Khan J H, McElhinney D B, Hall T S, Merrick S H
Department of Cardiothoracic Surgery, University of California, San Francisco, USA.
Arch Surg. 1998 Aug;133(8):887-93. doi: 10.1001/archsurg.133.8.887.
Although cardiac valve procedures are being performed more frequently in the elderly, long-term functional outcomes have not been well characterized.
To evaluate changes in quality of life and functional status in octogenarians after cardiac valve surgery.
Retrospective medical record review and patient telephone interview. Median follow-up 30 months (range, 6-95 months).
Tertiary care university hospital.
Octogenarians undergoing cardiac valve surgery (N = 61; mean age, 83.5 years; range, 80-89 years).
Forty-seven patients had aortic valve replacement, 14 had mitral valve replacement and/or repair, and 27 had a combined procedure with coronary artery bypass grafting.
Actuarial survival, morbidity, length of hospital stay, and discharge disposition were evaluated. Functional status, using the New York Heart Association classification, and Karnofsky performance status were evaluated preoperatively and postoperatively at 1 and 3 months after hospital discharge.
Operative (<30 days) mortality occurred in 7 (11.4%) of 61 patients. Preoperative intensive care unit stay (P < .001) and New York Heart Association class 4 (P < .02) were independent predictors of early death by multivariable analysis. Among hospital survivors, there were no major complications in 34 patients (63%), and this group had a mean (+/- SD) postoperative hospital stay of 12.2 +/- 5.5 days. Twenty patients (37%) incurred significant complications, the most common of which were bleeding, pneumonia, and renal insufficiency. The mean (+/- SD) postoperative hospital stay in this group was 25 +/- 17 days. Although significant complications were associated with an increased postoperative stay, this was not predictive of disposition to a skilled nursing facility or the final score on the postoperative Karnofsky performance scale. Actuarial survival was 85% at 1 year and 66% at 5 years. Patients with perioperative complications had significantly decreased actuarial survival by the Cox proportional hazards regression model (P < .001). Among hospital survivors, the score on the Karnofsky performance scale 1 month after discharge had improved 50% from a preoperative median score of 30% (severely disabled, requiring special care) to a postoperative median score of 80% (being able to perform normal activity with only moderate symptoms). The New York Heart Association classification improved a median of 2 classes in this group. These benefits were sustained at the 3-month follow-up.
Although greater resource expenditure is required for the initial perioperative convalescence, octogenarians can be expected to have an excellent functional outcome and long-term performance status after cardiac valve surgery.
尽管心脏瓣膜手术在老年人中开展得越来越频繁，但其长期功能结局尚未得到充分描述。
评估八旬老人心脏瓣膜手术后生活质量和功能状态的变化。
回顾性病历审查和患者电话访谈。中位随访时间30个月（范围6 - 95个月）。
三级医疗大学医院。
接受心脏瓣膜手术的八旬老人（N = 61；平均年龄83.5岁；范围80 - 89岁）。
47例患者接受主动脉瓣置换术，14例患者接受二尖瓣置换和/或修复术，27例患者接受冠状动脉旁路移植术联合手术。
评估精算生存率、发病率、住院时间和出院处置情况。使用纽约心脏协会分级评估功能状态，并在术前及出院后1个月和3个月评估卡诺夫斯基功能状态量表。
61例患者中有7例（11.4%）发生手术（<30天）死亡。多变量分析显示，术前重症监护病房住院时间（P <.001）和纽约心脏协会4级（P <.02）是早期死亡的独立预测因素。在医院幸存者中，34例患者（63%）无重大并发症，该组术后平均（±标准差）住院时间为12.2±5.5天。20例患者（37%）发生严重并发症，最常见的是出血、肺炎和肾功能不全。该组术后平均（±标准差）住院时间为25±17天。尽管严重并发症与术后住院时间延长有关，但这并不能预测患者是否会入住专业护理机构或术后卡诺夫斯基功能状态量表的最终得分。1年精算生存率为85%，5年为66%。根据Cox比例风险回归模型，围手术期有并发症的患者精算生存率显著降低（P <.001）。在医院幸存者中，出院后1个月卡诺夫斯基功能状态量表得分从术前中位数30%（严重残疾，需要特殊护理）提高到术后中位数80%（仅伴有中度症状即可进行正常活动），提高了50%。该组纽约心脏协会分级中位数改善了2级。这些益处持续到3个月随访时。
尽管围手术期初期康复需要更多资源投入，但八旬老人心脏瓣膜手术后有望获得良好的功能结局和长期功能状态。
