Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany.
Eur J Cardiothorac Surg. 2021 Jul 30;60(2):276-283. doi: 10.1093/ejcts/ezab090.
The choice of prosthesis for aortic valve replacement (AVR) in younger patients remains controversial. Stentless AVR was introduced 3 decades ago, with the aim of better haemodynamics and durability than stented xenografts. The objective of this analysis was to compare the long-term outcomes to mechanical prostheses in younger patients (age ≤60 years).
All adult patients who underwent AVR due to aortic valve stenosis and/or insufficiency between 1993 and 2002 were identified. After the exclusion of patients with congenital heart defects, aortic dissections and Ross-procedures, 158 patients with stentless valves and 226 patients with bi-leaflet mechanical valves were finally included in this analysis. Sixty-six patient pairs could be included in a propensity matched analysis. Mortality and morbidity including stroke, bleeding, endocarditis and reoperation were analysed.
Group baseline characteristics and operative data did not differ significantly after propensity matching. Hospital mortality was 0.0% in the stentless and 1.5% in the mechanical group. Total patient years/median follow-up was 2029.1/15.4 years (completeness: 100.0%, range: 0-25 years). After 20 years, actuarial survival was 47.0 ± 6.4% in the stentless and 53.3 ± 6.6% in mechanical group (P = 0.69). Bleeding, endocarditis and stroke occurred rarely and did not differ significantly between groups. After 20 years, actuarial overall freedom-from-reoperation was 45.1 ± 8.2% in the stentless group and 90.4 ± 4.1% in the mechanical group (P < 0.001). Hospital mortality while reoperation was 7.4% in the stentless group and 0% in the mechanical group (P = 1.0).
Long-term morbidity and mortality of stentless and mechanical aortic valves were statistically not different besides a significantly higher reoperation rate after stentless AVR combined with a probably higher risk of in-hospital mortality. Thus, mechanical AVR should remain the procedure of choice in younger patients.
在年轻患者中，主动脉瓣置换术（AVR）的假体选择仍存在争议。无支架 AVR 于 30 年前问世，其目的是比带支架的异种移植物具有更好的血液动力学和耐久性。本分析的目的是比较年轻患者（≤60 岁）中机械假体的长期结果。
确定了 1993 年至 2002 年间因主动脉瓣狭窄和/或不全而接受 AVR 的所有成年患者。排除先天性心脏病、主动脉夹层和 Ross 手术患者后，最终纳入本分析的无支架瓣膜患者 158 例和双叶机械瓣膜患者 226 例。可纳入倾向匹配分析的 66 对患者。分析死亡率和发病率，包括卒中和出血、心内膜炎和再次手术。
在倾向匹配后，组间基线特征和手术数据无显著差异。无支架组的院内死亡率为 0.0%，机械组为 1.5%。总患者年/中位随访时间为 2029.1/15.4 年（完整性：100.0%，范围：0-25 年）。20 年后，无支架组的实际生存率为 47.0±6.4%，机械组为 53.3±6.6%（P=0.69）。出血、心内膜炎和卒中很少发生，两组之间无显著差异。20 年后，无支架组的实际总体免于再次手术的生存率为 45.1±8.2%，机械组为 90.4±4.1%（P<0.001）。再次手术时的院内死亡率为无支架组 7.4%，机械组 0%（P=1.0）。
除无支架 AVR 后再次手术率较高且可能导致院内死亡率较高外，无支架和机械主动脉瓣的长期发病率和死亡率在统计学上无显著差异。因此，机械 AVR 应仍然是年轻患者的首选治疗方法。
