Chen Jian, Lin Yiyun, Kang Bo, Wang Zhinong
Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China.
Eur J Cardiothorac Surg. 2014 Feb;45(2):234-40. doi: 10.1093/ejcts/ezt245. Epub 2013 May 16.
Prosthesis-patient mismatch (PPM) is defined as a too-small effective orifice area (EOA) of an inserted prosthetic relative to body size, resulting in an abnormally high postoperative gradient. It is unclear, however, whether residual stenosis after aortic valve replacement (AVR) has a negative impact on mid- and long-term survivals. We searched electronic databases, including PubMed, Embase, Medline and the Cochrane controlled trials register, through October 2012, to identify published full-text English studies on the association between PPM and mortality rates. A significant PPM was defined as an indexed EOA (iEOA)<0.85 cm2/m2, and severe PPM as an iEOA<0.65 cm2/m2. Two reviewers independently assessed the studies for inclusion and extracted data. Fourteen observational studies, involving 14 874 patients, met our final inclusion criteria. Meta-analysis demonstrated that PPM significantly increased mid-term (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.19-1.69) and long-term (OR 1.52, 95% CI 1.26-1.84) all-cause mortalities. Subgroup analysis showed that PPM was associated with higher mid- and long-term mortality rates only in younger and predominantly female populations. Risk-adjusted sensitivity analysis showed that severe PPM was associated with reduced survival (adjusted hazard ratio [HR] 1.50, 95% CI 1.24-1.80), whereas moderate PPM was not (adjusted HR 0.96, 95% CI 0.86-1.07). Regardless of severity, however, PPM had a negative effect on survival in patients with impaired ejection fraction (adjusted HR 1.26, 95% CI 1.09-1.47). PPM (iEOA<0.85 cm2/m2) after AVR tended to be associated with increased long-term all-cause mortality in younger patients, females and patients with preoperative left ventricular dysfunction. Severe PPM (iEOA<0.65 cm2/m2) was a significant predictor of reduced long-term survival in all populations undergoing AVR.
人工瓣膜-患者不匹配（PPM）定义为植入的人工瓣膜有效瓣口面积（EOA）相对于身体大小过小，导致术后梯度异常升高。然而，主动脉瓣置换术（AVR）后残余狭窄是否对中长期生存率有负面影响尚不清楚。我们检索了电子数据库，包括截至2012年10月的PubMed、Embase、Medline和Cochrane对照试验注册库，以确定已发表的关于PPM与死亡率之间关联的英文全文研究。显著PPM定义为指数化EOA（iEOA）<0.85 cm2/m2，严重PPM定义为iEOA<0.65 cm2/m2。两名 reviewers 独立评估研究是否纳入并提取数据。14项观察性研究，涉及14874例患者，符合我们的最终纳入标准。荟萃分析表明，PPM显著增加中期（比值比[OR]1.42，95%置信区间[CI]1.19-1.69）和长期（OR 1.52，95%CI 1.26-1.84）全因死亡率。亚组分析表明，PPM仅在年轻且以女性为主的人群中与较高的中长期死亡率相关。风险调整敏感性分析表明，严重PPM与生存率降低相关（调整后风险比[HR]1.50，95%CI 1.24-1.80），而中度PPM则不然（调整后HR 0.96，95%CI 0.86-1.07）。然而，无论严重程度如何，PPM对射血分数受损患者的生存都有负面影响（调整后HR 1.26，95%CI 1.09-1.47）。AVR后PPM（iEOA<0.85 cm2/m2）在年轻患者、女性和术前左心室功能障碍患者中往往与长期全因死亡率增加相关。严重PPM（iEOA<0.65 cm2/m2）是所有接受AVR人群长期生存降低的重要预测因素。
