Department of Cardiology, Royal Melbourne Hospital, Parkville 3052, Australia.
Department of Cardiology, Royal Melbourne Hospital, Parkville 3052, Australia.
Heart Lung Circ. 2014 Feb;23(2):132-43. doi: 10.1016/j.hlc.2013.07.008. Epub 2013 Aug 17.
This prospective cohort study aimed to assess LV recovery post aortic valve replacement, stratified according to pre-operative valve lesion (aortic stenosis (AS), mixed disease (AS/AR) or aortic regurgitation (AR)), as well as define predictors of persistent LV dilatation post operation. We prospectively followed all patients post Ross procedure performed between 1992 and 2009 by a single surgeon. Echocardiography was performed pre-operatively, at approximately one year post operation then second yearly thereafter.
265 patients were followed for a mean of 6.4 years (range 1-14 years, total 1702 patient-years). Seventy percent were male and mean age was 38.8 ± 12.6 years. The indication for surgery was AS in 44.5% (118), AS/AR in 23.4% (62), and AR in 32.1% (85). Overall mortality was 1.8% and 80% of deaths were non-cardiac. Morbidity was low and the need for pacing was less than 1%. Ninety-nine percent of patients were NYHA class 1 at one year follow up. The indexed LV end diastolic diameter (LVEDDi) decreased significantly post-operation in the AR (3.34 ± 0.39-2.66 ± 0.32 cm/m(2), p<0.001) and mixed (2.85 ± 0.38-2.65 ± 0.30 cm/m(2), p = 0.01) groups, whilst the indexed systolic LV dimension decreased significantly post-operation in the AR group (2.26 ± 0.34-1.87 ± 0.27, p<0.001). At five years post operation, independent predictors for a larger LVEDDi were female gender, a pre-operative LVEDDi >3.0 cm/m(2) and the presence of mild aortic regurgitation at one year post-operation. Pre-operative valve lesion was not a predictor. The only independent predictor of a lesser reduction of LVEDDi at five year follow-up was mild post-operative AR, whilst predictors of a lesser reduction in indexed left ventricular end systolic diameter (LVESDi) at five year follow-up included mild post-operative AR and a larger pre-operative LVEDDi. LV wall thickness decreased significantly the AS and AS/AR groups within one year post operation, whilst the neo-aortic root size remained stable throughout follow-up.
Recovery of LV size post Ross procedure is influenced predominantly by the pre-operative LV size, in particular the indexed LV end diastolic diameter. The pre-operative valve lesion was not predictive of larger ventricular dimensions post AVR, but independent predictors of a larger ventricular dimensions post operation included female gender, enlarged pre-operative LVEDDi and the presence of mild AR in the first post operative year. Those with mild post-operative AR did not have progressive LV enlargement, thus the clinical significance of this finding remains unclear.
本前瞻性队列研究旨在评估主动脉瓣置换术后左心室（LV）恢复情况，根据术前瓣膜病变（主动脉瓣狭窄（AS）、混合病变（AS/AR）或主动脉瓣反流（AR））进行分层，并确定术后持续LV扩张的预测因素。我们前瞻性地随访了 1992 年至 2009 年间由同一位外科医生进行的 Ross 手术的所有患者。术前、术后约 1 年及此后每年进行超声心动图检查。
265 例患者平均随访 6.4 年（范围 1-14 年，总随访 1702 人年）。70%为男性，平均年龄为 38.8±12.6 岁。手术指征为 AS 占 44.5%（118 例），AS/AR 占 23.4%（62 例），AR 占 32.1%（85 例）。总体死亡率为 1.8%，80%的死亡是非心脏原因。发病率较低，起搏需求不到 1%。99%的患者在术后 1 年的随访中达到纽约心脏病协会（NYHA）心功能分级 1 级。AR（3.34±0.39-2.66±0.32 cm/m²，p<0.001）和混合病变（2.85±0.38-2.65±0.30 cm/m²，p=0.01）组的 LVEDDi 术后显著减小，而 AR 组的 LVESDi（2.26±0.34-1.87±0.27，p<0.001）术后显著减小。术后 5 年，LVEDDi 增大的独立预测因素为女性、术前 LVEDDi>3.0 cm/m²和术后 1 年存在轻度 AR。术前瓣膜病变不是预测因素。LVEDDi 减少较少的唯一独立预测因素是术后轻度 AR，而 LVESDi 减少较少的独立预测因素包括术后轻度 AR 和术前较大的 LVEDDi。术后 1 年内，AS 和 AS/AR 组的 LV 壁厚度显著减少，而新主动脉根部大小在整个随访期间保持稳定。
Ross 手术后 LV 大小的恢复主要受术前 LV 大小的影响，特别是 LV 舒张末期指数。术前瓣膜病变不能预测主动脉瓣置换术后较大的心室尺寸，但术后较大心室尺寸的独立预测因素包括女性、术前较大的 LVEDDi 和术后 1 年内存在轻度 AR。那些存在轻度术后 AR 的患者没有进行性 LV 扩大，因此这一发现的临床意义仍不清楚。
