Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
Duke University Medical School.
J Card Surg. 2021 Jun;36(6):1969-1978. doi: 10.1111/jocs.15472. Epub 2021 Mar 2.
Infective endocarditis (IE) involving the aortic valve and root is associated with high risk requiring thoughtful surgical decision-making. The impact of valve and conduit choices and patient factors on long-term outcomes in this patient population is poorly documented.
From January 1976 to December 2013, 485 patients underwent aortic root and valve replacement at a single institution. Cox's proportional hazard model identified predictors of long-term survival and cumulative incidence functions were compared to assess need for reoperation with death as a competing risk.
Median age at time of operation was 56.6 years (interquartile range: 23.1) with the indication for operation being endocarditis in 14.6% (n = 71). Stentless root replacement was used in 70% IE versus 34% non-IE (p < .001). Endocarditis at time of root replacement did not have a significant impact on survival through 15 years (IE: 37.3% vs. non-IE: 42.5%; log-rank; p = .13). After multivariable adjustment, survival was similar between patients with and without endocarditis (hazard ratio: 1.1; 95% confidence interval: [0.77, 1.62]; p = .57). Freedom from reoperation at 15 years did not vary significantly by endocarditis status (IE: 95.9% vs. non-IE: 73.6%; p = .07). Among endocarditis patients, freedom from reoperation at 10 years was similar between homograft and stentless bioprosthetic conduits (95.3% vs. 88.5%; log-rank; K-sample; p = .46).
In a sample with frequent use of stentless prostheses, aortic root replacement for infective endocarditis had acceptable risk and long-term survival similar to root replacement for other indications. In the setting of endocarditis, root replacement with homograft or stentless bioprosthetic root has excellent durability through 15 years.
感染性心内膜炎（IE）累及主动脉瓣和根部与高风险相关，需要慎重的手术决策。然而，该患者人群中，瓣膜和管道选择以及患者因素对长期结果的影响记录甚少。
1976 年 1 月至 2013 年 12 月，485 例患者在一家机构接受了主动脉根部和瓣膜置换术。Cox 比例风险模型确定了长期生存的预测因素，并比较了累积发生率函数，以评估因死亡而出现的再次手术的需要作为竞争风险。
手术时的中位年龄为 56.6 岁（四分位距：23.1），手术指征为感染性心内膜炎占 14.6%（n=71）。无支架根部置换术在感染性心内膜炎患者中的使用率为 70%，而非感染性心内膜炎患者为 34%（p<.001）。在 15 年的随访中，心内膜炎患者的生存情况并未明显影响（感染性心内膜炎：37.3% vs. 非感染性心内膜炎：42.5%；对数秩检验；p=0.13）。多变量调整后，心内膜炎患者和非心内膜炎患者的生存情况相似（风险比：1.1；95%置信区间：[0.77，1.62]；p=0.57）。15 年时，再次手术的无复发率在感染性心内膜炎患者中无显著差异（感染性心内膜炎：95.9% vs. 非感染性心内膜炎：73.6%；p=0.07）。在心内膜炎患者中，同种异体移植物和无支架生物瓣在 10 年时的无再次手术率相似（95.3% vs. 88.5%；对数秩检验；K 样本；p=0.46）。
在支架使用率较高的患者中，感染性心内膜炎患者主动脉根部置换术的风险可接受，长期生存率与其他适应证的患者相似。在心内膜炎患者中，同种异体移植物或无支架生物瓣的根部置换术在 15 年内具有极好的耐用性。
