2022 年第 6 期 第 17 卷

自体主动脉瓣单独受累感染性心内膜炎患者行机械瓣膜与生物瓣膜主动脉瓣置换术后的预后比较

Outcomes of mechanical versus bioprosthetic valve for surgical aortic valve replacement in patients with native-aortic valve infective endocarditis

作者：贾一琼朱光发

英文作者：Jia Yiqiong Zhu Guangfa

单位：首都医科大学附属北京安贞医院感染科，北京 100029

英文单位：Department of Infectious Diseases Beijing Anzhen Hospital Capital Medical University Beijing 100029 China

关键词：感染性心内膜炎；外科主动脉瓣置换术；人工瓣膜

英文关键词：Infectiveendocarditis;Surgicalaorticvalvereplacement;Prostheticvalve

• 摘要：

• 目的 比较自体主动脉瓣单独受累感染性心内膜炎(IE)患者行机械瓣膜或生物瓣膜外科主动脉瓣置换术（SAVR）后的远期预后。方法 回顾性分析2013年1月至2019年12月在首都医科大学附属北京安贞医院行SAVR的215例自体主动脉瓣单独受累IE患者（年龄18~69岁）的病历资料。根据置换的瓣膜类型分为M组（172例，置换机械瓣膜）和B组（43例，置换生物瓣膜）。对所有患者进行长期随访（中位随访时间60个月，最长104个月），分析术后生存率及缺血性脑卒中、大出血、主动脉瓣再手术的累积发生率。结果 随访期间，M组27例、B组12例患者死亡，B组患者SAVR术后长期生存率明显低于M组（Log-rank P=0.024）；M组14例、B组7例患者发生缺血性脑卒中，B组患者缺血性脑卒中累积发生率明显高于M组（Log-rank P=0.045）；M组21例、B组6例患者发生大出血，2组大出血累积发生率比较差异无统计学意义(Log-rank P=0.553)；M组6例、B组3例患者再次行主动脉瓣手术，2组患者再次行主动脉瓣手术的累积发生率比较，差异无统计学意义(Log-rank P=0.183)。多因素Cox回归分析结果显示，年龄50~69岁、术后缺血性脑卒中和术后大出血的自体主动脉瓣单独受累IE患者SAVR术后死亡风险更高。结论 与置换机械瓣膜的自体主动脉瓣单独受累IE患者相比，置换生物瓣膜的患者术后发生缺血性脑卒中和死亡的风险增加；年龄大、术后出现缺血性脑卒中或大出血的患者SAVR术后死亡风险更高。不建议＜70岁成年主动脉瓣受累IE患者行SAVR手术时常规选择生物瓣膜。

• Objective To compare the long-term outcomes between mechanical and bioprosthetic valve for surgical aortic valve replacement (SAVR) in patients with native-aortic valve infective endocarditis (IE). Methods Clinical data of 215 patients with native-aortic valve IE (aged 18-69 years) were retrospectively analyzed, who underwent SAVR in Beijing Anzhen Hospital, Capital Medical University from January 2013 to December 2019. The patients were divided into group M(172 cases, with mechanical valve replacement) and group B(43 cases, with bioprosthetic valve replacement) according to the type of valve prosthesis. Long term follow-up was available for all patients (median follow-up duration as 60 months and the longest as 104 months). Postoperative survival, proportions of ischemic stroke, major bleeding and aortic valve reoperation after operation were analyzed. Results   During follow-up, 27 cases died in group M, 12 cases died in group B, and the long-term survival in group B after SAVR was lower than that in group M (Log-rank P=0.024); ischemic stroke occurred in 14 cases in group M and 7 cases in group B, and the cumulative incidence of ischemic stroke in group B was higher than that in group M (Log-rank P=0.045); major bleeding occurred in 21 cases in group M and 6 cases in group B, and the difference was not statistically significant between the two groups (Log-rank P=0.553); aortic valve surgery occurred in 6 cases in group M and 3 cases in group B, and the difference was not statistically significant between the two groups (Log-rank P=0.183). Multivariate Cox regression analysis showed that patients with native-aortic valve IE had high risk of death after SAVR when they were 50-69 years, combined with postoperative ischemic stroke and postoperative major bleeding. Conclusions  Compared mechanical valve, bioprosthetic valve replacement increases the risk of ischemic stroke and death in patients with native-aortic valve IE. Patients who are older and have ischemic stroke or major bleeding after SAVR have a higher risk of postoperative mortality. We do not support the routine choice of bioprosthetic valve for SAVR in adult patients with native-aortic valve IE aged <70 years.