Department of Surgery, University of California San Francisco Medical Center, and San Francisco Veterans Affairs Medical Center, San Francisco, California 94143-0118, USA.
Ann Thorac Surg. 2011 Sep;92(3):866-72. doi: 10.1016/j.athoracsur.2011.04.028.
Transcatheter aortic valves were developed as an alternative to surgery for the one third to two thirds of patients with severe aortic stenosis who do not undergo aortic valve replacement. In this study, we examined reasons for medical management of aortic stenosis in relation to operative risks and outcomes for veterans with and without valve replacement.
The echocardiography database was screened from 2000 to 2007 for severe aortic stenosis. The Society of Thoracic Surgeons risk scores and survival were determined for patients with and without aortic valve replacement.
Of 132 severe aortic stenosis patients included, 42% were medically managed. Predicted operative mortality risk was lower for surgical patients than for medical patients (4.5%±4.2% versus 6.8%±5.1%, p=0.002). Overall, the most common reason for medical management of aortic stenosis was assumption that the patient was high risk for surgery (30.4%). The surgery group had significantly higher median survival (92.2 versus 32.4 months) and 5-year survival (71% versus 37%, p<0.001) than the medical group. Cardiac surgery was not consulted in 61% of medically managed patients, of whom only 18% had Society of Thoracic Surgeons risk score of 10 or greater. Aortic valve replacement was an independent predictor of lower mortality (hazard ratio 0.43, p=0.008).
Although operative risk was higher among patients who did not undergo surgery, most were not the 10% or greater required for transcatheter valves. Given the significantly lower survival with medical therapy, aortic valve replacement should be carefully considered for most severe aortic stenosis patients whereas transcatheter aortic valves should be reserved for patients with high operative risks.
经导管主动脉瓣置换术是一种替代手术的方法，适用于三分之一至三分之二的重度主动脉瓣狭窄患者，这些患者不接受主动脉瓣置换术。在这项研究中，我们研究了与手术风险和结果相关的主动脉瓣狭窄的药物治疗原因，以及有和没有瓣膜置换的退伍军人的原因。
从 2000 年到 2007 年，我们筛选了超声心动图数据库，以寻找严重的主动脉瓣狭窄患者。确定了有和没有主动脉瓣置换术的患者的胸外科医师协会风险评分和生存率。
在 132 名严重主动脉瓣狭窄患者中，42%接受了药物治疗。手术患者的预计手术死亡率低于药物治疗患者（4.5%±4.2%对 6.8%±5.1%，p=0.002）。总的来说，主动脉瓣狭窄药物治疗的最常见原因是假设患者手术风险高（30.4%）。手术组的中位生存率（92.2 对 32.4 个月）和 5 年生存率（71%对 37%，p<0.001）均显著高于药物治疗组。在接受药物治疗的患者中，有 61%没有咨询心脏外科医生，其中只有 18%的患者胸外科医师协会风险评分大于或等于 10。主动脉瓣置换是降低死亡率的独立预测因素（风险比 0.43，p=0.008）。
尽管未接受手术的患者手术风险较高，但大多数患者的风险并不大于需要经导管瓣膜置换的 10%。鉴于药物治疗的生存率明显较低，对于大多数严重主动脉瓣狭窄患者，应仔细考虑主动脉瓣置换术，而经导管主动脉瓣置换术应保留给手术风险高的患者。
