Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Heart. 2018 May;104(10):835-840. doi: 10.1136/heartjnl-2017-312024. Epub 2017 Nov 1.
Although guidelines support aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR) and left ventricular ejection fraction (LVEF) <50%, severe left ventricular dysfunction (LVEF <35%) is thought to confer high surgical risk. We sought to determine if a survival benefit exists with AVR compared with medical management in this high-risk, relatively rare population.
A large institutional echocardiography database was queried to identify patients with severe AR and LVEF <35%. Manual chart review was performed. Due to small sample size and population heterogeneity, corrected group prognosis method was applied, which calculates the adjusted survival curve for each individual using fitted Cox proportional hazard model. Average survival adjusted for comorbidities and age was then calculated using the weighted average of the individual survival curves.
Initially, 2 54 614 echocardiograms were considered, representing 1 45 785 unique patients, of which 40 patients met inclusion criteria. Of those, 18 (45.0%) underwent AVR and 22 (55.0%) were managed medically. Absolute mortality was 27.8% in the AVR group and 91.2% in the medical management group. After multivariate adjustment, end-stage renal disease (HR=17.633, p=0.0335) and peripheral arterial disease (HR=6.050, p=0.0180) were associated with higher mortality. AVR was associated with lower mortality (HR=0.143, p=0.0490). Mean follow-up time of the study cohort was 6.58 years, and mean survival for patients undergoing AVR was 6.31 years.
Even after adjustment for clinical characteristics and patient age, AVR is associated with higher survival for patients with low LVEF and severe AR. Although treatment selection bias cannot be completely eliminated by this analysis, these results provide some evidence that surgery may be associated with prolonged survival in this high-risk patient group.
尽管指南支持对严重主动脉瓣反流（AR）和左心室射血分数（LVEF）<50%的患者进行主动脉瓣置换术（AVR），但严重左心室功能障碍（LVEF<35%）被认为具有较高的手术风险。我们试图确定在这种高危、相对罕见的人群中，与药物治疗相比，AVR 是否存在生存获益。
对大型机构超声心动图数据库进行了查询，以确定严重 AR 和 LVEF<35%的患者。进行了手动图表审查。由于样本量小且人群异质性，应用校正组预后方法，该方法使用拟合 Cox 比例风险模型为每个个体计算校正后的生存曲线。然后，使用个体生存曲线的加权平均值计算考虑合并症和年龄后的平均生存调整。
最初，考虑了 254614 次超声心动图，代表 145785 个独特的患者，其中 40 个患者符合纳入标准。其中，18 例（45.0%）接受了 AVR，22 例（55.0%）接受了药物治疗。AVR 组的绝对死亡率为 27.8%，药物治疗组为 91.2%。经过多变量调整后，终末期肾病（HR=17.633，p=0.0335）和外周动脉疾病（HR=6.050，p=0.0180）与更高的死亡率相关。AVR 与较低的死亡率相关（HR=0.143，p=0.0490）。研究队列的平均随访时间为 6.58 年，接受 AVR 的患者的平均生存时间为 6.31 年。
即使在调整了临床特征和患者年龄后，AVR 与低 LVEF 和严重 AR 患者的生存率提高相关。尽管这种分析不能完全消除治疗选择偏倚，但这些结果提供了一些证据，表明手术可能与该高危患者群体的延长生存相关。
