Lund O, Nielsen T T, Pilegaard H K, Magnussen K, Knudsen M A
Department of Thoracic Surgery, Skejby Sygehus, Aarhus University Hospital, Denmark.
J Thorac Cardiovasc Surg. 1990 Sep;100(3):327-37.
The influence of coronary artery disease and bypass grafting on survival after valve replacement for aortic stenosis (1975 to 1986, N = 512) was analyzed. Mean follow-up for 30-day survivors was 5.1 years (0.1 to 12.9 years). A total of 205 patients had coronary angiography performed: 122 did not have coronary artery disease, 55 with coronary artery disease underwent bypass grafting, and 28 with coronary artery disease did not. Early mortality rates (less than or equal to 30 days)/5-year cumulative survivals (standard error) were 4.1%/86% (4%), 3.6%/68% (8%), and 17.9%/51% (13%), respectively (p less than 0.05/p less than 0.01). Triple vessel/left main stem disease was more prevalent in patients with coronary disease who underwent bypass grafting (47%) than in those who did not (14%; p less than 0.05). Multivariate analysis revealed that right ventricular failure and omission of bypass grafting in patients with coronary artery disease were independent determinants of early mortality. A Cox regression analysis identified coronary artery disease and aortic valve gradient as determinants of mortality after hospital dismissal, which was not influenced by bypass grafting. On the basis of a coronary artery disease score (positive predictive value for coronary artery disease of 66%) developed on the patients with angiography, 307 patients without angiography were divided into 234 with a low score and 73 with a high score. Early mortality rates/5-year survivals (standard error) were 6.4%/86% (2%) and 16.4%/67% (6%), respectively (p less than 0.01/p less than 0.001). Autopsy revealed stenotic or occlusive coronary artery disease in 92% of 12 early deaths in the group with a high coronary artery disease score and in 33% of 15 in the group with a low score (p less than 0.01). Left ventricular failure and a high coronary artery disease score were independent determinants of early mortality, whereas cardiothoracic index, a high coronary artery disease score, and left ventricular failure were independent predictors of death after hospital dismissal. Despite more severe coronary artery disease, bypass grafting reduced early mortality to a level comparable with that of patients without coronary artery disease, contrasting with a high early mortality rate for unbypassed coronary artery disease. Coronary artery disease increased the late mortality rate, which was not modified by bypass grafting. In the group without angiography, undiagnosed and unbypassed coronary artery disease probably increased both early and late mortality. Coronary angiography should be performed in all adult patients with aortic stenosis, and those with significant coronary artery disease should undergo bypass grafting concomitant with valve replacement.
分析了冠状动脉疾病和搭桥术对主动脉瓣狭窄瓣膜置换术后生存情况的影响（1975年至1986年，N = 512）。对30天存活者的平均随访时间为5.1年（0.1至12.9年）。共有205例患者接受了冠状动脉造影：122例无冠状动脉疾病，55例有冠状动脉疾病的患者接受了搭桥术，28例有冠状动脉疾病的患者未接受搭桥术。早期死亡率（≤30天）/5年累积生存率（标准误）分别为4.1%/86%（4%）、3.6%/68%（8%）和17.9%/51%（13%）（p<0.05/p<0.01）。接受搭桥术的冠心病患者中三支血管/左主干病变比未接受搭桥术的患者更常见（47%比14%；p<0.05）。多因素分析显示，右心室衰竭和冠心病患者未进行搭桥术是早期死亡的独立决定因素。Cox回归分析确定冠状动脉疾病和主动脉瓣梯度是出院后死亡的决定因素，不受搭桥术影响。根据对接受造影患者制定的冠状动脉疾病评分（冠状动脉疾病的阳性预测值为66%），将307例未接受造影的患者分为234例低评分患者和73例高评分患者。早期死亡率/5年生存率（标准误）分别为6.4%/86%（2%）和16.4%/67%（6%）（p<0.01/p<0.001）。尸检显示，冠状动脉疾病评分高的组中12例早期死亡患者中有92%存在狭窄或闭塞性冠状动脉疾病，冠状动脉疾病评分低的组中15例中有33%存在（p<0.01）。左心室衰竭和高冠状动脉疾病评分是早期死亡的独立决定因素，而心胸指数、高冠状动脉疾病评分和左心室衰竭是出院后死亡的独立预测因素。尽管冠状动脉疾病更严重，但搭桥术将早期死亡率降低到了与无冠状动脉疾病患者相当的水平，这与未搭桥的冠状动脉疾病患者早期死亡率高形成对比。冠状动脉疾病增加了晚期死亡率，搭桥术并未改变这一情况。在未接受造影的组中，未诊断和未搭桥的冠状动脉疾病可能增加了早期和晚期死亡率。所有成年主动脉瓣狭窄患者均应进行冠状动脉造影，有严重冠状动脉疾病的患者应在瓣膜置换的同时进行搭桥术。
