Kuntz R E, Tosteson A N, Berman A D, Goldman L, Gordon P C, Leonard B M, McKay R G, Diver D J, Safian R D
Charles A. Dana Research Institute, Boston.
N Engl J Med. 1991 Jul 4;325(1):17-23. doi: 10.1056/NEJM199107043250104.
Balloon aortic valvuloplasty was developed as an alternative to aortic-valve replacement in selected elderly patients with aortic stenosis. The use of this procedure is limited, however, by a high incidence of restenosis.
Between December 1985 and April 1989, valvuloplasty was performed in 205 patients. We evaluated 40 demographic and hemodynamic variables as univariate predictors of event-free survival by Cox regression analysis and identified independent predictors of event-free survival by stepwise multivariate analysis.
Early hemodynamic results indicated a decrease in the peak transaortic-valve pressure gradient from 67 +/- 28 to 33 +/- 15 mm Hg after valvuloplasty and an increase in aortic-valve area from 0.6 +/- 0.2 to 0.9 +/- 0.3 cm2 (P less than 0.001 for both comparisons). The rate of event-free survival (defined as survival without recurrent symptoms, repeated valvuloplasty, or aortic-valve replacement) was 18 percent over the mean (+/- SD) follow-up period of 24 +/- 12 months (range, 1 to 47). Significant predictors of event-free survival included the left ventricular ejection fraction and the left ventricular and aortic systolic pressure before valvuloplasty, and the percent reduction in the aortic-valve pressure gradient; the pulmonary-capillary wedge pressure was inversely associated with event-free survival. Although the predicted event-free survival rate for the entire patient group was 50 percent at one year (95 percent confidence interval, 43 to 57 percent) and 25 percent at two years (95 percent confidence interval, 19 to 31 percent), the probability of event-free survival at one year varied between 23 and 65 percent when patients were stratified according to three independent predictors: the aortic systolic pressure, the pulmonary-capillary wedge pressure, and the percent reduction in the peak aortic-valve gradient.
The most important predictors of event-free survival after balloon aortic valvuloplasty were related to base-line left ventricular performance. The best long-term results after valvuloplasty were observed among patients who would also have been expected to have excellent long-term results after aortic-valve replacement.
球囊主动脉瓣成形术是作为某些老年主动脉瓣狭窄患者主动脉瓣置换术的替代方法而开发的。然而，该手术的应用受到再狭窄高发生率的限制。
1985年12月至1989年4月期间，对205例患者进行了瓣膜成形术。我们通过Cox回归分析评估了40个人口统计学和血流动力学变量作为无事件生存的单变量预测因素，并通过逐步多变量分析确定了无事件生存的独立预测因素。
早期血流动力学结果显示，瓣膜成形术后经主动脉瓣峰值压力梯度从67±28降至33±15 mmHg，主动脉瓣面积从0.6±0.2增加至0.9±0.3 cm²（两项比较P均<0.001）。在平均（±标准差）24±12个月（范围1至47个月）的随访期内，无事件生存（定义为无复发症状、重复瓣膜成形术或主动脉瓣置换术的生存）率为18%。无事件生存的重要预测因素包括左心室射血分数、瓣膜成形术前左心室和主动脉收缩压以及主动脉瓣压力梯度降低百分比；肺毛细血管楔压与无事件生存呈负相关。尽管整个患者组的预测无事件生存率在一年时为50%（95%置信区间，43%至57%），两年时为25%（95%置信区间，19%至31%），但根据三个独立预测因素（主动脉收缩压、肺毛细血管楔压和主动脉瓣峰值梯度降低百分比）对患者进行分层时，一年时无事件生存的概率在23%至65%之间变化。
球囊主动脉瓣成形术后无事件生存的最重要预测因素与基线左心室功能有关。在那些预计主动脉瓣置换术后也会有良好长期结果的患者中，观察到瓣膜成形术后的最佳长期结果。
