Holper K, Wottke M, Lewe T, Baumer L, Meisner H, Paek S U, Sebening F
Department of Cardiovascular Surgery, German Heart Center Munich.
Ann Thorac Surg. 1995 Aug;60(2 Suppl):S443-6. doi: 10.1016/0003-4975(95)00252-g.
There is controversy over whether elderly patients benefit from the durability of mechanical valves when balanced against the risk of anticoagulation. From 1976 to 1993, 576 patients 65 years old or older underwent isolated valve replacement with mechanical (n = 250) or bioprosthetic valves (n = 326). Total follow-up was 2,222 patient-years. Probability of survival and freedom from thromboembolism and prosthetic valve endocarditis were not different between the two groups. There was a significant difference (p = 0.015) in freedom from anticoagulant-related hemorrhage. Two patients with mechanical prostheses and 7 patients with bioprostheses were reoperated. However, actuarial freedom from reoperation was not different (p = 0.73) in both groups, with no hospital mortality, whereas mortality from thromboembolic events and anticoagulant-related hemorrhage was three times higher in patients with mechanical prostheses as compared with patients with bioprostheses (1.08% versus 0.36% per patient-year). The benefit from the durability of mechanical valves, compared with bioprostheses, is smaller than expected because of the limited number of patients exposed to the onset of bioprosthetic structural deterioration. Elderly patients without absolute indication for anticoagulation should preferentially receive bioprostheses for valvular replacement.
在权衡抗凝风险的情况下，老年患者是否能从机械瓣膜的耐用性中获益存在争议。1976年至1993年，576例65岁及以上患者接受了单纯瓣膜置换术，其中250例使用机械瓣膜，326例使用生物瓣膜。总随访时间为2222患者年。两组患者的生存率、无血栓栓塞和人工瓣膜心内膜炎的概率无差异。在无抗凝相关出血方面存在显著差异（p = 0.015）。2例使用机械瓣膜的患者和7例使用生物瓣膜的患者接受了再次手术。然而，两组患者再次手术的精算无事件生存率无差异（p = 0.73），均无住院死亡率，而机械瓣膜患者血栓栓塞事件和抗凝相关出血导致的死亡率是生物瓣膜患者的三倍（每年每例患者1.08%对0.36%）。与生物瓣膜相比，机械瓣膜耐用性带来的益处小于预期，因为暴露于生物瓣膜结构恶化起始阶段的患者数量有限。无绝对抗凝指征的老年患者应优先接受生物瓣膜进行瓣膜置换。
