主动脉瓣不匹配对老年病人术后生活质量的影响
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摘要
目的
本前瞻性研究的主要目的是研究主动脉瓣置换术后远期病人生活质量指数的变化。同时评估瓣膜-病人不匹配是否影响老年人主动脉瓣置换术后改善生活质量。
材料与方法
使用了前瞻性研究设计。从1995年8月10日到1998年8月19日期间,在我医疗中心实施单纯主动脉瓣置换术或同时施行冠状动脉旁路移植术,且年龄在70岁以上的100例病人列入本研究。病人-瓣膜不匹配被定义为主动脉瓣有效瓣口面积指数小于等于0.85 cm~2/m2。临床随访定期在术后4周、6个月、以后每隔一年进行。收集并比较分析病人长期生存,跨瓣压差等数据;生活质量采用短期健康调查表(SF-36量表)问卷评估。
结果
病人平均年龄为74.7±5.7岁(范围70-87岁)。平均随访年(7.3±4.7年)。术后三十天死亡率,病人-瓣膜不匹配组6.3%,病人-瓣膜匹配组,3.3%。:在第1年、第3年、第5年随访,病人长期生存率在组间并未表现出显著差异,但第7年随访,病人-瓣膜匹配与不匹配组两组间差异显著。在第1、第5年随访点,心脏超声数据显示病人-瓣膜匹配与不匹配组两组间跨主动脉平均压差差异显著。在随访的大多数点位上,病人的一般健康状况、体力/活力较术前都有所改善。、社会活动、精神健康评估在第三、第五和第七个年头的随访中较术前没有显着改善;而情感、社会活动、尤其是精神健康评估在术后第一年的随访中较术前有非常显著的改善。但组间差异不明显。
结论
老年患者主动脉瓣置换术后生活质量改善。但在生活质量的改善程度似乎与病人-瓣膜不匹配不相关。病人-瓣膜不匹配对主动脉瓣置换术后临床结果的影响仍然是一个有争议的问题。
Objectives
The main purpose of this prospective study was to determine if there are differences in changes in QOL scores at long-term postoperatively in elderly patient after aortic valve replacement.An additional aim was to assess whether the prosthesis-patient mismatch impacts the improvement of quality of life in elderly people after aortic valve replacement.
Methods
We used a prospective cohort study design.100 Consecutive patients whose age were more than 70 undergoing isolated aortic valve or simultaneous aortic valve-coronary artery bypass graft(CABG)procedures at our hospital from August 10,1995,through August 19,1998,were identified for enrollment.Patient-prosthesis mismatch(PPM)was defined as the prosthetic aortic valve EOAI was 0.85 cm2/m2 or less.The clinical follow-up was done 4 weeks,6 months after the operation,and at annual intervals.Cumulative and comparative analyses of long-term outcome and gradient pressure of prosthesis valve were performed.The quality of life was evaluated with the Short Form 36-Item Health Survey(SF-36)questionnaire.
Results
Mean age at implantation was 74.7±5.7 years(range,70-87 years).Mean follow-up was years(7.3±4.5years).The thirty days mortality is 6.3%in mismatch group,3.3%in no mismatch group.The freedom from death in interval follow-up year didn't show significant difference between two groups in 1st,third,and fifth follow-up year,but shows significant difference between mismatch and no mismatch group in seventh follow-up year.The echocardiographic data shows significant difference of mean gradient pressure between two groups in the 1st year and 5th year following up.The general health and energy/vitality all improved from preoperative levels at most points of follow-up,there was no significant improvement at the third, fifth,and seventh year follow-up for emotional role,social role,or general mental health.At the first year follow-up,there was some evidence of improvement for the latter 2 categories,with the greater significant improvement in social function,but there is not significant difference between the two groups.
Conclusions
Quality of life improved after aortic vale replacement in elderly patients,but Improvements in quality of life appears to be not related PPM.The interpret of PPM impacting Clinic outcome remains a controversial issue.
