Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Ann Thorac Surg. 2018 Jul;106(1):14-22. doi: 10.1016/j.athoracsur.2018.01.090. Epub 2018 Apr 6.
The goal of this study was to determine the relationship of prosthesis-patient mismatch (PPM) with long-term survival and to assess whether growing concern about PPM has resulted in a decreased incidence over time.
Using The Society of Thoracic Surgeons Adult Cardiac Surgery Database, we identified 59,779 patients ≥65 years old who underwent isolated surgical aortic valve replacement (AVR) between 2004 and 2014. The degree of PPM was calculated using literature-derived effective orifice areas for commonly used valves. Outcomes to 10 years were stratified by degree of PPM.
The distribution of PPM was as follows: 35%, none (n = 21,053); 54%, moderate (n = 32,243); and 11%, severe (n = 6,483). Compared with patients with no PPM, patients with moderate or severe PPM had a significantly increased risk of readmission for heart failure (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.09 to 1.21; HR, 1.37; 95% CI, 1.26 to 1.48) and redo AVR (HR, 1.41; 95% CI, 1.13 to 1.77; HR, 2.68; 95% CI, 2.01 to 3.56) for moderate or severe PPM, respectively. Survival was significantly worse for any degree of PPM (moderate to none: HR, 1.08; 95% CI, 1.05 to 1.12; severe to none: HR, 1.32; 95% CI, 1.25 to 1.39), with 10-year adjusted survival rates of 46%, 43%, and 35% for none, moderate, and severe, respectively (p < 0.001). The incidence of severe PPM decreased by 55% over the study period, from 13.8% in 2004 to 6.2% in 2014.
Any degree of PPM significantly decreased long-term survival and increased readmission rates for both heart failure and reoperation for AVR. Temporal trends show a significant decrease in the incidence of PPM over the past decade.
本研究旨在确定假体-患者不匹配（PPM）与长期生存率的关系，并评估对 PPM 的日益关注是否导致其发生率随时间的推移而降低。
我们使用胸外科医师学会成人心脏外科学数据库，确定了 2004 年至 2014 年间 59779 名年龄≥65 岁的接受单纯外科主动脉瓣置换术（AVR）的患者。使用文献中常用瓣膜的有效瓣口面积计算 PPM 的程度。根据 PPM 的程度对 10 年的结果进行分层。
PPM 的分布如下：35%，无（n=21053）；54%，中度（n=32243）；11%，严重（n=6483）。与无 PPM 的患者相比，中度或重度 PPM 患者因心力衰竭再入院（风险比[HR]，1.15；95%置信区间[CI]，1.09 至 1.21；HR，1.37；95%CI，1.26 至 1.48）和再次 AVR（HR，1.41；95%CI，1.13 至 1.77；HR，2.68；95%CI，2.01 至 3.56）的风险显著增加。任何程度的 PPM 患者的生存率均显著降低（中度至无 PPM：HR，1.08；95%CI，1.05 至 1.12；严重至无 PPM：HR，1.32；95%CI，1.25 至 1.39），无 PPM、中度 PPM 和重度 PPM 的 10 年校正生存率分别为 46%、43%和 35%（p<0.001）。研究期间，严重 PPM 的发生率下降了 55%，从 2004 年的 13.8%降至 2014 年的 6.2%。
任何程度的 PPM 均显著降低长期生存率，并增加心力衰竭和再次 AVR 手术的再入院率。时间趋势显示，在过去十年中，PPM 的发生率显著下降。
