Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky.
Department of Epidemiology and Biostatistics, University of Georgia College of Public Health, Athens, Georgia.
Ann Thorac Surg. 2022 Jan;113(1):166-173. doi: 10.1016/j.athoracsur.2020.12.014. Epub 2020 Dec 24.
Aortic valve replacement in young children is associated with technical difficulties and potential morbidity. In contrast to the versatile Ross operation, mechanical prostheses (MP) are uncommonly used.
We examined transplant-free survival and cardiac reoperation among 124 young children (aged 1-6 years) who underwent the Ross operation (n = 84) or MP (n = 40) for congenital disease (1982-2003) using the Pediatric Cardiac Care Consortium database. We explored variables influencing outcomes.
Children who received MP were operated in an earlier era and were more likely to have aortic regurgitation, conotruncal abnormalities, prior aortic valve surgery, and to need Konno annular enlargement. Although no significant differences were found in hospital mortality (1.2% vs 5.0%, P = .24) or 15-year transplant-free survival (94.1% vs 87.5%, P = .16) between Ross and MP recipients, survival diverged with later follow-up (91.3% vs 68.9%, respectively, at 25 years; P = .01). On multivariable regression analysis the association of MP use and transplant-free survival changed over time (hazard ratios, 0.8 [95% confidence interval, 0.1-4.4; P = .78] vs 6.0 [95% confidence interval, 0.6-63.1; P = .13], respectively) before and after 17 years. Cumulative incidence of cardiac reoperation at 10 years was 37.7% and 53.6% after the Ross procedure and MP, respectively (P = .05). The most common reoperation after the Ross procedure was conduit replacement and pacemaker ± automated internal cardiac defibrillator and after MP was pacemaker ± automated internal cardiac defibrillator and redo aortic valve replacement.
Over the study period there was a trend for increased Ross utilization. Interestingly MP use was associated with comparable operative mortality and survival up to 17 years, albeit with higher need for redo aortic valve replacement. On longer follow-up survival diverged with increased attrition in the MP group, likely because of late valve- and reoperation-related complications.
在幼儿中进行主动脉瓣置换术会带来技术上的困难和潜在的发病率。与多功能的罗斯手术不同，机械假体（MP）并不常用。
我们使用儿科心脏护理协会数据库，检查了 124 名接受罗斯手术（n=84）或 MP（n=40）治疗先天性疾病（1982-2003 年）的 1-6 岁幼儿的无移植存活率和心脏再次手术情况。我们探讨了影响结果的变量。
接受 MP 的儿童在较早的时期接受了手术，他们更有可能患有主动脉瓣反流、圆锥动脉干异常、既往主动脉瓣手术以及需要 Konno 环形扩大。尽管罗斯组和 MP 组之间在住院死亡率（1.2% vs. 5.0%，P=.24）或 15 年无移植存活率（94.1% vs. 87.5%，P=.16）方面没有显著差异，但随着随访时间的延长，存活率出现了差异（分别在 25 年时为 91.3%和 68.9%；P=.01）。多变量回归分析表明，MP 使用与无移植存活率的相关性随着时间的推移而发生变化（风险比，0.8 [95%置信区间，0.1-4.4；P=.78] vs. 6.0 [95%置信区间，0.6-63.1；P=.13]），分别在 17 年之前和之后。罗斯手术和 MP 术后 10 年的心脏再次手术累积发生率分别为 37.7%和 53.6%（P=.05）。罗斯手术后最常见的再次手术是导管置换和起搏器±自动心脏除颤器，而 MP 术后则是起搏器±自动心脏除颤器和再次主动脉瓣置换。
在研究期间，罗斯手术的使用率呈上升趋势。有趣的是，在 17 年之前，MP 使用与手术死亡率和存活率相当，但需要再次进行主动脉瓣置换的几率更高。在更长的随访中，随着 MP 组的死亡率增加，存活率出现了差异，这可能是由于晚期瓣膜和再手术相关并发症所致。
