合并非对称性室间隔肥厚的主动脉瓣重度狭窄患者在换瓣同期行或不行室间隔心肌切除术的比较研究

Surgical Treatment Strategy for Patients With Severe Aortic Stenosis Combined With Asymmetric Septal Hypertrophy

目的:探讨主动脉瓣重度狭窄合并非对称性室间隔肥厚的患者行主动脉瓣置换术同期行室间隔心肌切除术的必要性。方法:回顾性分析2007年10月至2017年2月阜外医院159例主动脉瓣重度狭窄合并非对称性室间隔肥厚接受手术治疗患者的资料,其中主动脉瓣置换术同期行室间隔心肌切除术的患者列为A组(n=19),单纯行主动脉瓣置换术的患者列为B组(n=140),为了调整两组之间基线数据的不同和选择偏倚,按照1:1的比例进行倾向性评分匹配,每组各匹配11例患者进行分析,比较匹配前后两组患者近期和远期的临床转归。结果:术后30天内,两组患者的室间隔厚度、左心室后壁厚度、左心室重量和左心室重量指数均较术前明显降低(P均<0.01)。平均随访(55.3±27.4)个月期间,A组患者较B组患者室间隔厚度下降幅度大,比例高(P均<0.05),而左心室后壁厚度、左心室重量和左心室重量指数下降的幅度和比例两组之间差异无统计学意义,死亡率、二次手术和并发症发生率方面两组也相似(P均> 0.05),在匹配的患者中,结果相似。Cox比例风险模型提示,主动脉瓣置换术同期行室间隔心肌切除术,或单纯行主动脉瓣置换术并非影响远期死亡率的独立危险因素(HR=4.96,95%CI:0.65~37.81,P=0.122)。Kaplan-Meier生存曲线显示两组患者远期生存率差异无统计学意义(P=0.233)。结论:主动脉瓣重度狭窄合并非对称性室间隔肥厚的患者行主动脉瓣置换术的同期,未必需要行室间隔心肌切除术。

Objectives: To explore the necessity of concomitant septal myectomy(SM) at the time of aortic valve replacement(AVR) in severe aortic stenosis(AS) patients with asymmetric septal hypertrophy(ASH).Methods: We conducted a retrospective review of data collected from severe AS patients with ASH hospitalized in our institute from October 2007 to February 2017. Patients underwent AVR plus SM were grouped as Group A(n=19), patients underwent AVR only were grouped as Group B(n=140). Propensity score matching were used to balance various risk factors of the two groups. Short-and long-term outcomes were compared between 11 matched patients from each group.Results: At 30 days after surgery, interventricular septum thickness, posterior wall thickness, left atrial(LA) dimension, left ventricular mass(LVM) and left ventricular mass index(LVMI) were significantly decreased in both groups(P<0.01). At a mean of(55.3±27.4) months follow-up, either in all study patients or in matched patients, the regression and regression ratio of interventricular septum thickness in Group A was more significant than in Group B(P<0.05). The regression of posterior wall thickness, LVM and LVMI was similar between two groups. Mortality, percent of reoperation and complication rate were also similar between the two groups. Similar results were observed in matched patients. Furthermore, the operative procedure(AVR+SM or AVR) was not associated with long-term mortality(HR=4.96, 95%CI: 0.65-37.81, P=0.122). Survival analysis demonstrated similar mortality rate between the two groups(P=0.233).Conclusions: For severe AS patients with ASH,concomitant SM is not necessary at the time of AVR.