高危主动脉瓣置换术：结果是否如预期的那般糟糕？

High-risk aortic valve replacement: are the outcomes as bad as predicted?

作者信息

Grossi Eugene A, Schwartz Charles F, Yu Pey-Jen, Jorde Ulrich P, Crooke Gregory A, Grau Juan B, Ribakove Greg H, Baumann F Gregory, Ursumanno Patricia, Culliford Alfred T, Colvin Stephen B, Galloway Aubrey C

机构信息

Department of Cardiothoracic Surgery, Division of Cardiology, New York University School of Medicine, New York, New York, USA.

出版信息

Ann Thorac Surg. 2008 Jan;85(1):102-6; discussion 107. doi: 10.1016/j.athoracsur.2007.05.010.

DOI:10.1016/j.athoracsur.2007.05.010

PMID:18154791

Abstract

BACKGROUND

Percutaneous aortic valve replacement (PAVR) trials are ongoing in patients with an elevated European System for Cardiac Operative Risk Evaluation (EuroSCOREs), patients believed to have high mortality rates and poor long-term prognoses with valve replacement surgery. It is, however, uncertain that the EuroSCORE model is well calibrated for such high-risk AVR patients. We evaluated EuroSCORE prediction vs a single institution's surgical results in this target population.

METHODS

From January 1996 through March 2006, 731 patients with EuroSCOREs of 7 or higher underwent isolated AVR. In this cohort, 313 (42.8%) were septuagenarians, 322 (44.0%) were octogenarians or nonagenarians, 233 (31.9%) had had previous cardiac procedures, 237 (32.4%) had atheromatous aortas, and 127 (17.4%) had cerebrovascular disease. A minimally invasive approach was used in 469 (64.2%). Data collection was prospective. Long-term survival was computed from the Social Security Death Benefit Index.

RESULTS

The mean EuroSCORE was 9.7 (median, 10), and the mean logistic EuroSCORE was 17.2%. Actual hospital mortality was 7.8% (57 of 731). Multivariate analysis showed ejection fraction of less than 0.30 (p = 0.002; odds ratio [OR], 3.13), chronic obstructive pulmonary disease (p = 0.019; OR, 2.14), and peripheral vascular disease (p = 0.048; OR, 2.13) were significant predictors of hospital mortality. Complication(s) occurred in 73 patients (9.9%). Freedom from all-cause death (including hospital mortality) was 72.4% at 5 years (n = 152). Age (p < 0.001), previous cardiac operations (p < 0.014; OR, 1.51), renal failure (p < 0.002; OR, 2.37), and chronic obstructive pulmonary disease (p < 0.007; OR, 1.30) were predictors of worse survival.

CONCLUSIONS

Logistic EuroSCORE greatly overpredicts mortality in these patients. Five-year survival is good, unlike suggestions from earlier EuroSCORE analyses. This raises concern about unknown long-term percutaneous prosthesis function. Clinical trials for these patients must include randomized surgical controls and have long-term end points.

摘要

背景

欧洲心脏手术风险评估系统（EuroSCOREs）升高的患者正在进行经皮主动脉瓣置换术（PAVR）试验，这些患者被认为瓣膜置换手术的死亡率高且长期预后差。然而，对于此类高危主动脉瓣置换（AVR）患者，EuroSCORE模型是否经过良好校准尚不确定。我们在这一目标人群中评估了EuroSCORE预测与单一机构的手术结果。

方法

从1996年1月至2006年3月，731例EuroSCOREs为7或更高的患者接受了单纯AVR。在这个队列中，313例（42.8%）为七十多岁患者，322例（44.0%）为八十多岁或九十多岁患者，233例（31.9%）曾接受过心脏手术，237例（32.4%）有动脉粥样硬化性主动脉，127例（17.4%）有脑血管疾病。469例（64.2%）采用了微创方法。数据收集是前瞻性的。长期生存从社会保障死亡福利指数计算得出。

结果

平均EuroSCORE为9.7（中位数为10），平均逻辑EuroSCORE为17.2%。实际医院死亡率为7.8%（731例中的57例）。多变量分析显示射血分数小于0.30（p = 0.002；比值比[OR]，3.13）、慢性阻塞性肺疾病（p = 0.019；OR，2.14）和外周血管疾病（p = 0.048；OR，2.13）是医院死亡率的重要预测因素。73例患者（9.9%）发生了并发症。5年时无全因死亡（包括医院死亡率）的比例为72.4%（n = 152）。年龄（p < 0.001）、既往心脏手术（p < 0.014；OR，1.51）、肾衰竭（p < 0.002；OR，2.37）和慢性阻塞性肺疾病（p < 0.007；OR，1.30）是生存较差的预测因素。