Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
J Thorac Cardiovasc Surg. 2014 Jun;147(6):1907-17. doi: 10.1016/j.jtcvs.2013.07.019. Epub 2013 Aug 28.
Prosthetic valve type selection combined with surgical ablation during left-sided heart valve replacement in older individuals with atrial fibrillation remains controversial.
A total of 573 patients aged 60 years or older (median, 65; range, 60-84) who underwent left-sided valve replacement surgery in the presence of atrial fibrillation from 1990 to 2010 were evaluated for all-cause mortality during a median follow-up period of 58.0 months (interquartile range, 33.1-84.1).
Mechanical and bioprosthetic valves were implanted in 356 (62.1%) and 217 (37.9%) patients, respectively, and 203 patients (35.4%) underwent surgical ablation concomitantly. During the follow-up period, 166 patients died. The 5- and 10- year survival rate was 76.3% ± 2.1% and 58.4% ± 3.2%, respectively. On Cox regression analysis, age (P < .001), diabetes (P = .014), left ventricular ejection fraction (P = .010), left atrial size (P = .038), the requirement for coronary bypass (P = .015), and cardiopulmonary bypass time (P < .001) emerged as significant and independent predictors of death. In addition, surgical ablation was protective against all-cause mortality (hazard ratio, 0.63; P = .033). The improved survival observed with surgical ablation was verified by propensity score adjustment models (hazard ratio, 0.64; 95% confidence interval, 0.30-0.99; P = .046). The choice of prosthetic type, however, affected neither survival (P = .79) nor event-free survival (P = .48).
Long-term survival after valve replacement in older individuals with atrial fibrillation was affected by several preoperative characteristics and the performance of surgical ablation but not by the choice of prosthesis. These findings suggest that surgical atrial fibrillation ablation should always be considered for these patients, regardless of the prosthesis type used.
在老年心房颤动患者行左侧心脏瓣膜置换术中，人工瓣膜类型的选择与外科消融联合应用仍存在争议。
回顾性分析 1990 年至 2010 年期间行左侧瓣膜置换术且伴有心房颤动的 573 例年龄在 60 岁及以上患者（中位年龄 65 岁，范围 60-84 岁）的全因死亡率，中位随访时间为 58.0 个月（四分位距 33.1-84.1）。
共植入机械瓣和生物瓣 356 例（62.1%）和 217 例（37.9%），203 例（35.4%）同期行外科消融术。随访期间，166 例患者死亡。5 年和 10 年生存率分别为 76.3%±2.1%和 58.4%±3.2%。Cox 回归分析显示，年龄（P<0.001）、糖尿病（P=0.014）、左心室射血分数（P=0.010）、左心房大小（P=0.038）、需要冠状动脉旁路移植术（P=0.015）和体外循环时间（P<0.001）是死亡的显著独立预测因素。此外，外科消融术可降低全因死亡率（风险比 0.63；P=0.033）。倾向评分调整模型也证实了外科消融术可改善生存（风险比 0.64；95%置信区间 0.30-0.99；P=0.046）。然而，人工瓣膜类型的选择既不影响生存（P=0.79），也不影响无事件生存（P=0.48）。
老年心房颤动患者行瓣膜置换术后的长期生存率受多种术前特征和外科消融术的影响，但不受人工瓣膜类型的影响。这些发现表明，无论使用何种人工瓣膜，对于这些患者均应考虑行外科房颤消融术。
