Une Dai, Ruel Marc, David Tirone E
Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada.
Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
Eur J Cardiothorac Surg. 2014 Nov;46(5):825-30. doi: 10.1093/ejcts/ezu014. Epub 2014 Feb 7.
There is a current trend towards the use of bioprosthetic aortic valves in the aortic position in young patients, but there is limited information on durability beyond the first decade. The Hancock II bioprosthesis has been reported to have excellent durability in patients ≥ 60 years of age. This study examines the long-term durability of the Hancock II bioprosthesis in the aortic position in patients <60 years of age.
From 1982 to 2008, 304 patients aged 59 years or less underwent aortic valve replacement (AVR) with a Hancock II bioprosthesis at two centres. The mean age was 49.2 ± 9.0 years, and 79% of the patients were male. Valve function was serially assessed by echocardiography. The median follow-up was 14.6 years (maximum 27.5 years). Survival and freedom from adverse events were calculated by using a Kaplan-Meier method. Independent predictors of those events were assessed by using Cox proportional hazards analyses.
Survival and freedom from repeat AVR (re-AVR) at 20 years were 57.0 ± 6.1 and 25.4 ± 4.7%, respectively. During the follow-up, 100 patients (33%) underwent re-AVR: 78 for structural valve deterioration (SVD), 11 for endocarditis, 4 for non-structural valve dysfunction and 7 for other reasons. The overall 10-, 15- and 20-year freedom from re-AVR due to SVD were 91.4 ± 2.1, 64.7 ± 4.3 and 29.1 ± 5.3%, respectively. By age group, the 20-year freedom from re-AVR due to SVD amounted to 14.1 ± 8.7% in patients younger than 40 years of age, 21.5 ± 8.5% in patients aged 40-49 and 41.4 ± 8.2% in patients between 50 and 59 (P = 0.04). The independent predictors of re-AVR due to SVD were age [odds ratio (OR): 0.72 per 10 years; 95% confidence interval (CI): 0.58, 0.90; P < 0.01] and prosthesis-patient mismatch (PPM) (effective orifice area index <0.80 cm(2)/m(2)) (OR: 1.63; 95% CI: 1.01, 2.63; P = 0.045).
The Hancock II bioprosthesis for AVR in patients <60 years of age is associated with excellent durability during the first decade. However, SVD increases dramatically during the second decade and by 20 years, especially in patients aged <50 and/or with PPM. These findings may assist prosthesis selection for patients and their surgeons.
目前有在年轻患者的主动脉位置使用生物人工主动脉瓣的趋势，但关于十年后的耐久性信息有限。据报道，汉考克二代生物瓣膜在60岁及以上患者中具有出色的耐久性。本研究探讨汉考克二代生物瓣膜在60岁以下患者主动脉位置的长期耐久性。
1982年至2008年，304例年龄59岁及以下的患者在两个中心接受了汉考克二代生物瓣膜主动脉瓣置换术（AVR）。平均年龄为49.2±9.0岁，79%的患者为男性。通过超声心动图对瓣膜功能进行连续评估。中位随访时间为14.6年（最长27.5年）。采用Kaplan-Meier方法计算生存率和无不良事件生存率。通过Cox比例风险分析评估这些事件的独立预测因素。
20年时的生存率和免于再次AVR（re-AVR）率分别为57.0±6.1%和25.4±4.7%。在随访期间，100例患者（33%）接受了再次AVR：78例因瓣膜结构恶化（SVD），11例因心内膜炎，4例因非瓣膜结构功能障碍，7例因其他原因。因SVD导致的再次AVR的总体10年、15年和20年免于率分别为91.4±2.1%、64.7±4.3%和29.1±5.3%。按年龄组划分，40岁以下患者因SVD导致的再次AVR的20年免于率为14.1±8.7%，40 - 49岁患者为21.5±8.5%，50 - 59岁患者为41.4±8.2%（P = 0.04）。因SVD导致再次AVR的独立预测因素为年龄[比值比（OR）：每10年0.72；95%置信区间（CI）：0.58，0.90；P < 0.01]和人工瓣膜 - 患者不匹配（PPM）（有效瓣口面积指数<0.80 cm²/m²）（OR：1.63；95% CI：1.01，2.63；P = 0.045）。
60岁以下患者使用汉考克二代生物瓣膜进行AVR在第一个十年具有出色的耐久性。然而，在第二个十年中SVD显著增加，到20年时，特别是在50岁以下和/或存在PPM的患者中。这些发现可能有助于患者及其外科医生选择人工瓣膜。
