主动脉根部扩大联合环上瓣置换策略治疗成人小瓣环主动脉瓣狭窄的近中期结果

Early and mid-term outcomes of aortic root enlargement with supraannular prostheses replacement for adult patients with aortic stenosis and small aortic root

的总结主动脉根部扩大(aortic root enlargement,ARE)联合环上型人工瓣膜置换策略与单独环上型人工瓣膜置换策略治疗成人小瓣环主动脉瓣狭窄的近中期结果,探讨成人小瓣环主动脉瓣狭窄的最佳治疗策略。方法回顾性分析我院2005年1月至2017年1月,98例成人小瓣环主动脉瓣狭窄应用主动脉瓣环扩大联合环上型人工瓣膜置换策略治疗(ARE组),选取同期125例成人小瓣环主动脉瓣狭窄患者应用环上瓣置换策略治疗作为对照组(SP组),排除主动脉瓣关闭不全为主或多个瓣膜病变。两组患者年龄相仿[(41.69±13.83)岁对(43.88±12.86)岁,P=0.224],男性所占比例分别为37.8%及47.2%(P=0.157),ARE组体表面积略大于SP组[(1.62±0.04)m2对(1.61±0.04)m2,P=0.015]。两组患者术前心功能(NYHA分级)、病因分类、合并疾病(冠心病、2型糖尿病、高血压病、肾功能不全、房性心律失常、慢性阻塞性肺疾病)、既往史(晕厥史、卒中史)等基线特征差异无统计学意义。结果围手术期死亡6例(2.7%),死因为低心排血量综合征3例,多器官功能衰竭2例,卒中1例。开胸止血5例,急性肾功能衰竭9例,肺部感染5例,切口并发症8例,临时起搏治疗24例。ARE组1例术后早期发生中度以上急性二尖瓣反流。两组围手术期病死率、二次开胸率、切口并发症发生率差异无统计学意义。ARE组置换人工生物瓣膜比例明显高于SP组,有效瓣口面积指数(indexed effective orifice area,iEOA)、主动脉跨瓣压差及人工瓣膜-患者不匹配(prosthesis-patient mismatch,PPM)发生率低于SP组。随访2年,ARE组主动脉瓣跨瓣压差、左心室质量指数明显低于SP组,iEOA明显高于SP组,两组患者生存率差异无统计学意义。结论主动脉根部扩大联合环上瓣置换策略较单独环上瓣置换治疗成人小瓣环主动脉瓣狭窄,可获得更优的血流动力学效果,与单独环上瓣置换相比,未增加围手术期风险,更有助于肥厚左心室的改善性重构。

Objective To summarize the short and mid-term outcome of adult patient suffered with aortic stenosis and small aortic root treated by aortic root enlargement with supraannular prostheses replacement or supraannular prostheses replacement. MethodsFrom January 2005 to January 2017, 223 patients with aortic stenosis and small aortic root who underwent isolated aortic valve replacement(AVR) were included in this retrospective study cohort. Patients with aortic insufficiency who underwent isolated AVR or those who underwent combined valve replacement were excluded from the study cohort. Aortic root enlargement with supraannular prostheses replacement was performed in 98 patients(ARE), and supraannular prostheses replacement was performed in the remaining 125 patients as a control group(SP). The mean age and other baseline characteristics were compared between the two group, except that body surface area(BSA) in ARE were higher than that in SP[(1.62±0.04)m^2 vs(1.61±0.04)m^2,P=0.015]. Results Operative mortality occurred in 6 patients(2.7%), the cause of death including low cardiac output syndrome(LCOS, 3 patients), multiple organ failure(MOF, 2 patients) and stroke(1 patient). Reoperation for bleeding occurred in 5 patients and acute renal failure in 9 patients, pneumonia in 5 patients. The other nonfatal operative complications included wound complication(8 patients), temporary pacing therapy(24 patients), and new onset of acute mitral regurgitation(1 patient). The operative mortality and nonfatal complication were not statistically different between the two groups. Patients in ARE received more bioprotheses and iEOA was higher than those in SP. Transvalvular pressure gradients and incidence of patient-prostheses mismatch were lower in ARE. At the 2 years of follow-up, transvalvular pressure gradients and left ventricular mass index were statistically lower in ARE compared with SP. The iEOA of ARE was higher than that in SP(1.22±0.13 vs 0.87±0.13, P<0.01). However, during the mid-term follow up(mean duration of follow-up was 6.31years), the overall survival rate was not statistically different between the two groups. Conclusion The strategy of aortic root enlargement with supraannular prostheses to treat adult patients with aortic stenosis and small aortic root can provide more optimal hemodynamic effect, effectively avoid PPM and was not associated with increased risk of mortality or adverse event when compared with strategy of supraannular prostheses replacement. However, the mid-term survival rate was not statistically different between the two strategies.