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无症状主动脉瓣狭窄患者早期手术与保守治疗的比较
Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis


Duk-Hyun Kang ... 心脑血管疾病 • 2020.01.09
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重度主动脉瓣狭窄但尚无症状,立即手术还是再等等

 

朱云鹏,赵强*

上海交通大学医学院附属瑞金医院心外科

*通讯作者

 

随着人口老龄化,主动脉瓣狭窄是发达国家最常见的需要手术的心脏瓣膜疾病。目前的欧美及国内指南均明确指出,当重度主动脉瓣狭窄的患者出现临床症状(气急、胸痛、黑矇、晕厥等)或出现左心室不良结构改变(LVEF<50%)时,有明确的指征(Ⅰ类推荐)进行主动脉瓣置换手术。

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摘要


背景

无症状重度主动脉瓣狭窄患者的手术干预时机和适应证仍有争议。

 

方法

在一项多中心试验中,我们根据现行指南的建议将145例无症状的极重度主动脉瓣狭窄(定义为主动脉瓣口面积≤0.75 cm2,并且峰值跨主动脉瓣流速≥4.5 m/s或平均跨主动脉瓣压差≥50 mmHg)患者随机分配接受早期手术或保守治疗。主要终点是由手术期间或术后30日内死亡(通常称为手术死亡)或者整个随访期间心血管原因死亡构成的复合结局。关键次要终点是随访期间的全因死亡。

 

结果

在早期手术组中,73例患者中的69例(95%)在随机分组后2个月内接受了手术,手术死亡的患者人数为0。在意向治疗分析中,早期手术组1例患者(1%)和保守治疗组72例患者中的11例患者(15%)发生了主要终点事件(风险比,0.09;95%置信区间[CI],0.01~0.67;P=0.003)。早期手术组5例患者(7%)和保守治疗组15例患者(21%)死亡(风险比,0.33;95% CI,0.12~0.90)。4年和8年时,保守治疗组的累积猝死率分别为4%和14%。

 

结论

在无症状的极重度主动脉瓣狭窄患者中,接受早期主动脉瓣置换术患者的复合终点(手术死亡或随访期间心血管原因死亡)发生率显著低于接受保守治疗的患者(由韩国医学研究所[Korean Institute of Medicine]资助;RECOVERY在ClinicalTrials.gov注册号为NCT01161732)。





作者信息

Duk-Hyun Kang, M.D., Ph.D., Sung-Ji Park, M.D., Ph.D., Seung-Ah Lee, M.D., Sahmin Lee, M.D., Ph.D., Dae-Hee Kim, M.D., Ph.D., Hyung-Kwan Kim, M.D., Ph.D., Sung-Cheol Yun, Ph.D., Geu-Ru Hong, M.D., Ph.D., Jong-Min Song, M.D., Ph.D., Cheol-Hyun Chung, M.D., Ph.D., Jae-Kwan Song, M.D., Ph.D., Jae-Won Lee, M.D., Ph.D., and Seung-Woo Park, M.D., Ph.D.
From the Division of Cardiology (D.-H. Kang, S.-A.L., S.L., D.-H. Kim, J.-M.S., J.-K.S.) and the Departments of Cardiothoracic Surgery (C.-H.C., J.-W.L.) and Biostatistics (S.-C.Y.), Asan Medical Center, College of Medicine, University of Ulsan, the Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine (S.-J.P., S.-W.P.), the Division of Cardiology, Severance Hospital (G.-R.H.), and the Cardiovascular Center, Seoul National University Hospital (H.-K.K.) — all in Seoul, South Korea. Address reprint requests to Dr. Kang at the Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, 388-1, Poongnap-dong, Songpa-gu, Seoul, South Korea, or at dhkang@amc.seoul.kr, or to Dr. S.-W. Park at the Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea, or at s.woo.park@samsung.com.

 

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