Kalyanasundaram Asanish, Vinholo Thais Faggion, Zafar Mohammad A, Anis Osama, Charilaou Paris, Ziganshin Bulat, Elefteriades John A
Aortic Institute at Yale-New Haven Hospital, New Haven, CT 06510, USA.
Saint Peter's University Hospital, New Brunswick, NJ 08901, USA.
Rev Cardiovasc Med. 2022 Jun 24;23(7):223. doi: 10.31083/j.rcm2307223. eCollection 2022 Jul.
According to the 2020 American College of Cardiology/American Heart Association guidelines, the aortic valve should be replaced in the setting of severe aortic stenosis or regurgitation, independent of left ventricular function (even for EF 55%). However, in clinical practice, especially in a very low EF range, surgeons may avoid surgical aortic valve replacement (SAVR) because of concern over operative risk. This study examines outcomes of patients with EF 35% undergoing SAVR.
From 2004 to 2019, 895 patients underwent SAVR for aortic stenosis (AS) and/or regurgitation (AR) by a single surgeon at our institution. From among these, 40 patients (4.47%) had an ejection fraction (EF) of 35% or less, forming the study group. Intra-aortic balloon pump was placed intraoperatively prophylactically pre-bypass in 18 out of the 40. Preoperative and post-operative echocardiograms were compared to determine changes in ejection fraction. Mid-term survival was assessed.
16 patients presented with AS, 20 with AR, and 4 with a combination of AS and AR. Hospital survival was 97.5% (one patient death). The average ejection fraction progressively improved over time from 26% initially to 46% mid-term with mean follow-up of 43 months (0.1-140.7). Remarkably, five-year survival was comparable between the study group and an age- and gender-matched general population ( = 0.834). Downward trends in LV end-diastolic diameter and end-systolic diameter were seen. The former achieved statistical significance (6.0 cm to 5.3 cm; = 0.0046), while the latter fell slightly short (4.8 cm to 4.1 cm; = 0.056). Patients in whom an IABP was used had lower EFs than those without IABP (range 10-35, mean 23% vs. 15-35%, mean 27.6%). The EFs of the three subgroups improved significantly postoperatively ( 0.001 for AS, = 0.002 for AR, and = 0.046 for AS and AR).
Surgical AVR can be done safely in patients with a failing LV with EF 35%. Significant improvements in the ejection fraction are seen over time. We believe there is a role for prophylactic pre-bypass IABP. Five-year survival is normalized. Surgeons should not hesitate to perform AVR in these highly jeopardized patients.
根据2020年美国心脏病学会/美国心脏协会指南，在严重主动脉瓣狭窄或反流的情况下，无论左心室功能如何（即使射血分数[EF]＞55%），均应更换主动脉瓣。然而，在临床实践中，尤其是在EF范围极低的情况下，外科医生可能会因担心手术风险而避免进行外科主动脉瓣置换术（SAVR）。本研究探讨了EF≤35%的患者接受SAVR的结局。
2004年至2019年，在我们机构由一名外科医生为895例因主动脉狭窄（AS）和/或反流（AR）接受SAVR的患者进行手术。其中，40例患者（4.47%）射血分数（EF）为35%或更低，构成研究组。40例患者中有18例在体外循环前预防性置入主动脉内球囊泵。比较术前和术后超声心动图以确定射血分数的变化。评估中期生存率。
16例患者表现为AS，20例为AR，4例为AS和AR合并存在。住院生存率为97.5%（1例患者死亡）。平均射血分数随时间逐渐改善，从最初的26%提高到中期的46%，平均随访43个月（0.1 - 140.7个月）。值得注意的是，研究组与年龄和性别匹配的普通人群的五年生存率相当（P = 0.834）。左心室舒张末期直径和收缩末期直径呈下降趋势。前者具有统计学意义（从6.0 cm降至5.3 cm；P = 0.0046），而后者略低于统计学意义（从4.8 cm降至4.1 cm；P = 0.056）。使用主动脉内球囊泵的患者EF低于未使用的患者（范围10 - 35，平均23%对15 - 35%，平均27.6%）。三个亚组的EF术后均显著改善（AS组P＜0.001，AR组P = 0.002，AS和AR合并组P = 0.046）。
对于EF≤35%的左心室功能衰竭患者，可以安全地进行外科主动脉瓣置换术。随着时间推移，射血分数有显著改善。我们认为预防性体外循环前主动脉内球囊泵有作用。五年生存率恢复正常。外科医生在这些高危患者中进行主动脉瓣置换术时不应犹豫。
