Beckmann Erik, Martens Andreas, Alhadi Firas, Hoeffler Klaus, Umminger Julia, Kaufeld Tim, Sarikouch Samir, Koigeldiev Nurbol, Cebotari Serghei, Schmitto Jan Dieter, Haverich Axel, Shrestha Malakh
Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
Interact Cardiovasc Thorac Surg. 2016 Jun;22(6):744-9. doi: 10.1093/icvts/ivw041. Epub 2016 Feb 25.
Aortic valve replacement in patients with a small aortic annulus may result in patient-prosthesis mismatch (PPM). Aortic root enlargement (ARE) can reduce PPM, but leads to extended cardiac ischaemia times. Sutureless valves have the potential to prevent PPM while reducing cardiac ischaemia times.
Between January 2007 and December 2011, a total of 128 patients with a small aortic annulus underwent surgery for aortic valve stenosis at our centre. Thirty-six (17% male, n = 6) patients received conventional valve replacement with ARE and 92 (16% male, n = 18) subjects received sutureless valve implantation (Sorin Perceval). We conducted a comparative, retrospective study with follow-up.
The sutureless group showed a significantly higher age (79 years) than the ARE patients (62 years, P < 0.001) and received significantly more concomitant cardiac procedures (33%, n = 30 vs 6%, n = 2, P = 0.001). The mean operation, cardiopulmonary bypass and cross-clamp times were significantly lower in sutureless patients (147 ± 42, 67 ± 26 and 35 ± 13 min, respectively) than in ARE patients (181 ± 41, 105 ± 29 and 70 ± 19 min, respectively, P < 0.001). The mean postoperative effective orifice area (EOA) indexed to the body surface area was 0.91 ± 0.2 cm(2)/m(2) in ARE patients and 0.83 ± 0.14 cm(2)/m(2) in sutureless patients (P = 0.040). The rate of patients with severe PPM was 6% (n = 2) in ARE patients and 11% (n = 8%) in sutureless patients (not significant, n.s.). The 30-day mortality rates were 2% (n = 2) in sutureless patients and 6% (n = 2) in ARE patients (n.s.). The 1- and 5-year survival rates of the sutureless group were 92 and 54% years, respectively, whereas the 1- and 5-year survival rates of the ARE group were 76% (n.s.).
Although the sutureless valve patients received significantly more concomitant procedures, all operation-associated times were significantly shorter. Despite sutureless valve patients being older, the 30-day mortality and survival rates were comparable in the two groups. Since the indexed EOA was only slightly lower and the incidence of severe PPM was not significantly higher in the sutureless valve patients, we conclude that sutureless valve implantation is an alternative to conventional ARE to treat a small aortic annulus and avoid PPM, especially in geriatric patients who benefit from the quick implantation process.
主动脉瓣环较小的患者进行主动脉瓣置换可能会导致患者-人工瓣膜不匹配（PPM）。主动脉根部扩大术（ARE）可减少PPM，但会延长心脏缺血时间。无缝合瓣膜有可能预防PPM，同时减少心脏缺血时间。
2007年1月至2011年12月期间，共有128例主动脉瓣环较小的患者在我们中心接受了主动脉瓣狭窄手术。36例（男性17%，n = 6）患者接受了带ARE的传统瓣膜置换，92例（男性16%，n = 18）患者接受了无缝合瓣膜植入（索林Perceval）。我们进行了一项有随访的对比性回顾性研究。
无缝合组患者的年龄（79岁）显著高于ARE组患者（62岁，P < 0.001），且接受的同期心脏手术显著更多（33%，n = 30对6%，n = 2，P = 0.001）。无缝合患者的平均手术时间、体外循环时间和主动脉阻断时间显著低于ARE组患者（分别为147 ± 42、67 ± 26和35 ± 13分钟）（分别为181 ± 41、105 ± 29和70 ± 19分钟，P < 0.001）。ARE组患者术后平均有效瓣口面积（EOA）与体表面积的比值为0.91 ± 0.2 cm²/m²，无缝合组患者为0.83 ± 0.14 cm²/m²（P = 0.040）。ARE组患者中重度PPM的发生率为6%（n = 2），无缝合组患者为11%（n = 8%）（无显著差异，n.s.）。无缝合组患者的30天死亡率为2%（n = 2），ARE组患者为6%（n = 2）（无显著差异）。无缝合组的1年和5年生存率分别为92%和54%，而ARE组的1年和5年生存率为76%（无显著差异）。结论：尽管无缝合瓣膜组患者接受的同期手术显著更多，但所有与手术相关的时间均显著缩短。尽管无缝合瓣膜组患者年龄较大，但两组的30天死亡率和生存率相当。由于无缝合瓣膜组患者的EOA与体表面积的比值仅略低，且重度PPM的发生率没有显著更高，我们得出结论，无缝合瓣膜植入是治疗小主动脉瓣环并避免PPM的传统ARE的替代方法，特别是对于受益于快速植入过程的老年患者。
