中度瓣膜-患者不匹配对17 mm St.Jude Medical Regent主动脉瓣置换术后中期临床效果的影响

The impact of moderate prosthesis-patient mismatch on midterm outcomes after aortic valve replacement with 17 mm St.Jude Medical Regent valve

目的 观察术后早期中度瓣膜-患者不匹配现象（prosthesis-patient mismatch,PPM）对应用17 mm St.Jude Medical Regent（SJMR）行主动脉瓣置换术后患者中远期临床效果的影响,并探讨患者个体因素与PPM影响效果的关系.方法 我们对106例应用17 mm SJMR行主动脉瓣置换术的患者进行随访,于术前、出院时及术后29～ 74个月,平均（48.6＆#177;11.9）个月,评估患者术后临床指标和Regent瓣膜在体血流动力学参数变化.结果 围手术期死亡比例2.8％,术后1、3、5年免于心脏不良事件相关死亡比例分别为98.1％、95.9％、88.2％.其中45例（43.7％）患者在术后院内末次超声心动图评估发现合并中度PPM.随访期间,患者NYHA心功能分级、主动脉瓣跨瓣压差及左心室质量指数均较术前明显改善,合并中度PPM患者与非PPM患者在各临床指标与血流动力学参数之间并无明显差异.但在术前左心功能受损的患者中（左心室射血分数＜0.50）,中度PPM会显著增加此亚组患者中远期死亡比例（HR 1.46,P=0.02）.多因素回归分析发现,糖尿病与左心室射血分数＜0.35是导致全组患者术后中远期死亡比例增加的独立危险因素.结论 17 mm SJMR主动脉瓣置换术后早期出现的中度PPM与左心功能受损患者术后中远期死亡比例增加密切相关.合理选择小主动脉瓣环患者接受17 mm SJMR瓣膜的置入能取得满意的中远期临床效果.

Objective The study was designed to evaluate the effects of moderate prosthesis-patient mismatch（PPM） on midterm outcomes after aortic valve replacement（AVR） with the 17 mm St.Jude Medical Regent valve in a large series of patients,and to determine if these effects are modulated by patient＆#39; s confounding variables.Methods Methods One-hundred and six patients with and without moderate PPM after implantation of a 17 mm Regent valve at aortic position were included.Both clinical and echocardiographic assessments were performed preoperatively,at discharge and at follow-up,mean follow-up （42.6 ＆#177; 15.9） months.Results The prevalence of moderate PPM was documented in 45 patients（43.7%） at discharge.During the follow-up,no difference in the regression of left ventricular mass,decrease of transvalvular pressure gradients,mortality and valve-related complications was observed between patients with and without moderate PPM.After adjustment for several risk factors,moderate PPM was associated with increased midterm mortality in a subgroup of patients with baseline left ventricular ejection fraction 〈 0.50 （HR 1.46,P =0.02）,but with normal prognosis in those with preserved ventricular function.Conclusion Moderate PPM after AVR with a small mechanical prosthesis is associated with increased mortality and complications in patients with pre-existing LV dysfunction.Selected patients with small aortic annulus can experience satisfactory clinical improvements and midterm survival after AVR with 17 mm Regent valve.