Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio.
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Research Institute, Cleveland, Ohio.
J Thorac Cardiovasc Surg. 2022 Nov;164(5):1444-1455.e4. doi: 10.1016/j.jtcvs.2020.11.181. Epub 2021 Jan 20.
Improved durability and preference to avoid anticoagulation have led to increasing use of bioprostheses in younger patients despite the need for eventual reoperation. Therefore, we compared in-hospital complications, reoperation, and survival after bioprosthetic and mechanical aortic valve replacement.
From January 1990 to January 2020, 6143 patients underwent isolated aortic valve replacement at Cleveland Clinic; 637 patients received a mechanical prosthesis and 5506 a bioprosthesis. Propensity matching identified 527 well-matched pairs (83% of possible matches) for comparison of perioperative outcomes. The average age of patients was 54 years in the bioprosthesis group and 55 years in the mechanical prosthesis group. Random Forest machine-learning analysis was performed to compare survival using the entire cohort of 6143 patients.
Among matched patients, major in-hospital complications, including stroke, deep sternal wound infection, and reoperation for bleeding, were similar, as was in-hospital mortality (2 in the bioprosthesis group [0.38%] vs 3 in the mechanical prosthesis group [0.57%]; P > .9). Patients receiving a bioprosthesis had shorter hospital stays (median 6 vs 7 days, P < .0001). Fifty-one patients (32% at 14 years) in the bioprosthesis group and 17 patients in the mechanical prosthesis group (8% at 14 years) underwent reoperation (P [log-rank] < .0001); 5-year survival after reoperation was 85% versus 82% (P = .6). Risk-adjusted Random Forest prediction of 18-year survival was 60% in the bioprosthetic group and 58% in the mechanical prosthesis group.
Aortic valve bioprostheses are associated with excellent short-term outcomes and 18-year survival similar to that of patients receiving mechanical valves. Reoperation does not adversely affect survival. These results suggest that risk for reoperation alone should not deter the use of bioprostheses in younger patients.
尽管需要最终再次手术，但生物假体的耐用性提高和对避免抗凝的偏好导致其在年轻患者中的使用不断增加。因此，我们比较了生物假体和机械主动脉瓣置换术后的院内并发症、再次手术和生存情况。
1990 年 1 月至 2020 年 1 月，克利夫兰诊所共有 6143 例患者接受了单纯主动脉瓣置换术；其中 637 例接受了机械假体，5506 例接受了生物假体。通过倾向性匹配确定了 527 对匹配良好的患者（可能匹配的 83%），以比较围手术期结果。生物假体组患者的平均年龄为 54 岁，机械假体组为 55 岁。对 6143 例患者的整个队列进行了随机森林机器学习分析，以比较生存情况。
在匹配的患者中，主要的院内并发症包括卒中、深部胸骨伤口感染和因出血再次手术，以及院内死亡率（生物假体组 2 例[0.38%]，机械假体组 3 例[0.57%]；P>0.9）均相似。接受生物假体的患者住院时间更短（中位数为 6 天 vs 7 天，P<0.0001）。生物假体组 51 例（14 年时 32%）和机械假体组 17 例（14 年时 8%）患者接受了再次手术（P[log-rank] <0.0001）；再次手术后 5 年生存率分别为 85%和 82%（P=0.6）。生物假体组 18 年生存率的风险调整随机森林预测为 60%，机械假体组为 58%。
主动脉瓣生物假体具有良好的短期结果和 18 年生存率，与接受机械瓣膜的患者相似。再次手术不会对生存产生不利影响。这些结果表明，仅因再次手术的风险而不应该阻止在年轻患者中使用生物假体。
