Zapolanski Alex, Mak Andrew W C, Ferrari Giovanni, Johnson Christopher, Shaw Richard E, Brizzio Mariano E, Sperling Jason S, Grau Juan B
Columbia University College of Physicians and Surgeons, The Valley Columbia Heart Center, Ridgewood, NJ, USA.
Interact Cardiovasc Thorac Surg. 2012 Sep;15(3):371-6. doi: 10.1093/icvts/ivs231. Epub 2012 Jun 4.
OBJECTIVES More elderly patients (>80 years of age) are being referred for aortic valve replacement (AVR) with or without CABG. Current risk stratification models may not accurately predict the preoperative risk in these patients. We sought to determine which perioperative variables were relevant in determining short-term (30-day to in-hospital) outcomes in our intuition's series of consecutive AVR and AVR+CABG surgeries. We constructed a novel variable, patient-prosthesis mismatch (PPM) in the presence of diminished functional status (NYHA) classification, and studied its role as a predictor of mortality risk. METHODS From 2006 to 2010, 509 patients undergoing AVR or AVR+CABG were evaluated. We created four groups based on the age and procedure (AVR >80, AVR+CABG >80, AVR <80 and AVR+CABG <80). PPM was defined as a calculated effective orifice area index value of ≤ 0.85, and it was calculated from manufacturer-generated charts. In-hospital and 30-day outcomes were assessed using the Chi-square and logistic regression analyses. RESULTS Overall observed 30-day mortality for all groups was lower (n = 8, 1.6%) than the STS-predicted mortality. Reoperation and PPM+NYHA class III-IV were associated with short-term mortality, but age >80 years was not. Octogenarians referred for surgery often had advanced heart failure. CONCLUSIONS Overall, short-term outcomes after AVR with or without CABG were excellent and lower than predicted by the STS model. The low risk of AVR with CABG supports the consideration for earlier surgical referral and intervention for patients with a high likelihood of aortic stenosis progression before the onset of advanced heart failure ensues, regardless of the age. This should help further decrease the already very low mortality observed in these series. Efforts to avoid PPM in the setting of advanced heart failure may improve short-term results in this subset of patients.
目的 越来越多的老年患者（>80岁）接受了有或没有冠状动脉旁路移植术（CABG）的主动脉瓣置换术（AVR）。目前的风险分层模型可能无法准确预测这些患者的术前风险。我们试图确定在我们机构连续进行的AVR和AVR+CABG手术系列中，哪些围手术期变量与短期（30天至住院期间）结局相关。我们构建了一个新的变量，即在功能状态（纽约心脏协会[NYHA]）分级降低的情况下的患者-人工瓣膜不匹配（PPM），并研究其作为死亡风险预测指标的作用。方法 对2006年至2010年期间接受AVR或AVR+CABG的509例患者进行了评估。我们根据年龄和手术方式（AVR>80、AVR+CABG>80、AVR<80和AVR+CABG<80）创建了四组。PPM定义为计算得出的有效瓣口面积指数值≤0.85，它是根据制造商提供的图表计算得出的。使用卡方检验和逻辑回归分析评估住院期间和30天的结局。结果 所有组观察到的总体30天死亡率（n = 8，1.6%）低于胸外科医师协会（STS）预测的死亡率。再次手术和PPM+NYHA III-IV级与短期死亡率相关，但年龄>80岁则不然。接受手术的八旬老人通常患有晚期心力衰竭。结论 总体而言，有或没有CABG的AVR术后短期结局良好，低于STS模型的预测值。AVR联合CABG的低风险支持对主动脉瓣狭窄进展可能性高的患者在晚期心力衰竭发作之前尽早进行手术转诊和干预，无论其年龄如何。这应有助于进一步降低这些系列中已非常低的死亡率。在晚期心力衰竭情况下避免PPM的努力可能会改善这部分患者的短期结果。
