Department of Cardio-thoracic and Vascular Surgery, G.B. Pant Hospital, New Delhi, India.
J Cardiovasc Med (Hagerstown). 2010 Nov;11(11):836-42. doi: 10.2459/JCM.0b013e32833e5687.
The ideal management of aortic stenosis in patients with a small aortic root remains controversial. Reports of adverse effects of patient-prosthesis mismatch (PPM) from a small-sized valve have to be weighed against the increased morbidity and mortality of aortic root enlargement procedures.
The present study retrospectively reviewed and compared clinical data of patients with predominant aortic stenosis with small aortic root (n = 209) who underwent isolated aortic valve replacement without (AVR group, n = 162) or with aortic root enlargement (AVR + ARE group, n = 47) using a single prosthesis type between January 2002 and June 2008 to assess their effect on perioperative outcomes.
The in-hospital mortality (4.28% in AVR + ARE vs. 3.08% in AVR group) and other perioperative outcomes were similar in both the groups. Although patients of the AVR + ARE group had a greater degree of left-ventricular (LV) mass regression (-41.3 ± 32.1 vs. -21.5 ± 37.4) in the follow-up period at 12 months, there was no significant difference in functional outcome. Patients with severe postoperative PPM (indexed effective orifice area ≤0.65 cm²/m² body surface area) showed increased perioperative mortality (9.52 vs. 1.85%) and less regression of LV mass (-13.2.8 ± 27.1 vs. -27.6 ± 31.9), higher transvalvular gradient and were more symptomatic at 12-month follow-up (New York Heart Association class 1.44 ± 0.41 vs. 1.22 ± 0.28) compared to those who were having only mild to moderate PPM (indexed effective orifice area > 0.65).
ARE procedures are invaluable techniques in surgical management of small aortic root patients and can be used without significantly increasing early morbidity and mortality, particularly in those cases in which AVR with a small prosthesis will lead to severe PPM.
对于主动脉瓣狭窄合并小主动脉根部患者，理想的治疗方案仍存在争议。使用小型号瓣膜可能会导致患者-假体不匹配（PPM）的不良后果，因此需要权衡这一风险与主动脉根部扩大手术带来的更高发病率和死亡率。
本研究回顾性分析了 2002 年 1 月至 2008 年 6 月期间采用同种瓣膜行单纯主动脉瓣置换术的 209 例以主动脉瓣狭窄为主合并小主动脉根部患者的临床资料，其中未行主动脉根部扩大术（AVR 组，n = 162）或行主动脉根部扩大术（AVR + ARE 组，n = 47），评估其对围手术期结果的影响。
AVR + ARE 组的院内死亡率（4.28%比 AVR 组的 3.08%）和其他围手术期结果与 AVR 组相似。虽然 AVR + ARE 组患者在 12 个月的随访中左心室（LV）质量的回归程度更大（-41.3 ± 32.1 比-21.5 ± 37.4），但心功能无显著差异。严重术后 PPM（有效瓣口面积指数≤0.65 cm²/m²体表面积）患者的围手术期死亡率较高（9.52%比 1.85%），LV 质量的回归较少（-13.2.8 ± 27.1 比-27.6 ± 31.9），跨瓣压差较高，且在 12 个月的随访中症状更明显（纽约心脏协会心功能分级 1.44 ± 0.41 比 1.22 ± 0.28），与仅存在轻至中度 PPM（有效瓣口面积指数＞0.65）的患者相比。
对于小主动脉根部患者，主动脉根部扩大术是一种有价值的手术治疗方法，在不显著增加早期发病率和死亡率的情况下，可以安全使用，特别是在使用小型号瓣膜会导致严重 PPM 的情况下。
