McCarthy Fenton H, Bavaria Joseph E, McDermott Katherine M, Moeller Patrick, Spragan Danielle, Hoedt Ashley, Dibble Taylor, Savino Danielle, Williams Matthew L, Vallabhajosyula Prashanth, Szeto Wilson Y, Desai Nimesh D
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Ann Thorac Surg. 2016 Oct;102(4):1199-205. doi: 10.1016/j.athoracsur.2016.03.071. Epub 2016 Jun 1.
There is growing interest in aortic valve-sparing and valve repair operations, but the ideal operation and timing of intervention in these generally younger patients undergoing operations for aortic insufficiency (AI) and dilated ascending aorta remains controversial.
Root replacements at a single institution from 2002 to 2014 were reviewed. Inclusion criteria were age younger than 70 and presence of moderate or greater aortic insufficiency (AI), with or without aortic aneurysm. Of 1,425 root replacements, 220 patients were considered in the final analysis.
Moderate AI was present in 87 patients and severe AI in 133 patients. The 30-day mortality was 0% in moderate AI patients and 2% (n = 3) in severe AI patients (p = 0.3). Freedom from reoperation was 95% at 10 years. Severe preoperative AI was associated with worse long-term survival compared with moderate AI (hazard ratio, 2.6; p = 0.04). Patients undergoing root replacement with moderate AI had similar survival compared with the age- and gender-matched United States population (log-rank p = 0.93), whereas patients with severe AI had significantly worse survival (log-rank p = 0.02). Other multivariable predictors of decreased long-term survival were age (hazard ratio, 1.1; p = 0.01) and preoperative renal failure (hazard ratio, 6.9; p < 0.01).
Elective root replacement operations in patients younger than 70 are associated with low rates of mortality and reoperation, which should be considered the benchmark operation for aortic valve-sparing or repair operations in similar patients. Worse survival was associated with severe AI and older age, suggesting earlier intervention may be an appropriate therapeutic strategy in selected patients.
保留主动脉瓣和瓣膜修复手术越来越受到关注，但对于这些通常较为年轻的主动脉瓣关闭不全（AI）和升主动脉扩张患者，理想的手术方式和干预时机仍存在争议。
回顾了2002年至2014年在单一机构进行的根部置换手术。纳入标准为年龄小于70岁且存在中度或更严重的主动脉瓣关闭不全（AI），伴有或不伴有主动脉瘤。在1425例根部置换手术中，最终分析纳入了220例患者。
87例患者存在中度AI，133例患者存在重度AI。中度AI患者的30天死亡率为0%，重度AI患者为2%（n = 3）（p = 0.3）。10年时再次手术的自由度为95%。与中度AI相比，术前重度AI与较差的长期生存率相关（风险比，2.6；p = 0.04）。中度AI患者进行根部置换后的生存率与年龄和性别匹配的美国人群相似（对数秩p = 0.93），而重度AI患者的生存率明显较差（对数秩p = 0.02）。长期生存率降低的其他多变量预测因素为年龄（风险比，1.1；p = 0.01）和术前肾衰竭（风险比，6.9；p < 0.01）。
70岁以下患者的择期根部置换手术死亡率和再次手术率较低，应被视为类似患者保留主动脉瓣或修复手术的基准手术。较差的生存率与重度AI和高龄相关，提示在部分患者中早期干预可能是合适的治疗策略。
