先天性心脏病患儿及青年机械主动脉瓣置换术后的结果。
Outcomes after mechanical aortic valve replacement in children and young adults with congenital heart disease.
机构信息
Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass; Division of Cardiovascular Surgery, Geneva University Medical School, Geneva, Switzerland.
Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass.
出版信息
J Thorac Cardiovasc Surg. 2019 Jan;157(1):329-340. doi: 10.1016/j.jtcvs.2018.08.077. Epub 2018 Sep 21.
OBJECTIVES
There are little recent data on the outcomes of mechanical aortic valve replacement (AVR) in children and young adults with congenital aortic valve disease. We sought to review the survival and associated thromboembolic or bleeding complications after mechanical AVR at a single center.
METHODS
Data were retrospectively collected for 121 patients undergoing prosthetic AVR from 2000 to 2014. Kaplan-Meier estimates and Cox proportional hazards were employed.
RESULTS
Median age at AVR was 16 years (interquartile range, 12-22.8 years). The valves implanted were the St Jude valve (St Jude Medical Inc, St Paul, Minn) in 79 patients (62%), the On-X valve (On-X Life Technologies Inc, Austin, Tex) in 45 patients (35%), and CarboMedics (Sorin SpA, Milan, Italy) in 3 patients (2.4%). Median valve size was 23 mm (range, 21-25 mm). There were 5 early deaths (3.9%). Median follow-up was 5 years (range, 1.6-9.2 years; 600 patient-years). There were 14 deaths during follow-up. Survival was 90.6% ± 2.8% at 1 year, 85.4% ± 3.7% at 5 years, and 81.5% ± 4.5% at 10 years. Freedom from aortic valve reoperation was 98% ± 1.4% at 1 and 5 years, 91.5% ± 3.9% at 7 years, and 78.4% ± 6.9% at 10 years and at latest follow-up. Univariable analysis identified younger age, lower weight, and use of a 16-mm CarboMedics valve as predictors of reoperation. Valve sizes of 16 or 17 mm have a significantly higher risk of reoperation compared with larger valves (log-rank test, P < .001). At multivariable analysis, only younger age was a significant independent predictor of reoperation (hazard ratio, 0.84; 95% confidence interval, 0.71-0.99; P = .038). All patients were treated with warfarin to a goal international normalized ratio of 2.0 to 3.0. Four patients (3.1%; 0.66% per patient-year) had thromboembolic complications, and 5 patients (3.9%; 0.83% per patient-year) had bleeding events during follow-up.
CONCLUSIONS
Mechanical AVR in patients with congenital heart disease has excellent short- and midterm outcomes. Younger age was an independent predictor of reoperation.
目的
关于先天性主动脉瓣疾病患儿和青年患者行机械主动脉瓣置换术（AVR）的近期结局数据较少。我们旨在研究单一中心行机械 AVR 后患者的生存情况以及与之相关的血栓栓塞或出血并发症。
方法
回顾性收集 2000 年至 2014 年期间 121 例行人工瓣膜 AVR 的患者数据。采用 Kaplan-Meier 估计和 Cox 比例风险进行分析。
结果
AVR 时的中位年龄为 16 岁（四分位距，12-22.8 岁）。植入的瓣膜为 St Jude 瓣膜（明尼苏达州圣保罗市 St Jude Medical Inc）79 例（62%），On-X 瓣膜（德克萨斯州奥斯汀市 On-X Life Technologies Inc）45 例（35%），CarboMedics 瓣膜（意大利米兰 Sorin SpA）3 例（2.4%）。中位瓣膜尺寸为 23mm（范围，21-25mm）。早期死亡 5 例（3.9%）。中位随访时间为 5 年（范围，1.6-9.2 年；600 患者-年）。随访期间共有 14 例死亡。随访 1 年时的生存率为 90.6%±2.8%，5 年时为 85.4%±3.7%，10 年时为 81.5%±4.5%。1 年和 5 年时主动脉瓣再次手术的无失败率为 98%±1.4%，7 年时为 91.5%±3.9%，10 年时和随访结束时为 78.4%±6.9%。单变量分析发现，年龄较小、体重较轻和使用 16mm CarboMedics 瓣膜是再次手术的预测因素。16 或 17mm 瓣膜的尺寸与较大的瓣膜相比，再次手术的风险显著增加（对数秩检验，P<0.001）。多变量分析显示，只有年龄较小是再次手术的独立显著预测因素（风险比，0.84；95%置信区间，0.71-0.99；P=0.038）。所有患者均接受华法林治疗，目标国际标准化比值为 2.0 至 3.0。4 例（3.1%；0.66%/患者-年）发生血栓栓塞并发症，5 例（3.9%；0.83%/患者-年）发生出血事件。
结论
先天性心脏病患者行机械 AVR 具有极好的短期和中期结局。年龄较小是再次手术的独立预测因素。
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