，P<0.001）。然而，126例未接受手术的有症状患者中有28例（24%）计算得出的围手术期风险低于接受AVR患者的中位数风险。191例未接受手术的患者中只有57例（30%）接受了心脏外科医生的评估。不同医疗机构的干预率相似，有症状且手术风险低的患者未接受手术的比例也相似。
三分之一有严重AS的患者有症状但未接受AVR，在多个医疗机构中均有类似发现。对于大多数未接受手术的患者，客观计算得出的手术风险似乎并非过高。尽管如此，只有少数未接受手术的患者被转诊进行外科咨询。一些有严重症状性AS的患者可能被不恰当地拒绝了可能挽救生命的治疗。
