Department of Cardiac and Thoracic Vascular Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
Department of Cardiac and Thoracic Vascular Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
J Thorac Cardiovasc Surg. 2018 Feb;155(2):549-559.e2. doi: 10.1016/j.jtcvs.2017.08.131. Epub 2017 Sep 14.
This study aims to fine-tune the decision making for ascending aorta treatment in bicuspid aortic valve surgery.
A total of 1693 patients with a primary indication for aortic valve surgery were investigated retrospectively with respect to a multifactorial decision-making policy including the z score and the clinical outcome in relation to different techniques for ascending aorta treatment (no intervention n = 1116; intervention n = 577 either by ascending aorta replacement n = 404 or aortoplasty n = 173). Follow-up was 99.5% complete (mean 7.0 ± 4.4 years, range 0-17.7 years, 11,895 patient-years).
Hospital mortality was 1.2% for the no-intervention group and 0.9% for the intervention group and was not different between groups (P = .629). Survival compared with the adjusted normal population was lower for both groups (no intervention: P < .001) but not by such a great margin for the intervention group (P = .27). Determinants for death were not related to the ascending aorta treatment. Aortoplasty led to significantly more reoperations (P = .002). The z score thresholds for intervention on the ascending aorta were greater for younger patients, intervention was more liberal in young age, depicted in nomograms.
In our study, ascending aorta intervention could be performed with low hospital mortality and obviously did not add to the overall mortality compared with no intervention. Ascending aorta replacement was the most definite intervention. The multifactorial decision for ascending aorta intervention including the z score of the ascending aorta was more liberal in younger patients compared to the simple aortic size guidelines and provided excellent results. However, generalizability needs further data.
本研究旨在优化二叶式主动脉瓣手术中升主动脉治疗的决策制定。
回顾性调查了 1693 例因主动脉瓣手术指征而行多因素决策策略的患者，该策略包括 z 评分和与不同升主动脉治疗技术相关的临床结果（无干预组 n=1116；干预组 n=577，分别行升主动脉置换术 n=404 或主动脉成形术 n=173）。随访率为 99.5%（平均随访时间 7.0±4.4 年，范围 0-17.7 年，11895 患者年）。
无干预组和干预组的院内死亡率分别为 1.2%和 0.9%，两组间无差异（P=0.629）。与调整后的正常人群相比，两组的生存率均较低（无干预组：P<0.001），但干预组的差异并不显著（P=0.27）。死亡的决定因素与升主动脉治疗无关。主动脉成形术导致再次手术的比例显著增加（P=0.002）。对于年轻患者，干预升主动脉的 z 评分阈值更高，在年轻患者中干预更为宽松，这些在列线图中有所体现。
在本研究中，升主动脉干预的院内死亡率较低，与不干预相比，明显不会增加整体死亡率。升主动脉置换是最明确的干预措施。包括升主动脉 z 评分在内的多因素升主动脉干预决策在年轻患者中比单纯的主动脉大小指南更为宽松，提供了出色的结果。然而，推广应用需要进一步的数据支持。
