Rinewalt Daniel, McCarthy Patrick M, Malaisrie Sukit Chris, Fedak Paul W M, Andrei Adin-Cristian, Puthumana Jyothy J, Bonow Robert O
Division of Cardiac Surgery, Martha and Richard Melman Family Bicuspid Aortic Valve Program, Bluhm Cardiovascular Institute, Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Ill.
Division of Cardiac Surgery, Martha and Richard Melman Family Bicuspid Aortic Valve Program, Bluhm Cardiovascular Institute, Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Ill.
J Thorac Cardiovasc Surg. 2014 Nov;148(5):2060-9. doi: 10.1016/j.jtcvs.2014.03.027. Epub 2014 Mar 20.
Bicuspid aortic valve (BAV) disease is associated with aortic dilatation and aneurysm (AN) formation. The American College of Cardiology/American Heart Association (ACC/AHA) 2006 guidelines recommend replacement of the ascending aorta for an aortic diameter (AD)> 45 mm in patients undergoing aortic valve replacement (AVR). We evaluated the outcomes of AVR and AVR with aortic replacement (AVR/AN).
We retrospectively reviewed (2004-2011) the data from 456 patients with BAV and compared the morbidity and mortality between the AVR and AVR/AN groups and 3 subgroups: AVR with an AD<45 mm; AVR/AN with an AD of 45 to 49 mm; and AVR/AN with an AD of ≥50 mm. Propensity score matching was used to reduce bias.
Of the 456 patients, 250 (55%) underwent AVR and 206 (45%) AVR/AN, with 98% compliance with the current guidelines. The overall 30-day mortality was 0.9%. The AVR AD<45-mm group had adjusted short- and medium-term survival similar to that of the AVR/AN AD 45- to 49-mm and AVR/AN AD≥50-mm groups, with a 30-day mortality of 0.8%, 0%, and 1.9%, respectively (P=.41). The propensity score-matched AVR/AN AD≥50-mm group had significantly greater rates of reintubation than either the AVR AD<45-mm (P=.012) or AVR/AN AD 45- to 49-mm (P=.04) group and greater rates of prolonged ventilation (P=.022) than the AVR AD<45-mm group. No significant differences were found in reoperation or myocardial infarction among the subgroups.
In patients with undergoing AVR, no increase was seen in morbidity or mortality when adding aortic replacement with an AD of 45 to 49 mm, in accordance with the 2006 ACC/AHA guidelines, although the AVR/AN AD≥50-mm group had a greater risk of respiratory complications. Our findings indicate that compliance with the ACC/AHA guidelines is safe in select centers.
二叶式主动脉瓣（BAV）疾病与主动脉扩张及动脉瘤（AN）形成相关。美国心脏病学会/美国心脏协会（ACC/AHA）2006年指南建议，在接受主动脉瓣置换术（AVR）的患者中，若主动脉直径（AD）>45 mm，则应置换升主动脉。我们评估了AVR以及联合主动脉置换术（AVR/AN）的治疗效果。
我们回顾性分析了（2004 - 2011年）456例BAV患者的数据，并比较了AVR组与AVR/AN组以及三个亚组之间的发病率和死亡率，这三个亚组分别为：AD<45 mm的AVR组；AD为45至49 mm的AVR/AN组；AD≥50 mm的AVR/AN组。采用倾向评分匹配法以减少偏倚。
456例患者中，250例（55%）接受了AVR，206例（45%）接受了AVR/AN，遵循当前指南的比例为98%。30天总体死亡率为0.9%。AD<45 mm的AVR组调整后的短期和中期生存率与AD为45至49 mm的AVR/AN组以及AD≥50 mm的AVR/AN组相似，30天死亡率分别为0.8%、0%和1.9%（P = 0.41）。倾向评分匹配后的AD≥50 mm的AVR/AN组再次插管率显著高于AD<45 mm的AVR组（P = 0.012）和AD为45至49 mm的AVR/AN组（P = 0.04），且机械通气延长率高于AD<45 mm的AVR组（P = 0.022）。各亚组在再次手术或心肌梗死方面未发现显著差异。
在接受AVR的患者中，按照2006年ACC/AHA指南，增加AD为45至49 mm的主动脉置换术时，发病率和死亡率并未增加，尽管AD≥50 mm的AVR/AN组发生呼吸并发症的风险更高。我们的研究结果表明，在特定中心遵循ACC/AHA指南是安全的。
