Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and University of Berne, Berne, Switzerland.
J Thorac Cardiovasc Surg. 2012 Nov;144(5):1075-83. doi: 10.1016/j.jtcvs.2012.01.024. Epub 2012 Feb 17.
Aortic valve replacement using a tissue valve is controversial for patients younger than 60 years old. The long-term survival in this age group, the expected event rates during long-term follow-up, and valve-related complications are not clearly determined.
From January 2000 to December 2009, overall survival, valve-related events, and echocardiographic outcomes were analyzed in all patients younger than 60 years of age, who underwent biologic aortic valve replacement. Patients who received a Perimount Carpentier-Edwards pericardial tissue valve (n = 103) were selected and compared with a propensity matched group of 103 patients who received aortic valve replacement using a mechanical bileaflet valve. The mean follow-up was 33 ± 24 months (range, 2-120), and the mean age at implantation was 50.6 ± 8.8 years (bioprosthesis, 55 ± 8.9 years; mechanical valve, 50 ± 8.6 years; P = .03).
Survival was significantly reduced in patients after biologic aortic valve replacement (90.3% vs 98%; P = .038). Freedom from all valve-related complications (bioprosthesis, 54.5%; mechanical valve, 51.6%; P = NS) and freedom from reoperation (bioprostheses, 100%; mechanical valve, 98%; P = NS) were comparable in both groups. The average transvalvular mean (11.2 ± 4.2 mm Hg vs 10.5 ± 6.0 mm Hg, P = .05) and peak (19.9 ± 6.7 mm Hg vs 16.7 ± 8.0 mm Hg, P = .03) gradients were greater after biologic aortic valve replacement. Regression of the left ventricular mass index was more pronounced after mechanical valve replacement (118.5 ± 24.9 g/m(2) vs 126.5 ± 38.5 g/m(2); P = NS). The echocardiographic patient-prosthesis mismatch was greater at follow-up after biological aortic valve replacement (0.876 ± 0.2 cm(2)/m(2) vs 1.11 ± 0.4 cm(2)/m(2); P = .01). Oral anticoagulation was a protective factor for survival among the bioprosthetic valve patients (P = .024).
In the present limited cohort of patients younger than 60 years old, biologic aortic valve replacement was associated with reduced mid-term survival compared with survival after mechanical aortic valve replacement. Despite similar valve-related event rates in both groups, the better hemodynamic performance of the mechanical valves and/or protective effect of oral anticoagulation seemed to improve the outcome. The transcatheter valve-in-valve intervention as potential treatment of tissue valve degeneration should not be considered the sole bailout strategy for younger patients because no evidence is available that this would improve the outcome.
对于 60 岁以下的患者，使用组织瓣膜进行主动脉瓣置换存在争议。该年龄段患者的长期生存率、长期随访期间的预期事件发生率以及与瓣膜相关的并发症尚不清楚。
从 2000 年 1 月至 2009 年 12 月，对所有 60 岁以下接受生物主动脉瓣置换术的患者进行总体生存率、与瓣膜相关的事件和超声心动图结果分析。选择接受心包组织瓣（Perimount Carpentier-Edwards）的患者（n=103），并与接受机械双叶瓣置换术的 103 名患者进行倾向性匹配。平均随访时间为 33±24 个月（范围为 2-120），植入时的平均年龄为 50.6±8.8 岁（生物瓣膜组为 55±8.9 岁；机械瓣膜组为 50±8.6 岁；P=0.03）。
生物主动脉瓣置换后患者的生存率显著降低（90.3%比 98%；P=0.038）。两组的所有与瓣膜相关的并发症发生率（生物瓣膜组为 54.5%；机械瓣膜组为 51.6%；P=NS）和再次手术率（生物瓣膜组为 100%；机械瓣膜组为 98%；P=NS）均无差异。生物主动脉瓣置换后跨瓣平均（11.2±4.2mmHg 比 10.5±6.0mmHg，P=0.05）和峰值（19.9±6.7mmHg 比 16.7±8.0mmHg，P=0.03）梯度更高。机械瓣膜置换后左心室质量指数的回归更为明显（118.5±24.9g/m2比 126.5±38.5g/m2；P=NS）。生物主动脉瓣置换后随访时超声心动图患者-瓣膜不匹配更为明显（0.876±0.2cm2/m2比 1.11±0.4cm2/m2；P=0.01）。生物瓣膜患者的口服抗凝是生存的保护因素（P=0.024）。
在目前 60 岁以下的有限患者队列中，与机械主动脉瓣置换相比，生物主动脉瓣置换与中期生存率降低相关。尽管两组的与瓣膜相关的事件发生率相似，但机械瓣膜的更好的血流动力学性能和/或口服抗凝的保护作用似乎改善了预后。经导管瓣膜内瓣置换术作为组织瓣膜退行性变的潜在治疗方法不应被视为年轻患者的唯一抢救策略，因为目前尚无证据表明这会改善预后。
