Esaki Jiro, Leshnower Bradley G, Binongo Jose N, Lasanajak Yi, McPherson LaRonica, Guyton Robert A, Chen Edward P
Department of Cardiovascular Surgery, Otsu Red Cross Hospital, Otsu, Japan.
Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
Ann Thorac Surg. 2017 Nov;104(5):1479-1487. doi: 10.1016/j.athoracsur.2017.04.005. Epub 2017 Jun 29.
Valve-sparing root replacement (VSRR) is an established therapy for aortic root pathology. However, late aortic valve dysfunction requiring reoperation remains a primary concern of this procedure. This study examines risk factors for late aortic insufficiency (AI) and aortic stenosis (AS) after David V VSRR.
A retrospective review from 2005 to 2015 at a US academic center identified 282 patients who underwent VSRR. Cox proportional hazards regression analysis was used to identify risk factors for late AI and AS after VSRR.
The mean age was 46.4 years. Sixty-four patients (22.7%) had bicuspid valves, and 41 patients (14.5%) had Marfan syndrome. The incidence of reoperations was 27 (9.6%), and 42 cases (14.9%) presented with acute type A dissection. Operative mortality was 8 (2.8%). Seven-year survival was 90.9%. Seven-year cumulative incidence of reoperation, greater than 2+ AI and greater than moderate AS were 3.1%, 2.2%, and 0.8%, respectively. Multivariable analysis showed aortic root size 55 mm or larger (hazard ratio 3.44, 95% confidence interval: 1.27 to 9.29, p = 0.01) to be a risk factor for late AI whereas bicuspid valve (hazard ratio 16.07, 95% confidence interval: 3.12 to 82.68, p = 0.001) and cusp repair were found to be risk factors (hazard ratio 5.91, 95% confidence interval: 1.17 to 29.86, p = 0.03) for late AS.
Valve-sparing root replacement can be performed with low operative risk and good overall long-term survival even in complex clinical settings. Durable valve function can be expected; however, aortic root size 55 cm or more, bicuspid valve anatomy, and cusp repair represent independent risk factors for late aortic valve dysfunction after these procedures.
保留瓣膜的主动脉根部置换术（VSRR）是治疗主动脉根部病变的一种既定疗法。然而，晚期主动脉瓣功能障碍需要再次手术仍然是该手术的主要关注点。本研究探讨了大卫V型VSRR术后晚期主动脉瓣关闭不全（AI）和主动脉瓣狭窄（AS）的危险因素。
对美国一家学术中心2005年至2015年的病例进行回顾性研究，确定了282例行VSRR的患者。采用Cox比例风险回归分析确定VSRR术后晚期AI和AS的危险因素。
平均年龄为46.4岁。64例（22.7%）患者为二叶式主动脉瓣，41例（14.5%）患者患有马凡综合征。再次手术发生率为27例（9.6%），42例（14.9%）出现急性A型主动脉夹层。手术死亡率为8例（2.8%）。7年生存率为90.9%。再次手术、重度AI（>2+）和中度以上AS的7年累积发生率分别为3.1%、2.2%和0.8%。多变量分析显示，主动脉根部直径55mm或更大（风险比3.44，95%置信区间：1.27至9.29，p = 0.01）是晚期AI的危险因素，而二叶式主动脉瓣（风险比16.07，95%置信区间：3.12至82.68，p = 0.001）和瓣叶修复被发现是晚期AS的危险因素（风险比5.91，95%置信区间：1.17至29.86，p = 0.03）。
即使在复杂的临床情况下，保留瓣膜的主动脉根部置换术也可以在低手术风险和良好的总体长期生存率下进行。可以预期瓣膜功能持久；然而，主动脉根部直径55cm或更大、二叶式主动脉瓣解剖结构和瓣叶修复是这些手术后晚期主动脉瓣功能障碍的独立危险因素。
