Kachroo Puja, Kelly Meghan O, Bakir Nadia H, Cooper Catherine, Braverman Alan C, Kouchoukos Nicholas T, Moon Marc R
Division of Cardiothoracic Surgery, Department of Surgery.
Division of Cardiothoracic Surgery, Department of Surgery.
J Thorac Cardiovasc Surg. 2022 Dec;164(6):1672-1680.e3. doi: 10.1016/j.jtcvs.2022.02.065. Epub 2022 Apr 14.
This study evaluated the impact of anatomic aortic root parameters during valve-sparing root replacement on the probability of postoperative aortic insufficiency and freedom from aortic valve reoperation.
From 1995 to 2020, 177 patients underwent valve-sparing root replacement (163 reimplantations, 14 remodeling). Preoperative and postoperative echocardiograms were analyzed to measure annulus and sinus diameters, effective height of leaflet coaptation, and degree of aortic insufficiency. Logistic regression was used to evaluate predictors of 2+ or greater late postoperative aortic insufficiency. Fine-Gray regression determined predictors for aortic valve reintervention.
The study population included 122 (69%) men with a mean age of 43 ± 15 years. A total of 119 patients (67%) had an identified connective tissue disorder. The cumulative incidence of aortic valve reoperation was estimated as 7% at 5 years and 12% at 10 years. The probability of 2+ or greater late postoperative aortic insufficiency was inversely related to effective height during valve-sparing root replacement (P = .018). As postoperative effective height fell below 11 mm, the probability of 2+ or greater aortic insufficiency exceeded 10%. On multivariable logistic regression, effective height (odds ratio, 0.53; 0.33-0.86; P = .010), preoperative annulus diameter (odds ratio, 1.44; 1.13-1.82; P = .003), and degree of preoperative aortic insufficiency (odds ratio, 2.57; 1.45-4.52; P = .001) were associated with increased incidence of 2+ or greater late postoperative aortic insufficiency. On multivariable Fine-Gray regression, risk factors for aortic valve reintervention included preoperative annulus diameter (subdistribution hazard ratio, 1.28 [1.03-1.59], P = .027), history of 3+ or greater aortic insufficiency (subdistribution hazard ratio, 4.28; 1.60-11.44; P = .004), and 2+ or greater early postoperative aortic insufficiency (subdistribution hazard ratio, 5.22; 2.29-11.90; P < .001).
Measures to increase effective height during valve-sparing root replacement may decrease the risk of more than mild postoperative aortic insufficiency after repair and the need for aortic valve reoperation.
本研究评估了保留瓣膜的主动脉根部置换术中主动脉根部解剖参数对术后主动脉瓣关闭不全概率及无需再次进行主动脉瓣手术的影响。
1995年至2020年，177例患者接受了保留瓣膜的主动脉根部置换术（163例再植入术，14例重塑术）。分析术前和术后超声心动图，以测量瓣环和窦部直径、瓣叶对合有效高度及主动脉瓣关闭不全程度。采用逻辑回归评估术后晚期主动脉瓣关闭不全2级或以上的预测因素。使用Fine-Gray回归确定主动脉瓣再次干预的预测因素。
研究人群包括122例（69%）男性，平均年龄43±15岁。共有119例患者（67%）患有明确的结缔组织疾病。主动脉瓣再次手术的累积发生率估计在5年时为7%，在10年时为12%。术后晚期主动脉瓣关闭不全2级或以上的概率与保留瓣膜的主动脉根部置换术中的有效高度呈负相关（P = 0.018）。当术后有效高度降至11 mm以下时，主动脉瓣关闭不全2级或以上的概率超过10%。在多变量逻辑回归中，有效高度（比值比，0.53；0.33 - 0.86；P = 0.010）、术前瓣环直径（比值比，1.44；1.13 - 1.82；P = 0.003）和术前主动脉瓣关闭不全程度（比值比，2.57；1.45 - 4.52；P = 0.001）与术后晚期主动脉瓣关闭不全2级或以上的发生率增加相关。在多变量Fine-Gray回归中，主动脉瓣再次干预的危险因素包括术前瓣环直径（亚分布风险比，1.28 [1.03 - 1.59]，P = 0.027）、3级或以上主动脉瓣关闭不全病史（亚分布风险比，4.28；1.60 - 11.44；P = 0.004）和术后早期主动脉瓣关闭不全2级或以上（亚分布风险比，5.22；2.29 - 11.90；P < 0.001）。
在保留瓣膜的主动脉根部置换术中增加有效高度的措施可能会降低修复术后中重度以上主动脉瓣关闭不全的风险以及再次进行主动脉瓣手术的必要性。
