Kim Do Jung, Joo Hyun-Chel, Lee Seung-Hyun, Chang Byung-Chul, Lee Sak
Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
Department of Thoracic and Cardiovascular Surgery, Cha Bundang Medical Center, Cha University, Seoul, Korea.
Interact Cardiovasc Thorac Surg. 2018 Dec 1;27(6):828-835. doi: 10.1093/icvts/ivy176.
The aim of this study was to examine long-term clinical outcomes and to assess the eventual need for aortic valve replacement (AVR) in patients with mild aortic valve disease (AVD) at the time of mitral valve replacement.
Between 1990 and 2015, 1231 patients undergoing mitral valve replacement were reviewed, stratifying subjects as those with AVD (n = 363) or without AVD (NA; n = 868). Primary end points were progressive AVD (grade ≥ II) and subsequent AVR. Overall mortality and valve-related complications served as secondary end points. Propensity score matching was used for risk adjustment (n = 320 in each group).
No differences in postoperative complications or clinical outcomes were observed between groups. The 20-year overall survival was similar (before matching: NA 86.1% vs AVD 80.8%, P = 0.128; after matching: 83.5% vs 81.1%, P = 0.425). Of the entire cohort, progressive AVD was observed in 162 patients, and significant AVD (grade ≥ III) was observed in only 60 patients. Subsequent AVR was required in 37 patients due to mitral valve (MV) dysfunction or severe aortic stenosis. The 20-year freedom from significant AVD and subsequent AVR was significantly higher in the NA group than in the AVD group before and after matching (before: NA, 96.5% vs 73.7%, P < 0.001; AVD, 98.5% vs 82.3%, P < 0.001; after: 98.1% vs 73.3%, P < 0.001; 99.3% vs 82.5%, P < 0.001, respectively).
Although progressive AVD did not significantly impact long-term survival during the follow-up period, those patients qualifying initially as mild AVD may eventually progress to significant AVD after the first 5 postoperative years. Therefore, aggressive echocardiography should be performed at 5-year lapse after mitral valve replacement to determine the appropriate timing of AVR.
本研究旨在探讨二尖瓣置换术时轻度主动脉瓣疾病（AVD）患者的长期临床结局，并评估最终进行主动脉瓣置换（AVR）的必要性。
回顾1990年至2015年间接受二尖瓣置换术的1231例患者，将受试者分为有AVD组（n = 363）和无AVD组（NA；n = 868）。主要终点为进展性AVD（≥II级）和随后的AVR。总死亡率和瓣膜相关并发症作为次要终点。采用倾向评分匹配法进行风险调整（每组n = 320）。
两组术后并发症或临床结局无差异。20年总生存率相似（匹配前：NA组86.1% vs AVD组80.8%，P = 0.128；匹配后：83.5% vs 81.1%，P = 0.425）。在整个队列中，162例患者出现进展性AVD，仅60例患者出现严重AVD（≥III级）。37例患者因二尖瓣（MV）功能障碍或严重主动脉瓣狭窄需要进行后续AVR。NA组在匹配前后20年无严重AVD和后续AVR的自由度均显著高于AVD组（匹配前：NA组，96.5% vs 73.7%，P < 0.001；AVD组，98.5% vs 82.3%，P < 0.001；匹配后：98.1% vs 73.3%，P < 0.001；99.3% vs 82.5%，P < 0.001）。
虽然进展性AVD在随访期间对长期生存没有显著影响，但最初符合轻度AVD的患者在术后第5年可能最终进展为严重AVD。因此，二尖瓣置换术后5年应积极进行超声心动图检查，以确定AVR的合适时机。
