Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, South Korea.
Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea.
J Thorac Cardiovasc Surg. 2020 Dec;160(6):1421-1430.e5. doi: 10.1016/j.jtcvs.2019.12.118. Epub 2020 Feb 26.
This study aimed to evaluate the changes in postoperative aortic regurgitation (AR) and determine the predictors of significant AR and root reoperation after ascending aortic replacement (AAR) in patients with acute type A aortic dissection.
From January 1995 to December 2017, 271 consecutive patients underwent valve/root-preserving AAR (n = 225) and root replacement (n = 46). AR grade trend over time was analyzed by the ordinal mixed-effects model. Significant AR was defined as AR grade ≥3+ during the follow-up period. Predischarge and follow-up echocardiograms were obtained in 95.6% and 88.8% of enrolled patients, respectively.
At predischarge, postoperative ≥2+ AR was present in 20 (9.3%) and 1 (2.3%) patients in the AAR and root replacement groups, respectively. With increasing time after surgery, the grade of AR increased. At 10 years, 4.6% of patients had developed 3+ or 4+ AR. Considering death as the competing risk, the 10-year cumulative incidence of significant AR was significantly higher in the AAR than in the root replacement group (12.3% vs 2.2%; P = .047). The risk of root reoperation at 10 years was not different between the groups (P = .118). On Cox analysis, preoperative ≥3+ AR (P = .002), postoperative ≥2+ AR (P = .040), and false to true lumen ratio (P = .005) were associated predictors of significant AR.
Although valve/root-preserving AAR demonstrated reasonable long-term outcomes when compared with root replacement, preoperative ≥3+ AR, postoperative ≥2+ AR, and high false to true lumen ratio significantly increased the risk of significant AR. Therefore, careful echocardiographic surveillance may be warranted in patients with postoperative ≥2+ AR and small true lumen.
本研究旨在评估急性 A 型主动脉夹层患者升主动脉置换（AAR）术后主动脉瓣关闭不全（AR）的变化，并确定重度 AR 和根部再次手术的预测因素。
1995 年 1 月至 2017 年 12 月，连续 271 例患者接受了保留瓣/根部的 AAR（n=225）和根部置换（n=46）。采用有序混合效应模型分析随时间推移的 AR 分级趋势。随访期间 AR 分级≥3+定义为重度 AR。95.6%和 88.8%的入组患者分别获得了术前和随访期间的超声心动图。
术前，AAR 和根部置换组分别有 20（9.3%）和 1（2.3%）例患者存在术后≥2+AR。随着手术时间的延长，AR 分级逐渐升高。10 年后，4.6%的患者出现 3+或 4+AR。考虑死亡为竞争风险，AAR 组 10 年时重度 AR 的累积发生率显著高于根部置换组（12.3%比 2.2%；P=0.047）。两组间 10 年时根部再次手术的风险无差异（P=0.118）。Cox 分析显示，术前≥3+AR（P=0.002）、术后≥2+AR（P=0.040）和假真腔比（P=0.005）是重度 AR 的相关预测因素。
与根部置换相比，保留瓣/根部的 AAR 具有合理的长期结果，但术前≥3+AR、术后≥2+AR 和假真腔比高显著增加了重度 AR 的风险。因此，对于术后存在≥2+AR 和小真腔的患者，可能需要进行仔细的超声心动图监测。
