Nguyen Tom C, Thourani Vinod H, Pham Justin Q, Zhao Yelin, Terwelp Matthew D, Balan Prakash, Ocazionez Daniel, Loghin Catalin, Smalling Richard W, Estrera Anthony L, Lamelas Joseph
From the *Department of Cardiothoracic Surgery, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA; †Structural Heart and Valve Center, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA USA; ‡Division of Cardiology, Department of Internal Medicine, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA; §Department Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Memorial Hermann Hospital, Houston, TX USA; and ∥Department of Cardiac Surgery, Mount Sinai Medical Center, Miami Beach, FL USA.
Innovations (Phila). 2017 Jan/Feb;12(1):33-40. doi: 10.1097/IMI.0000000000000338.
Low ejection fraction (EF < 40%) portends adverse outcomes in patients undergoing valvular heart surgery. The role of traditional median sternotomy aortic valve replacement (SAVR) compared with minimally invasive aortic valve replacement (MIAVR) in this cohort remains incompletely understood.
A multi-institutional retrospective review of 1503 patients who underwent SAVR (n = 815) and MIAVR via right anterior thoracotomy (n = 688) from 2011 to 2014 was performed. Patients were stratified into two groups: EF of less than 40% and EF of 40% or more. In each EF group, SAVR and MIAVR patients were propensity matched by age, sex, body mass index, race, diabetes, hypertension, dyslipidemia, dialysis, cerebrovascular disease, cardiovascular disease, cerebrovascular accident, peripheral vascular disease, last creatinine level, EF, previous MI and cardiogenic shock, and the Society for Thoracic Surgeons (STS) score.
Among patients with an EF of 40% or more (377 pairs), patients who underwent MIAVR compared with SAVR had decreased intensive care unit hours (56.8% vs 84.6%, P < 0.001), postoperative length of stay (7.1 vs 7.9 days, P = 0.04), incidence of atrial fibrillation (18.8% vs 38.7%, P < 0.001), bleeding (0.8% vs 3.2%, P = 0.04), and a trend toward decreased 30-day mortality (0.3% vs 1.3%, P = 0.22). The STS scores were largely equivalent in patients undergoing MIAVR compared with SAVR (2.4% vs 2.6%, P = 0.09). In patients with an EF of less than 40% (35 pairs), there was no difference in intensive care unit hours (69% vs 72.6%, P = 0.80), postoperative length of stay (10.3 vs 7.2 days, P = 0.13), 30-day mortality (3.8% vs 0.8%, P = 0.50), or the STS score (3.3% vs 3.2%, P = 0.68).
Minimally invasive aortic valve replacement in patients with preserved EF was associated with improved short-term outcomes compared with SAVR. In patients with left ventricular dysfunction, short-term outcomes between MIAVR and SAVR are largely equivalent.
低射血分数（EF<40%）预示着接受心脏瓣膜手术患者的不良预后。在这一队列中，传统正中开胸主动脉瓣置换术（SAVR）与微创主动脉瓣置换术（MIAVR）相比的作用仍未完全明确。
对2011年至2014年期间接受SAVR（n=815）和经右前开胸的MIAVR（n=688）的1503例患者进行多机构回顾性研究。患者被分为两组：EF小于40%组和EF为40%或更高组。在每个EF组中，SAVR和MIAVR患者按年龄、性别、体重指数、种族、糖尿病、高血压、血脂异常、透析、脑血管疾病、心血管疾病、脑血管意外、外周血管疾病、末次肌酐水平、EF、既往心肌梗死和心源性休克以及胸外科医师协会（STS）评分进行倾向匹配。
在EF为40%或更高的患者中（377对），与接受SAVR的患者相比，接受MIAVR的患者重症监护病房住院时间减少（56.8%对84.6%，P<0.001）、术后住院时间缩短（7.1天对7.9天，P=0.04）、心房颤动发生率降低（18.8%对38.7%，P<0.001）、出血发生率降低（0.8%对3.2%，P=0.04），并且30天死亡率有降低趋势（0.3%对1.3%，P=0.22）。与接受SAVR的患者相比，接受MIAVR的患者STS评分大致相当（2.4%对2.6%，P=0.09）。在EF小于40%的患者中（35对），重症监护病房住院时间（69%对72.6%，P=0.80）、术后住院时间（10.3天对7.2天，P=0.13）、30天死亡率（3.8%对0.8%，P=0.50）或STS评分（3.3%对3.2%，P=0.68）均无差异。
与SAVR相比，EF保留的患者进行微创主动脉瓣置换术与短期预后改善相关。在左心室功能不全的患者中，MIAVR和SAVR的短期预后大致相当。
