Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada.
J Thorac Cardiovasc Surg. 2012 Jul;144(1):146-51. doi: 10.1016/j.jtcvs.2011.08.041. Epub 2011 Sep 29.
Recent evidence indicated that the use of a bioprosthesis in young patients at first-time aortic valve replacement (AVR) is associated with an increased reoperation risk, but not with an increase in long-term mortality, when compared with the use of a mechanical valve. However, at reoperative AVR, follow-up data by prosthesis type have been lacking from the literature. Therefore, we examined long-term survival and valve-related complications according to the type of prosthesis used at reoperative AVR.
We studied 437 patients who underwent reoperative AVR, at a mean age of 58.6 ± 14.2 years, for failure of a previously implanted aortic valve prosthesis. Thirty-day mortality at reoperative AVR was 6% (n = 27). A bioprosthesis was used in 135 (31%) patients. Patients were subsequently followed up for a mean of 7.6 ± 6.8 years after reoperative AVR.
The use of a bioprosthesis at reoperative AVR was not associated with impaired survival on adjusted analysis (hazard ratio [HR], 0.8 ± 0.4; P = .6). Freedom from thromboembolism, and endocarditis were similar between valve types (both P > .05); however, late postoperative major hemorrhage occurred only in patients who received a mechanical prosthesis at reoperative AVR. Risk factors for third-time AVR included the use of a bioprosthesis (HR, 14.0) and younger age (HR, 1.05 per decreasing year) at reoperative AVR (both P < .001). Thirty-day mortality of third-time AVR was 4% (n = 1/27).
At reoperative AVR, the use of a bioprosthesis is associated with equivalent long-term survival compared with a mechanical prosthesis. Patients who receive a bioprosthesis at reoperative AVR are less likely to experience major hemorrhage but more likely to require third-time AVR, albeit with an acceptable third-time perioperative mortality risk. Therefore, the patient's informed preferences regarding prosthesis choice should prevail, even in a reoperative context.
最近的证据表明，与使用机械瓣膜相比，在初次主动脉瓣置换（AVR）时，年轻患者使用生物瓣与再次手术风险增加相关，但与长期死亡率增加无关。然而，在再次 AVR 中，文献中缺乏关于假体类型的随访数据。因此，我们根据再次 AVR 中使用的假体类型检查了长期生存率和与瓣膜相关的并发症。
我们研究了 437 名因先前植入的主动脉瓣假体失效而接受再次 AVR 的患者，平均年龄为 58.6±14.2 岁。再次 AVR 术后 30 天死亡率为 6%（n=27）。135 例（31%）患者使用生物瓣。患者在再次 AVR 后平均随访 7.6±6.8 年。
调整分析显示，再次 AVR 中使用生物瓣与生存率降低无关（风险比[HR]，0.8±0.4；P=.6）。两种瓣膜类型的血栓栓塞和心内膜炎发生率相似（均 P＞.05）；然而，仅在再次 AVR 中接受机械瓣膜的患者中发生迟发性术后大出血。第三次 AVR 的危险因素包括再次 AVR 时使用生物瓣（HR，14.0）和年龄较小（HR，每年降低 1.05）（均 P＜.001）。第三次 AVR 的 30 天死亡率为 4%（n=1/27）。
在再次 AVR 中，与机械瓣膜相比，使用生物瓣与长期生存率相当。再次 AVR 中使用生物瓣的患者发生大出血的可能性较小，但更有可能需要第三次 AVR，尽管第三次围手术期死亡率风险可接受。因此，即使在再次手术的情况下，患者的假体选择知情偏好也应占主导地位。
