Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Harvard School of Public Health, Boston, Massachusetts.
Semin Thorac Cardiovasc Surg. 2020;32(2):219-228. doi: 10.1053/j.semtcvs.2019.01.005. Epub 2019 Jan 7.
The effects of patient-prosthesis mismatch (PPM) after surgical aortic valve replacement (SAVR) suggest worse outcomes with smaller valves. We assessed clinical outcomes of younger females undergoing SAVR, using small and large prostheses, and the incremental risk of PPM. Between January 2002 and June 2015, 451 younger (age ≤65 years) female patients underwent SAVR. Patients were stratified into small prostheses (SP) ≤21 mm (n = 256) and large prostheses (LP) ≥23 mm (n = 195) groups. PPM was classified as moderate if indexed effective orifice area (iEOA) 0.65-0.85 cm/m, or severe if iEOA <0.65 cm/m. Operative mortality was not statistically different between SP and LP groups (2.4% vs 0.5%; P = 0.146). Unadjusted 10-year survival was 82% (95% confidence interval 77-87%), and was similar in both groups (P = 0.210). When grouped by standard PPM thresholds, only severe PPM was associated with significantly decreased survival (P = 0.007). A significant survival decrease was detected in LP group with iEOA ≤0.75 cm/m (P < 0.001). Among SP patients, iEOA ≤0.65 cm/m was associated with increased mortality (P = 0.075). After adjusting for potential confounders, Cox proportional hazard model identified iEOAs of ≤0.65 cm/m (hazard ratio 1.85; P = 0.066) and ≤0.75 cm/m (hazard ratio 2.3; P ≤ 0.003) as predictors of decreased long-term survival, in SP and LP groups, respectively. Among younger females who underwent SAVR, postoperative complications and in-hospital outcomes were substantially similar between the SP and LP groups. However, patients who received LP were adversely affected at lesser degrees of PPM than those who received SP. While SP patients may tolerate until iEOA ≤0.65 cm/m, our results suggest that moderate PPM of iEOA ≤0.75 for LP patients should be avoided.
在主动脉瓣置换术后（SAVR）中，患者-假体不匹配（PPM）的影响表明，使用较小的瓣膜会导致更差的结果。我们评估了接受 SAVR 的年轻女性使用小和大假体的临床结果，以及 PPM 的增量风险。在 2002 年 1 月至 2015 年 6 月期间，451 名年龄≤65 岁的年轻女性患者接受了 SAVR。患者分为小假体（SP）≤21mm（n=256）和大假体（LP）≥23mm（n=195）两组。如果指数有效瓣口面积（iEOA）为 0.65-0.85cm/m，则将 PPM 分类为中度，如果 iEOA<0.65cm/m，则将 PPM 分类为重度。SP 组和 LP 组的手术死亡率无统计学差异（2.4%比 0.5%；P=0.146）。未调整的 10 年生存率为 82%（95%置信区间 77-87%），两组相似（P=0.210）。当按标准 PPM 阈值分组时，只有重度 PPM 与生存率显著下降相关（P=0.007）。在 LP 组中，iEOA≤0.75cm/m 时检测到生存率显著下降（P<0.001）。在 SP 患者中，iEOA≤0.65cm/m 与死亡率增加相关（P=0.075）。在校正潜在混杂因素后，Cox 比例风险模型确定 iEOA≤0.65cm/m（危险比 1.85；P=0.066）和 iEOA≤0.75cm/m（危险比 2.3；P≤0.003）分别为 SP 和 LP 组中降低长期生存率的预测因素。在接受 SAVR 的年轻女性中，SP 组和 LP 组之间的术后并发症和住院期间结局基本相似。然而，接受 LP 的患者在较小程度的 PPM 方面受到的影响比接受 SP 的患者更严重。虽然 SP 患者可能耐受 iEOA≤0.65cm/m，但我们的结果表明，LP 患者的 iEOA 中度 PPM 应避免≤0.75cm/m。
