Javadikasgari Hoda, Chemtob Raphaelle A, Gillinov A Marc, Pettersson Gösta B, Lowry Ashley M, Desai Milind Y, Svensson Lars G, Blackstone Eugene H, Wierup Per
Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
J Thorac Cardiovasc Surg. 2022 May;163(5):1804-1812.e5. doi: 10.1016/j.jtcvs.2020.08.067. Epub 2020 Aug 25.
Reoperation for structural valve deterioration (SVD) of bioprosthetic mitral valves carries a presumed high operative risk, and transcatheter mitral valve-in-valve implantation has emerged as an alternative. However, surgical risk and long-term outcome following mitral valve re-replacement in these patients remain ill-defined. Hence, we sought to evaluate outcomes and long-term survival following surgical mitral valve re-replacement and to identify risk factors for mortality.
From January 1990 to January 2017, 525 patients underwent surgical mitral valve re-replacement at Cleveland Clinic for bioprosthetic SVD: 133 (25%) isolated operations and 392 (75%) with concomitant procedures. Surgical complications and modes of death were compiled, long-term mortality assessed, and risk factors identified using a multivariable nonproportional hazards model and random forest analysis.
SVD was characterized by bioprosthetic regurgitation in 81% (425 out of 525) and stenosis in 44% (231 out of 525). One in-hospital death occurred after isolated valve re-replacement (0.75%) and 28 deaths occurred (7.1%; P = .003) after nonisolated re-replacement, 19 (68%) of which were from coagulopathy, vasoplegia, and multisystem organ failure. In the nonisolated group, incremental risk factors for time-related death after re-replacement included New York Heart Association functional class IV symptoms, concomitant coronary artery bypass grafting, prolonged cardiopulmonary bypass time, and transfusions.
Mitral valve re-replacement for bioprosthetic SVD was associated with low surgical risk and excellent long-term survival. Isolated mitral valve re-replacement for bioprosthetic SVD had near-zero surgical risk. Excessive cardiopulmonary bypass duration and multiple transfusions correlated with increased early mortality in nonisolated procedures, as did preoperative severe heart failure. Optimal surgical plan and timing of surgery are keys to success.
生物人工二尖瓣结构瓣膜退变（SVD）再次手术的手术风险被认为较高，经导管二尖瓣瓣中瓣植入术已成为一种替代方案。然而，这些患者二尖瓣再次置换术后的手术风险和长期预后仍不明确。因此，我们试图评估二尖瓣再次置换术后的结局和长期生存率，并确定死亡的危险因素。
1990年1月至2017年1月，525例患者在克利夫兰诊所因生物人工瓣膜SVD接受二尖瓣再次置换手术：133例（25%）为单纯手术，392例（75%）为同期手术。汇总手术并发症和死亡方式，评估长期死亡率，并使用多变量非比例风险模型和随机森林分析确定危险因素。
SVD的特征为生物人工瓣膜反流占81%（525例中的425例），狭窄占44%（525例中的231例）。单纯瓣膜再次置换术后发生1例院内死亡（0.75%）；非单纯再次置换术后发生28例死亡（7.1%；P = 0.003），其中19例（68%）死于凝血病、血管麻痹和多系统器官衰竭。在非单纯组中，再次置换术后与时间相关死亡的增量危险因素包括纽约心脏协会功能分级IV级症状、同期冠状动脉旁路移植术、体外循环时间延长和输血。
生物人工瓣膜SVD二尖瓣再次置换手术风险低，长期生存率高。生物人工瓣膜SVD单纯二尖瓣再次置换手术风险接近零。体外循环时间过长和多次输血与非单纯手术早期死亡率增加相关，术前严重心力衰竭也是如此。最佳手术方案和手术时机是成功的关键。
