Okada Noritaka, Tajima Kazuyoshi, Takami Yoshiyuki, Kato Wataru, Fujii Kei, Hibino Makoto, Munakata Hisaaki, Sakai Yoshimasa, Hirakawa Akihiro, Usui Akihiko
Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
Ann Thorac Surg. 2015 May;99(5):1524-31. doi: 10.1016/j.athoracsur.2014.11.055. Epub 2015 Feb 10.
Prosthetic valve selection in dialysis patients remains controversial because of the limited data available. This study aimed to clarify late clinical outcomes and discuss strategies for optimal valve selection in dialysis patients.
We retrospectively analyzed the data obtained from 406 consecutive patients who underwent aortic valve replacement between 1995 and 2010. We compared valve-related outcomes among 89 dialysis and 317 nondialysis patients. We selected bioprostheses for all patients older than 65 to 70 years, irrespective of the renal function.
Dialysis was found to be a significant risk factor for bleeding events (hazard ratio, 3.98; 95% confidence interval, 2.51 to 6.30; p < 0.001), however, no significant differences were observed according to the type of prosthesis. The overall survival was significantly worse in the dialysis patients (63% versus 85% at 5 years; p < 0.001), and freedom from structural valve deterioration was also lower in the dialysis patients (82% versus 100% at 5 years; p < 0.001). Among the dialysis patients, an advanced age (≥ 70 years; hazard ratio, 3.53; p = 0.011), diabetes mellitus (hazard ratio, 2.48; p = 0.041), and concomitant coronary artery bypass grafting (hazard ratio, 1.99; p = 0.071) were independent predictors for late death based on a multivariate analysis.
Our valve selection criteria in dialysis patients, which are the same as the current practice guidelines for nondialysis patients, are acceptable. Bioprostheses can be considered in all dialysis patients with diabetes or coronary artery disease.
由于可用数据有限，透析患者的人工瓣膜选择仍存在争议。本研究旨在阐明晚期临床结局，并讨论透析患者最佳瓣膜选择的策略。
我们回顾性分析了1995年至2010年间连续406例行主动脉瓣置换术患者的数据。我们比较了89例透析患者和317例非透析患者的瓣膜相关结局。我们为所有65至70岁以上的患者选择了生物瓣膜，无论其肾功能如何。
透析被发现是出血事件的一个重要危险因素（风险比，3.98；95%置信区间，2.51至6.30；p<0.001），然而，根据假体类型未观察到显著差异。透析患者的总体生存率明显较差（5年时分别为63%和85%；p<0.001），透析患者无人工瓣膜结构恶化的比例也较低（5年时分别为82%和100%；p<0.001）。在透析患者中，高龄（≥70岁；风险比，3.53；p=0.011）、糖尿病（风险比，2.48；p=0.041）和同期冠状动脉搭桥术（风险比，1.99；p=0.071）是基于多变量分析的晚期死亡独立预测因素。
我们在透析患者中的瓣膜选择标准与目前非透析患者的实践指南相同，是可以接受的。对于所有患有糖尿病或冠状动脉疾病的透析患者，可以考虑使用生物瓣膜。
