David Tirone E, Feindel Christopher M, David Carolyn M, Manlhiot Cedric
Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada.
Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada.
J Thorac Cardiovasc Surg. 2014 Sep;148(3):872-9; discussion 879-80. doi: 10.1016/j.jtcvs.2014.04.048. Epub 2014 May 15.
To examine the late outcomes of aortic valve-sparing operations to treat patients with aortic root aneurysm with and without aortic insufficiency (AI) in a cohort of patients followed up prospectively since 1988.
A total of 371 consecutive patients had undergone aortic valve-sparing surgery (mean age, 47 ± 15 years; 78% men) from 1988 through 2010. In addition to the aortic root aneurysm, 47% had moderate or severe AI, 35.5% had Marfan syndrome, 12.1% had type A aortic dissection, 9.2% had bicuspid aortic valve, 8.4% had mitral insufficiency, 16.1% had aortic arch aneurysm, and 10.2% had coronary artery disease. Reimplantation of the aortic valve was used in 296 patients and remodeling of the aortic root in 75. Cusp repair by plication of the free margin along the nodule of Arantius was used in 36.6% of patients, and reinforcement of the free margin with a double layer of fine Gore-Tex suture in 24.2%. The patients were followed up prospectively with images of the aortic root for a median follow-up of 8.9 ± 5.2 years.
A total of 4 operative and 39 late deaths occurred. Survival at 18 years was 76.8% ± 4.31%, lower than that for the general population matched for age and gender. Age, type A aortic dissection, impaired ventricular function, and preoperative AI were associated with increased mortality on multivariable analysis. Reoperations on the aortic valve were performed in 8 patients for recurrent AI and in 2 for infective endocarditis. Freedom from reoperation on the aortic valve at 18 years was 94.8% ± 2.0%. No predictors of the need for reoperation were found on multivariable analysis. Eighteen patients developed AI greater than mild. Freedom from AI greater than mild at 18 years was 78.0% ± 4.8%. No predictors of recurrent AI were identified on multivariable analysis.
Aortic valve-sparing operations continue to provide excellent clinical outcomes, although a slow but progressive deterioration of aortic valve function seems to occur during the first 2 decades of follow-up. Preoperative AI and cusp repair had no adverse effect on valve function.
对自1988年起进行前瞻性随访的一组患者，研究保留主动脉瓣手术治疗有或无主动脉瓣关闭不全（AI）的主动脉根部瘤患者的远期疗效。
1988年至2010年，共有371例连续患者接受了保留主动脉瓣手术（平均年龄47±15岁；78%为男性）。除主动脉根部瘤外，47%有中度或重度AI，35.5%有马方综合征，12.1%有A型主动脉夹层，9.2%有二叶式主动脉瓣，8.4%有二尖瓣关闭不全，16.1%有主动脉弓瘤，10.2%有冠状动脉疾病。296例患者采用主动脉瓣再植入术，75例采用主动脉根部重塑术。36.6%的患者采用沿阿兰特结节折叠游离缘的瓣叶修复术，24.2%的患者采用双层细戈尔泰克斯缝线加固游离缘。对患者进行主动脉根部图像的前瞻性随访，中位随访时间为8.9±5.2年。
共发生4例手术死亡和39例晚期死亡。18年生存率为76.8%±4.31%，低于年龄和性别匹配的普通人群。多变量分析显示，年龄、A型主动脉夹层、心室功能受损和术前AI与死亡率增加相关。8例患者因复发性AI接受主动脉瓣再次手术，2例因感染性心内膜炎接受再次手术。18年时主动脉瓣再次手术的无再手术率为94.8%±2.0%。多变量分析未发现再手术需求的预测因素。18例患者出现大于轻度的AI。18年时无大于轻度AI的发生率为78.0%±4.8%。多变量分析未发现复发性AI的预测因素。
保留主动脉瓣手术继续提供出色的临床疗效，尽管在随访的前20年中似乎出现了主动脉瓣功能缓慢但渐进性的恶化。术前AI和瓣叶修复对瓣膜功能无不良影响。
