Etnel Jonathan R G, Huygens Simone A, Grashuis Pepijn, Pekbay Begüm, Papageorgiou Grigorios, Roos Hesselink Jolien W, Bogers Ad J J C, Takkenberg Johanna J M
Department of Cardiothoracic Surgery (J.R.G.E., S.A.H., P.G., B.P., G.P., A.J.J.C.B., J.J.M.T.), Erasmus University Medical Center, Rotterdam, The Netherlands.
Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands (S.A.H.).
Circ Cardiovasc Qual Outcomes. 2019 Feb;12(2):e005481. doi: 10.1161/CIRCOUTCOMES.118.005481.
Background To support decision-making in aortic valve replacement in nonelderly adults, we aim to provide a comprehensive overview of reported outcome after bioprosthetic aortic valve replacement and to translate this to age-specific patient outcome estimates. Methods and Results A systematic review was conducted for papers reporting clinical outcome after aortic valve replacement with currently available bioprostheses in patients with a mean age <55 years, published between January 1, 2000, and January 9, 2016. Pooled reported event rates and time-to-event data were pooled and entered into a microsimulation model to calculate life expectancy and lifetime event risk for the ages of 25, 35, 45, and 55 years at surgery. Nineteen publications were included, encompassing a total of 2686 patients with 21 117 patient-years of follow-up (pooled mean follow-up: 7.9±4.2 years). Pooled mean age at surgery was 50.7±11.0 years. Pooled early mortality risk was 3.30% (95% CI, 2.39-4.55), late mortality rate was 2.39%/y (95% CI, 1.13-2.94), reintervention 1.82%/y (95% CI, 1.31-2.52), structural valve deterioration 1.59%/y (95% CI, 1.21-2.10), thromboembolism 0.53%/y (95% CI, 0.42-0.67), bleeding 0.22%/y (95% CI, 0.16-0.32), endocarditis 0.48%/y (95% CI, 0.37-0.62), and 20-year pooled actuarial survival was 58.7% and freedom from reintervention was 29.0%. Median time to structural valve deterioration was 17.3 years and median time to all-cause first reintervention was 16.9 years. For a 45-year-old adult, for example, this translated to a microsimulation-based estimated life expectancy of 21 years (general population: 32 years) and lifetime risk of reintervention of 78%, structural valve deterioration 71%, thromboembolism 12%, bleeding 5%, and endocarditis 9%. Conclusions Aortic valve replacement with bioprostheses in young adults is associated with high structural valve deterioration and reintervention rates and low, though not absent, hazards of thromboembolism and bleeding. Foremostly, most patients will require one or more reinterventions during their lifetime and survival is impaired in comparison with the age- and sex-matched general population. Prosthesis durability remains the main concern in nonelderly patients.
背景 为支持非老年成人主动脉瓣置换术的决策制定，我们旨在全面概述生物人工主动脉瓣置换术后报告的结局，并将其转化为特定年龄的患者结局估计值。方法与结果 对2000年1月1日至2016年1月9日发表的关于平均年龄<55岁患者使用现有生物人工瓣膜进行主动脉瓣置换术后临床结局的论文进行了系统评价。汇总报告的事件发生率和事件发生时间数据，并将其输入微观模拟模型，以计算手术时年龄为25、35、45和55岁患者的预期寿命和终身事件风险。纳入了19篇出版物，共2686例患者，随访21117患者年（汇总平均随访时间：7.9±4.2年）。手术时汇总平均年龄为50.7±11.0岁。汇总早期死亡风险为3.30%（95%CI，2.39-4.55），晚期死亡率为2.39%/年（95%CI，1.13-2.94），再次干预率为1.82%/年（95%CI，1.31-2.52），结构性瓣膜退化率为1.59%/年（95%CI，1.21-2.10），血栓栓塞率为0.53%/年（95%CI，0.42-0.67），出血率为0.22%/年（95%CI，0.16-0.32），心内膜炎率为0.48%/年（95%CI，0.37-0.62），20年汇总精算生存率为58.7%，无再次干预率为29.0%。结构性瓣膜退化的中位时间为17.3年,全因首次再次干预的中位时间为16.9年。例如，对于一名45岁的成年人，这转化为基于微观模拟的估计预期寿命为21年（一般人群：32年），再次干预的终身风险为78%，结构性瓣膜退化风险为71%，血栓栓塞风险为12%，出血风险为5%，心内膜炎风险为9%。结论 年轻成人使用生物人工瓣膜进行主动脉瓣置换术与高结构性瓣膜退化率和再次干预率相关，血栓栓塞和出血风险虽低但并非不存在。最重要的是，大多数患者在其一生中将需要进行一次或多次再次干预，与年龄和性别匹配的一般人群相比，生存率受到损害。假体耐用性仍然是非老年患者的主要关注点。
