再次行主动脉瓣手术：人工瓣膜心内膜炎对结局的影响。

Redo aortic valve surgery: Influence of prosthetic valve endocarditis on outcomes.

机构信息

Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany.

出版信息

J Thorac Cardiovasc Surg. 2011 Jul;142(1):99-105. doi: 10.1016/j.jtcvs.2010.08.042. Epub 2010 Oct 15.

DOI:10.1016/j.jtcvs.2010.08.042

PMID:20951390

Abstract

OBJECTIVE

Compared with reoperative aortic valve replacement for nonendocarditic causes, the contemporary risk and long-term outcomes of reoperation for aortic prosthetic valve endocarditis are ill-defined.

METHODS

Between December 1994 and April 2008, 313 patients underwent reoperative aortic valve replacement, of whom 152 (48.6%) had prosthetic valve endocarditis. Mean follow-up was 6.5 ± 0.4 years and 97.4% complete.

RESULTS

Patients with prosthetic valve endocarditis were older with a higher risk profile. The overall hospital mortality was 15.3% (n = 48) (prosthetic valve endocarditis vs nonendocarditis: 24.3%, n = 37, vs 6.8%, n = 11; P < .001). Independent predictors of perioperative mortality for prosthetic valve endocarditis were sepsis (odds ratio [OR], 6.5; 95% confidence interval [CI], 2.0-21.0; P < .01), ejection fraction less than 30% (OR, 5.8; 95% CI, 1.3-25.0; P = .02), concomitant coronary artery bypass grafting (OR, 3.3; 95% CI, 1.1-9.8; P = .03), and aortic root abscess (OR, 2.7; 95% CI, 1.2-6.4; P = .02), and for the nonendocarditis group were concomitant coronary artery bypass grafting (OR, 8.1; 95% CI, 2.0-33.0; P < .01), and mitral valve surgery (OR, 4.8; 95% CI, 1.3-17.9; P = .02). The 1-, 3-, 5-, and 10-year survivals for patients with and without prosthetic valve endocarditis were 52% ± 4% versus 82% ± 3%, 43% ± 5% versus 73% ± 4%, 37% ± 5% versus 63% ± 5%, and 31% ± 7% versus 56% ± 8%, respectively (log rank < 0.001). Predictors of long-term mortality in prosthetic valve endocarditis were sepsis (OR, 3.1; 95% CI, 1.5-4.5; P < .01) and unstable preoperative status (OR, 1.8; 95% CI, 1.2-3.5; P = .04), whereas in nonendocarditis patients the only predictor was New York Heart Association class IV (OR, 2.5; 95% CI, 2.8-7.4; P < .01). Five-year actuarial freedom from endocarditis was 80% ± 0.3% versus 95% ± 0.6% (prosthetic valve endocarditis cersus nonendocarditis; P = .002).

CONCLUSIONS

Despite contemporary therapy, reoperation for aortic prosthetic valve endocarditis is still associated with relatively high perioperative mortality and limited long-term survival.

摘要

目的

与非感染性病因的再次主动脉瓣置换术相比，目前对于主动脉人工瓣膜心内膜炎再次手术的风险和长期预后仍不明确。

方法

1994 年 12 月至 2008 年 4 月，共有 313 例患者接受了再次主动脉瓣置换术，其中 152 例（48.6%）患有人工瓣膜心内膜炎。平均随访 6.5±0.4 年，随访率为 97.4%。

结果

患有人工瓣膜心内膜炎的患者年龄较大，风险状况更高。总体院内死亡率为 15.3%（n=48）（心内膜炎 vs 非心内膜炎：24.3%，n=37；6.8%，n=11；P<.001）。人工瓣膜心内膜炎围手术期死亡的独立预测因素为败血症（优势比[OR]，6.5；95%置信区间[CI]，2.0-21.0；P<.01）、射血分数<30%（OR，5.8；95%CI，1.3-25.0；P=0.02）、同期行冠状动脉旁路移植术（OR，3.3；95%CI，1.1-9.8；P=0.03）和主动脉根部脓肿（OR，2.7；95%CI，1.2-6.4；P=0.02）；而非心内膜炎组的独立预测因素为同期行冠状动脉旁路移植术（OR，8.1；95%CI，2.0-33.0；P<.01）和同期行二尖瓣手术（OR，4.8；95%CI，1.3-17.9；P=0.02）。有心内膜炎和无心内膜炎患者的 1 年、3 年、5 年和 10 年生存率分别为 52%±4%和 82%±3%、43%±5%和 73%±4%、37%±5%和 63%±5%以及 31%±7%和 56%±8%（对数秩检验，P<.001）。人工瓣膜心内膜炎患者长期死亡的预测因素为败血症（OR，3.1；95%CI，1.5-4.5；P<.01）和不稳定的术前状态（OR，1.8；95%CI，1.2-3.5；P=0.04），而非心内膜炎患者的唯一预测因素为纽约心脏协会心功能分级 IV 级（OR，2.5；95%CI，2.8-7.4；P<.01）。5 年无瓣心内膜炎的累积生存率为 80%±0.3%和 95%±0.6%（心内膜炎 vs 非心内膜炎；P=0.002）。