Patrick William L, Rosen Jake L, Bavaria Joseph E, Ahmed Sania, Freas Andrew, Yarlagadda Siddharth, Cannon Brittany, Iyengar Amit, Kelly John J, Zhao Yu, Grimm Joshua C, Szeto Wilson Y, Desai Nimesh D
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA.
Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA.
Eur J Cardiothorac Surg. 2022 Sep 2;62(4). doi: 10.1093/ejcts/ezac393.
The purpose of this study was to evaluate the association between left ventricular (LV) dilation and outcomes following valve-sparing root reimplantation.
Patients with an indexed LV internal diameter during systole of ≥2.0 cm/m2 were categorized as having LV dilation. Outcomes were postoperative aortic insufficiency (AI), reintervention and all-cause mortality. The cumulative incidence of each outcome was computed using the Kaplan-Meier estimator. Adjusted comparisons between strata were performed for each outcome using a Cox proportional-hazards model. Where possible, the competing risk of death was accounted for. Multilevel mixed-effects ordered logistic regression was performed for AI grade at follow-up.
There were 295 patients of whom 52 had LV dilation. Operative outcomes were excellent; there were no significant differences between groups. Patients with LV dilation demonstrated significant improvement in indexed LV internal diameter during systole overtime. There was no association between LV dilation and postoperative AI grade >2 [hazard ratio 0.88, 95% confidence interval (CI) 0.21-3.67, P = 0.89] or odds of increased AI grade overtime (odds ratio = 0.76, 95% CI 0.30-1.93, P = 0.57). There were no re-interventions among those with LV dilation. Adjusted mortality was significantly higher among those with LV dilation (hazard ratio 5.56, 95% CI 1.56-19.9); however, deaths were unrelated to aortic valve dilation.
LV dilation is not associated with poorer operative outcomes, postoperative AI or reintervention. It is associated with an increased risk of mortality, though not from valvular dysfunction. LV dilation should not deter valve-sparing root reimplantation when otherwise indicated.
本研究旨在评估保留瓣膜的主动脉根部再植入术后左心室（LV）扩张与预后之间的关联。
将收缩期左心室内径指数≥2.0 cm/m²的患者归类为左心室扩张。观察指标为术后主动脉瓣关闭不全（AI）、再次干预和全因死亡率。采用Kaplan-Meier估计器计算各观察指标的累积发生率。使用Cox比例风险模型对各分层之间的观察指标进行校正比较。在可能的情况下，考虑死亡的竞争风险。对随访时的AI分级进行多水平混合效应有序逻辑回归分析。
共有295例患者，其中52例存在左心室扩张。手术效果良好；两组之间无显著差异。左心室扩张患者的收缩期左心室内径指数随时间显著改善。左心室扩张与术后AI分级>2[风险比0.88，95%置信区间（CI）0.21-3.67，P = 0.89]或AI分级随时间增加的几率（优势比=0.76，95%CI 0.30-1.93，P = 0.57）之间无关联。左心室扩张患者中无再次干预情况。校正后的死亡率在左心室扩张患者中显著更高（风险比5.56，95%CI 1.56-19.9）；然而，死亡与主动脉瓣扩张无关。
左心室扩张与较差的手术预后、术后AI或再次干预无关。它与死亡风险增加有关，尽管并非由瓣膜功能障碍引起。在其他指征明确时，左心室扩张不应妨碍保留瓣膜的主动脉根部再植入术。
