再次主动脉瓣置换术的简约评估；左心室射血分数降低和肾功能损害的威慑作用。
Parsimonious assessment for reoperative aortic valve replacement; the deterrent effect of low left ventricular ejection fraction and renal impairment.
作者信息
Yammine Maroun, Ramirez-Del Val Fernando, Ejiofor Julius I, Neely Robert C, Shi Diana, McGurk Siobhan, Aranki Sary F, Kaneko Tsuyoshi, Shekar Prem S
机构信息
Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
出版信息
Ann Cardiothorac Surg. 2017 Sep;6(5):484-492. doi: 10.21037/acs.2017.08.03.
BACKGROUND
Patient comorbidities play a pivotal role in the surgical outcomes of reoperative aortic valve replacement (re-AVR). Low left ventricular ejection fraction (LVEF) and renal insufficiency (Cr >2 mg/dL) are known independent surgical risk factors. Improved preoperative risk assessment can help determine the best therapeutic approach. We hypothesize that re-AVR patients with low LVEF and concomitant renal insufficiency have a prohibitive surgical risk and may benefit from transcatheter AVR (TAVR).
METHODS
From January 2002 to March 2013, we reviewed 232 patients who underwent isolated re-AVR. Patients older than 80 years were excluded to adjust for unobserved frailty. We identified 37 patients with a ≤35% LVEF (low ejection fraction group-LEF) and 195 patients with >35% LVEF (High ejection fraction group-HEF).
RESULTS
The mean age was 68.4±11.5 years and there were more females (86.5% versus 64.1%, P=0.007) in the LEF group. The prevalence of renal insufficiency was higher in LEF patients (27% versus 5.6%, P=0.001). Higher operative mortality (13.5% versus 3.1%, P=0.018) was observed in the LEF group. Stroke rates were similar in both groups (8.1% versus 4.1%, P=0.39). Unadjusted cumulative survival was significantly lower in LEF patients (6.6 years, 95% CI: 5.2-8.0, versus 9.7 years, 95% CI: 8.9-10.4, P=0.024). In patients without renal insufficiency, LEF and HEF had similar survival (8.3 years, 95% CI: 7.1-9.5, versus 9.9 years, 95% CI: 9.1-10.6, P=0.90). Contrarily, in patients with renal insufficiency, LEF led to a significantly lower survival (1.1 years, 95% CI: 0.1-2.0, versus 4.8 years, 95% CI: 2.2-7.3, P=0.050). Adjusted survival analysis revealed elevations in baseline creatinine (HR =4.28, P<0.001) and LEF (HR =5.33, P=0.041) as significant predictors of long-term survival, with a significant interaction between these comorbidities (HR =7.28, P<0.001).
CONCLUSIONS
In re-AVR patients, low LVEF (≤35%) is associated with increased operative mortality. Concomitant renal insufficiency in these patients results in a prohibitively low cumulative survival. These reoperative surgical outcomes should warrant expanding the role of TAVR for reoperative patients with LEF and renal impairment.
背景
患者合并症在再次主动脉瓣置换术（re-AVR）的手术结果中起关键作用。已知左心室射血分数（LVEF）降低和肾功能不全（肌酐>2mg/dL）是独立的手术危险因素。改善术前风险评估有助于确定最佳治疗方法。我们假设LVEF降低且伴有肾功能不全的re-AVR患者手术风险过高，可能从经导管主动脉瓣置换术（TAVR）中获益。
方法
2002年1月至2013年3月，我们回顾了232例行单纯re-AVR的患者。排除年龄大于80岁的患者以校正未观察到的虚弱因素。我们确定了37例LVEF≤35%的患者（低射血分数组-LEF）和195例LVEF>35%的患者（高射血分数组-HEF）。
结果
平均年龄为68.4±11.5岁，LEF组女性更多（86.5%对64.1%，P=0.007）。LEF患者肾功能不全的患病率更高（27%对5.6%，P=0.001）。LEF组观察到更高的手术死亡率（13.5%对3.1%，P=0.018）。两组的卒中发生率相似（8.1%对4.1%，P=0.39）。未调整的累积生存率在LEF患者中显著更低（6.6年，95%CI：5.2 - 8.0，对9.7年，95%CI：8.9 - ）。
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