Jaussaud Nicolas, Gariboldi Vlad, Grisoli Dominique, Berbis Julie, Kerbaul François, Riberi Alberto, Collart Frederic
Service de Chirurgie Cardiaque, Hôpital de la Timone, Marseille, France.
J Heart Valve Dis. 2012 Jan;21(1):56-60.
Today, when a mitral valve replacement is required, more patients and surgeons choose a bioprosthesis. Yet, the rationale of this choice is unclear in patients in whom age represents a predicting factor for reoperation. The study aim was to define the risk factors for reoperation after mitral bioprosthesis failure.
A total of 282 consecutive patients (202 women, 80 men; mean age at surgery 61 years; range: 28-88 years) who underwent reoperation for mitral bioprosthesis failure between 1990 and 2006 was reviewed. Surgery was undertaken because of bioprosthesis degeneration (91%), prosthetic valve infective endocarditis (6%), paravalvular leak (2%), or other causes (1%). Emergency procedures were performed in 7% of cases. Associated procedures included tricuspid valve surgery in 16% of patients (tricuspid valve repair in 11%, tricuspid valve replacement in 5%) and coronary artery bypass graft in 5%. Almost one-fifth of patients (18%) had undergone more than one previous mitral valve replacement.
The overall operative mortality was 7.4% (n = 21). Factors identified (by multivariate analysis) as predictors of operative death included: presence of diabetes mellitus (odds ratio (OR) = 8.69, 95% CI 2.55-29.61; p = 0.001), chronic obstructive pulmonary disease (OR = 9.01, 95% CI 1.72-47.18; p = 0.009), NYHA class III/IV (OR 5.46, 95% CI 1.41-21.16; p = 0.01), and pulmonary artery pressure > 60 mmHg (OR = 3.13, 95% CI 1.10-8.94; p = 0.03). Associated procedures were not significant risk factors for mortality. New prostheses were mechanical in 68% of cases, and bioprostheses in 32%.
One reoperation for mitral bioprosthesis dysfunction is acceptable if the patient can be expected to survive to reoperation while free from comorbidities and the severe effects of mitral disease. The application of strict selective criteria to recipients at the first valve replacement, combined with a close follow up, may allow this goal to be achieved.
如今，在需要进行二尖瓣置换时，越来越多的患者和外科医生选择生物瓣。然而，在年龄是再次手术预测因素的患者中，这种选择的理由尚不清楚。本研究的目的是确定二尖瓣生物瓣功能障碍再次手术后的危险因素。
回顾了1990年至2006年间因二尖瓣生物瓣功能障碍接受再次手术的282例连续患者（202例女性，80例男性；手术时平均年龄61岁；范围：28 - 88岁）。手术原因包括生物瓣退变（91%）、人工瓣膜感染性心内膜炎（6%）、瓣周漏（2%）或其他原因（1%）。7%的病例进行了急诊手术。相关手术包括16%的患者进行了三尖瓣手术（11%为三尖瓣修复，5%为三尖瓣置换），5%的患者进行了冠状动脉搭桥术。近五分之一的患者（18%）曾接受过不止一次二尖瓣置换术。
总体手术死亡率为7.4%（n = 21）。多因素分析确定的手术死亡预测因素包括：糖尿病（比值比（OR）= 8.69，95%可信区间2.55 - 29.61；p = 0.001）、慢性阻塞性肺疾病（OR = 9.01，95%可信区间1.72 - 47.18；p = 0.009）、纽约心脏协会（NYHA）心功能Ⅲ/Ⅳ级（OR 5.46，95%可信区间1.41 - 21.16；p = 0.01）以及肺动脉压> 60 mmHg（OR = 3.13，95%可信区间1.10 - 8.94；p = 0.03）。相关手术不是死亡的显著危险因素。68%的病例植入了新的机械瓣，32%植入了生物瓣。
如果预计患者能存活至再次手术且无合并症及二尖瓣疾病的严重影响，二尖瓣生物瓣功能障碍的一次再次手术是可以接受的。在首次瓣膜置换时对受者应用严格的选择标准，并结合密切随访，可能实现这一目标。
