Verheul H A, van den Brink R B, Bouma B J, Hoedemaker G, Moulijn A C, Dekker E, Bossuyt P, Dunning A J
Department of Cardiology, University of Amsterdam, The Netherlands.
J Am Coll Cardiol. 1995 Nov 1;26(5):1280-6. doi: 10.1016/0735-1097(95)00303-7.
This study sought to identify risk factors for both late observed and late "excess" mortality after aortic valve replacement and to examine the causes of late mortality.
Because operative mortality after aortic valve replacement is very low, the timing of surgical intervention should focus on maximizing long-term survival. However, to judge the effect of valve replacement on long-term survival in an elderly population, it is important to separate mortality resulting from extraneous causes (background mortality) from disease-related mortality (excess mortality). Background mortality can be estimated by calculating expected mortality on the basis of age and gender.
From 1966 to 1986, 643 patients (mean age 59.6 years, 138 [21%] > or = 70 years old) underwent aortic valve replacement, 129 of whom also underwent coronary bypass grafting; 594 patients survived > or = 30 days after the procedure. The overall operative mortality rate for isolated aortic valve replacement decreased over time from 25.5% (1966 to 1972) to 2.6% (1980 to 1986). Cumulative total follow-up after discharge was 3,603 patient-years. Multivariate analysis was performed for both observed and excess mortality.
Risk factors for both observed and excess mortality were previous myocardial infarction, coronary artery disease, heart failure and atrial fibrillation. Although age > or = 70 years was a risk factor for observed mortality (hazard rate ratio [HRR] 2.4, 95% confidence interval [CI] 1.6 to 3.7), it was not a risk factor for excess mortality. In contrast, isolated aortic regurgitation was an important risk factor for excess mortality only (HRR 3.8, 95% CI 1.3 to 11.2). Late mortality was valve related in 22% of patients, including sudden death in 7% and cerebral vascular accidents in 7%. Congestive heart failure was an important cause of death (21%) irrespective of the time elapsed since aortic valve replacement. In patients with aortic regurgitation, congestive heart failure was the main cause of death (38%); in patients with aortic regurgitation and preoperative heart failure or severe left ventricular dysfunction, heart failure was the cause of death in 44% and 63%, respectively.
Analysis of excess mortality revealed that older age in itself is not a risk factor for late mortality after aortic valve replacement. Aortic regurgitation carries a high risk, probably associated with left ventricular dysfunction at the time of operation. Earlier operation may be warranted in such patients.
本研究旨在确定主动脉瓣置换术后晚期观察到的死亡率和晚期“额外”死亡率的危险因素，并研究晚期死亡的原因。
由于主动脉瓣置换术后手术死亡率非常低，手术干预的时机应侧重于使长期生存率最大化。然而，为了判断瓣膜置换对老年人群长期生存的影响，将由外部原因导致的死亡率（背景死亡率）与疾病相关死亡率（额外死亡率）区分开来很重要。背景死亡率可通过根据年龄和性别计算预期死亡率来估计。
1966年至1986年，643例患者（平均年龄59.6岁，138例[21%]年龄≥70岁）接受了主动脉瓣置换术，其中129例还接受了冠状动脉搭桥术；594例患者术后存活≥30天。单纯主动脉瓣置换术的总体手术死亡率随时间从25.5%（1966年至1972年）降至2.6%（1980年至1986年）。出院后累计总随访时间为3603患者年。对观察到的死亡率和额外死亡率均进行了多变量分析。
观察到的死亡率和额外死亡率的危险因素均为既往心肌梗死、冠状动脉疾病、心力衰竭和心房颤动。虽然年龄≥70岁是观察到的死亡率的危险因素（风险率比[HRR]2.4，95%置信区间[CI]1.6至3.7），但不是额外死亡率的危险因素。相比之下，单纯主动脉瓣反流仅是额外死亡率的重要危险因素（HRR 3.8，95%CI 1.3至11.2）。22%的患者晚期死亡与瓣膜相关，包括7%的猝死和7%的脑血管意外。无论主动脉瓣置换术后经过的时间如何，充血性心力衰竭都是重要的死亡原因（21%）。在主动脉瓣反流患者中，充血性心力衰竭是主要死亡原因（38%）；在主动脉瓣反流且术前有心力衰竭或严重左心室功能障碍的患者中，心力衰竭分别是44%和63%的死亡原因。
对额外死亡率的分析显示，高龄本身并非主动脉瓣置换术后晚期死亡的危险因素。主动脉瓣反流风险很高，可能与手术时左心室功能障碍有关。对于此类患者，可能有必要更早进行手术。
