Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, UK.
Eur J Cardiothorac Surg. 2011 Sep;40(3):743-8. doi: 10.1016/j.ejcts.2010.12.036. Epub 2011 Feb 22.
High-risk patients with aortic stenosis are increasingly referred to specialist multidisciplinary teams (MDTs) for consideration of trans-catheter aortic valve implantation (TAVI). A subgroup of these cases is unsuitable for TAVI, and high-risk conventional aortic valve replacement (AVR) is undertaken. We have studied our outcomes in this cohort.
Data prospectively collected between March 2008 and November 2009 for patients (n = 28, nine male) undergoing high-risk AVR were analysed. The mean age was 78.4 ± 9.2 years. The mean additive EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 10.0 ± 3.6 and mean logistic EuroSCORE was 19.9 ± 18.8. Three patients had undergone previous coronary artery bypass grafting (CABG).
The mean ejection fraction was 51 ± 16%, mean valve area 0.56 ± 0.19 cm², and mean peak gradient 91 ± 27 mm Hg. Ascending aortic, right axillary artery and femoral artery cannulation was used in 64%, 29% and 7% of cases, respectively. Median cross-clamp and cardiopulmonary bypass times were 84 (68-143) min and 111 (94-223) min. The median (range) inserted valve size was 21 (19-25) mm. Median intensive care and overall hospital stay were 5 (2-37) and 11 (5-44) days, respectively. In-hospital mortality was 4% (one patient). Postoperative complications included re-operation for bleeding (7%), renal failure (21%), tracheostomy (14%), sternal wound infection (7%), atrial fibrillation (25%) and permanent pacemaker implantation (7%). Kaplan-Meier survival at median follow-up of 359 (148-744) days was 81% (one further death of non-cardiac aetiology). Quality-of-life assessment at follow-up also yielded satisfactory results.
MDT assessment of high-risk aortic stenosis in the era of TAVI has increased the number of referrals. Conventional open surgery remains a valid option for these patients, with acceptable in-hospital mortality and early/midterm outcomes but high in-hospital morbidity.
患有主动脉瓣狭窄的高危患者越来越多地被转介到多学科专家团队（MDT），以考虑行经导管主动脉瓣植入术（TAVI）。这些病例中有一部分不适合 TAVI，需要进行高危传统主动脉瓣置换术（AVR）。我们研究了这部分患者的结局。
对 2008 年 3 月至 2009 年 11 月期间接受高危 AVR 的 28 例患者（9 例男性）的数据进行前瞻性收集和分析。患者平均年龄为 78.4±9.2 岁。平均加用欧洲心脏手术风险评估系统（EuroSCORE）为 10.0±3.6，平均逻辑 EuroSCORE 为 19.9±18.8。3 例患者曾行冠状动脉旁路移植术（CABG）。
平均射血分数为 51±16%，平均瓣膜面积为 0.56±0.19cm²，平均峰值梯度为 91±27mmHg。升主动脉、右腋动脉和股动脉插管分别用于 64%、29%和 7%的病例。中位体外循环和心肺转流时间分别为 84（68-143）min 和 111（94-223）min。中位（范围）置入瓣膜大小为 21（19-25）mm。中位重症监护和总住院时间分别为 5（2-37）天和 11（5-44）天。院内死亡率为 4%（1 例患者）。术后并发症包括再次出血（7%）、肾功能衰竭（21%）、气管切开术（14%）、胸骨伤口感染（7%）、心房颤动（25%）和永久性起搏器植入（7%）。中位随访 359（148-744）天的 Kaplan-Meier 生存为 81%（1 例非心脏病因死亡）。随访时的生活质量评估也取得了满意的结果。
在 TAVI 时代，MDT 对高危主动脉瓣狭窄的评估增加了转诊人数。传统的开放手术仍然是这些患者的有效选择，具有可接受的院内死亡率和早期/中期结局，但院内发病率较高。
