Department of Paediatric Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
Department of Congenital Cardiac Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
Eur J Cardiothorac Surg. 2019 Sep 1;56(3):549-556. doi: 10.1093/ejcts/ezz046.
Subaortic stenosis (SAS) can present as various types of obstruction of the left ventricular outflow tract (LVOT) below the level of the aortic valve. Even though corrective surgery has been identified as the most effective treatment, SAS more frequently reoccurs requiring reoperation in a significant proportion of the patients. Previous studies have focused on predictors of recurrence in various subgroups of patients with SAS, but rarely in the overall population of patients with SAS. The aim of this study was to determine the predictors of recurrence of SAS after initial corrective surgery.
Patients from the database of the Congenital Cardiology Department of the University Hospital of Southampton with significant SAS requiring corrective surgery were included in the study. Data retrieved were obtained and used to determine the predictors of SAS recurrence after the initial corrective surgery.
Eighty-two patients (paediatric, n = 72 and adult, n = 10) who underwent initial successful resection were included in the analysis. Thirty patients required reoperation for recurrent SAS. These were significantly younger (median age 3.0 vs 6.7 years, P = 0.002). The recurrence of SAS was more common in patients with an interrupted aortic arch (23.3% vs 3.8%, P = 0.010) and unfavourable left ventricle geometry (43.3% vs 7.6%, P < 0.001), with steeper aortoseptal angle (131.0° ± 8.7° vs 136.1° ± 8.6°, P = 0.030), shorter distance between the point of obstruction of the LVOT and the aortic valve annulus in systole and diastole (median 4.30 vs 5.90 mm, P = 0.003 and 3.65 vs 4.95 mm, P = 0.006, respectively) and in those who had higher residual peak and mean LVOT gradients postoperatively (29.3 ± 16.0 vs 19.8 ± 10.7 mmHg, P = 0.006 and 15.9 ± 8.3 vs 10.1 ± 5.8 mmHg, P = 0.002, respectively). Overall, the presence of an interrupted aortic arch [odds ratio (OR) 10.34, 95% confidence interval (CI) 1.46-73.25; P < 0.019] and unfavourable left ventricle geometry (OR 10.42, 95% CI 1.86-58.39; P < 0.008) could independently predict reoperation for SAS after initial successful resection.
Patients who have initial corrective surgery for SAS at a younger age, unfavourable left ventricle geometry, an interrupted aortic arch and higher early postoperative LVOT gradients are more likely to have recurrent SAS requiring reoperation.
主动脉瓣下狭窄（SAS）可表现为主动脉瓣以下左心室流出道（LVOT）的各种类型梗阻。尽管已经确定矫正手术是最有效的治疗方法，但 SAS 更常复发，需要在很大一部分患者中进行再次手术。以前的研究集中在 SAS 各种亚组患者的复发预测因素上，但很少关注 SAS 患者的总体人群。本研究旨在确定初次矫正手术后 SAS 复发的预测因素。
纳入因 SAS 需要矫正手术而在南安普顿大学医院先天性心脏病科就诊的患者。获取并使用检索到的数据来确定初次矫正手术后 SAS 复发的预测因素。
本研究共纳入 82 例（儿科患者 72 例，成年患者 10 例），这些患者接受初次成功切除术。30 例患者因 SAS 复发需要再次手术。这些患者的年龄明显较小（中位年龄 3.0 岁 vs. 6.7 岁，P=0.002）。在患有主动脉弓中断（23.3% vs. 3.8%，P=0.010）和左心室几何结构不良（43.3% vs. 7.6%，P<0.001）的患者中，SAS 复发更为常见，其主动脉窦隔角更陡（131.0°±8.7° vs. 136.1°±8.6°，P=0.030），LVOT 梗阻点与主动脉瓣环在收缩期和舒张期之间的距离更短（中位数分别为 4.30 毫米 vs. 5.90 毫米，P=0.003 和 3.65 毫米 vs. 4.95 毫米，P=0.006），且术后 LVOT 峰值和平均梯度更高（29.3±16.0 毫米汞柱 vs. 19.8±10.7 毫米汞柱，P=0.006 和 15.9±8.3 毫米汞柱 vs. 10.1±5.8 毫米汞柱，P=0.002）。总体而言，主动脉弓中断（比值比 [OR] 10.34，95%置信区间 [CI] 1.46-73.25；P<0.019）和左心室几何结构不良（OR 10.42，95%CI 1.86-58.39；P<0.008）的存在可独立预测初次成功手术后 SAS 再次手术。
在较年轻、左心室几何结构不良、主动脉弓中断和术后早期 LVOT 梯度较高的患者中，初次行 SAS 矫正手术的患者更容易出现 SAS 复发，需要再次手术。
