Antunes M J
Division of Cardiothoracic Surgery, University of the Witwatersrand, Johannesburg Hospital, Republic of South Africa.
J Thorac Cardiovasc Surg. 1989 Oct;98(4):485-91.
The controversy surrounding the choice of a prosthesis for valve replacement in the elderly patient prompted me to review the performance of mechanical (Medtronic Hall [Medtronic, Inc., Minneapolis, Minn.] and St. Jude Medical [St. Jude Medical, Inc., St. Paul, Minn.]) valves implanted in 213 patients 65 years and older (mean 70.4 years) from 1980 to 1985. There were 63 mitral, 131 aortic, and 19 double (aortic and mitral) valve replacements. Most patients undergoing aortic valve replacement had stenotic lesions, but half of the patients in the mitral valve replacement group had regurgitation with or without stenosis. Early mortality rates for mitral, aortic, and double valve replacement were 4.8%, 6.1%, and 21.1%, respectively (p less than 0.01). The mortality rate for patients 65 to 74 years old was 6.5% and that for those older than 75 years was 9.1%. The cumulative follow-up for the survivors was 850 patient-years. The late mortality rate was 8.1% per patient-year but was valve-related in only 1.3% per patient-year. Noncardiac causes accounted for 43.5% of the late deaths. The late mortality rate was significantly higher in patients who had regurgitant lesions than in those who had stenotic or mixed disease. It was also higher in the older patients (10.3% per patient-year) than in the younger group (7.6% per patient-year; p less than 0.05). Reoperation was required in only six patients (0.7% per patient-year). Thrombotic obstruction of the prosthesis and systemic thromboembolism occurred at linearized rates of 0.6% per patient-year and 2.5% per patient year, respectively, and significant anticoagulant-related hemorrhage at a rate of 0.6% per patient-year. With the exception of late mortality, the incidence of all late complications was similar to that of patients younger than 65 years operated on during the same period. Actuarially, global survival (58% +/- 4%) and freedom from reoperation (95% +/- 2%), from thrombotic obstruction (96% +/- 1%), from thromboembolism (92% +/- 2%), from all valve-related mortality and morbidity (82% +/- 3%), and from valve failure (93% +/- 2%) were also similar to those of the younger patients. Mechanical prostheses perform well in elderly patients. I could not confirm an increase in thromboembolic or hemorrhagic episodes, and the respective mortality and morbidity indexes were similar to those observed in younger patients.
围绕老年患者瓣膜置换假体选择的争议促使我回顾了1980年至1985年期间植入213例65岁及以上（平均70.4岁）患者体内的机械瓣膜（美敦力霍尔瓣膜[美敦力公司，明尼阿波利斯，明尼苏达州]和圣犹达医疗瓣膜[圣犹达医疗公司，圣保罗，明尼苏达州]）的性能。其中有63例二尖瓣置换、131例主动脉瓣置换以及19例双瓣膜（主动脉瓣和二尖瓣）置换。大多数接受主动脉瓣置换的患者患有狭窄病变，但二尖瓣置换组中有一半患者伴有反流，伴或不伴有狭窄。二尖瓣、主动脉瓣和双瓣膜置换的早期死亡率分别为4.8%、6.1%和21.1%（p<0.01）。65至74岁患者的死亡率为6.5%，75岁以上患者的死亡率为9.1%。幸存者的累积随访时间为850患者年。晚期死亡率为每年8.1%，但与瓣膜相关的仅为每年1.3%。非心脏原因占晚期死亡的43.5%。有反流病变患者的晚期死亡率显著高于有狭窄或混合病变的患者。老年患者（每年10.3%）的晚期死亡率也高于年轻组（每年7.6%；p<0.05）。仅6例患者需要再次手术（每年0.7%）。人工瓣膜血栓形成梗阻和全身性血栓栓塞的发生率分别为每年0.6%和每年2.5%，与抗凝相关的严重出血发生率为每年0.6%。除晚期死亡率外，所有晚期并发症的发生率与同期接受手术的65岁以下患者相似。从 actuarially 角度看，总体生存率（58%±4%）、免于再次手术率（95%±2%）、免于血栓形成梗阻率（96%±1%）、免于血栓栓塞率（92%±2%）、免于所有与瓣膜相关的死亡率和发病率（82%±3%）以及免于瓣膜衰竭率（93%±2%）也与年轻患者相似。机械瓣膜在老年患者中表现良好。我无法证实血栓栓塞或出血事件有所增加，且各自的死亡率和发病率指标与年轻患者中观察到的数据相似。