本前瞻性研究的主要目的是研究主动脉瓣置换术后远期病人生活质量指数的变化。同时评估瓣膜-病人不匹配是否影响老年人主动脉瓣置换术后改善生活质量。
材料与方法
使用了前瞻性研究设计。从1995年8月10日到1998年8月19日期间,在我医疗中心实施单纯主动脉瓣置换术或同时施行冠状动脉旁路移植术,且年龄在70岁以上的100例病人列入本研究。病人-瓣膜不匹配被定义为主动脉瓣有效瓣口面积指数小于等于0.85 cm~2/m2。临床随访定期在术后4周、6个月、以后每隔一年进行。收集并比较分析病人长期生存,跨瓣压差等数据;生活质量采用短期健康调查表(SF-36量表)问卷评估。
结果
病人平均年龄为74.7±5.7岁(范围70-87岁)。平均随访年(7.3±4.7年)。术后三十天死亡率,病人-瓣膜不匹配组6.3%,病人-瓣膜匹配组,3.3%。:在第1年、第3年、第5年随访,病人长期生存率在组间并未表现出显著差异,但第7年随访,病人-瓣膜匹配与不匹配组两组间差异显著。在第1、第5年随访点,心脏超声数据显示病人-瓣膜匹配与不匹配组两组间跨主动脉平均压差差异显著。在随访的大多数点位上,病人的一般健康状况、体力/活力较术前都有所改善。、社会活动、精神健康评估在第三、第五和第七个年头的随访中较术前没有显着改善;而情感、社会活动、尤其是精神健康评估在术后第一年的随访中较术前有非常显著的改善。但组间差异不明显。
结论
老年患者主动脉瓣置换术后生活质量改善。但在生活质量的改善程度似乎与病人-瓣膜不匹配不相关。病人-瓣膜不匹配对主动脉瓣置换术后临床结果的影响仍然是一个有争议的问题。
Objectives
The main purpose of this prospective study was to determine if there are differences in changes in QOL scores at long-term postoperatively in elderly patient after aortic valve replacement.An additional aim was to assess whether the prosthesis-patient mismatch impacts the improvement of quality of life in elderly people after aortic valve replacement.
Methods
We used a prospective cohort study design.100 Consecutive patients whose age were more than 70 undergoing isolated aortic valve or simultaneous aortic valve-coronary artery bypass graft(CABG)procedures at our hospital from August 10,1995,through August 19,1998,were identified for enrollment.Patient-prosthesis mismatch(PPM)was defined as the prosthetic aortic valve EOAI was 0.85 cm2/m2 or less.The clinical follow-up was done 4 weeks,6 months after the operation,and at annual intervals.Cumulative and comparative analyses of long-term outcome and gradient pressure of prosthesis valve were performed.The quality of life was evaluated with the Short Form 36-Item Health Survey(SF-36)questionnaire.
Results
Mean age at implantation was 74.7±5.7 years(range,70-87 years).Mean follow-up was years(7.3±4.5years).The thirty days mortality is 6.3%in mismatch group,3.3%in no mismatch group.The freedom from death in interval follow-up year didn't show significant difference between two groups in 1st,third,and fifth follow-up year,but shows significant difference between mismatch and no mismatch group in seventh follow-up year.The echocardiographic data shows significant difference of mean gradient pressure between two groups in the 1st year and 5th year following up.The general health and energy/vitality all improved from preoperative levels at most points of follow-up,there was no significant improvement at the third, fifth,and seventh year follow-up for emotional role,social role,or general mental health.At the first year follow-up,there was some evidence of improvement for the latter 2 categories,with the greater significant improvement in social function,but there is not significant difference between the two groups.
Conclusions
Quality of life improved after aortic vale replacement in elderly patients,but Improvements in quality of life appears to be not related PPM.The interpret of PPM impacting Clinic outcome remains a controversial issue.
引文
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16 Del Rizzo DF,Abdoh A,Cartier P,et al.Factors affecting left ventricular mass regression after aortic valve replacement with stentless valves.Semin Thorac Cardiovasc Surg.1999;11:114-120
17 Blackstone EH,Cosgrove DM,Jamieson WR.Prosthesis size and long-term survival after aortic valve replacement.J Thorac Cardiovasc Surg.2003;126:783-796
18 Pibarot P,Honos GN,Durand LG,et al.The effect of patient-prosthesis mismatch on aortic bioprosthetic valve hemodynamic performance and patient clinical status.Can J Cardiol.1996;12:379-387
19 Pibarot P,Dumesnil JG,Lemieux M,et al.Impact of prosthesis-patient mismatch on hemodynamic and symptomatic status,morbidity,and mortality after aortic valve replacement with a bioprosthetic heart valve.J Heart Valve Dis.1998;7:211-218.
20 Del Rizzo DF,Abdoh A,Cartier P,et al.Factors affecting left ventricular mass regression after aortic valve replacement with stentless valves.Semin Thorac Cardiovasc Surg.1999;11:114- 120.
21 Pibarot P,DumesnilJG Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention.J Am Coll Cardiol.2000;36:1131-1141
22 Rao V,Jamieson WRE,Ivanov J,Armstrong S,et al.Prosthesis-patient mismatch affects survival following aortic valve replacement.Circulation.2000;102(suppl Ⅲ):Ⅲ5-Ⅲ9.
23 Milano AD,De Carlo M,Mecozzi G,et al..Clinical outcome in patients with 19-mm and 21-mm St.Jude aortic prostheses (comparison at long-term follow-up).Ann Thorac Surg.2002;73:37-43.
24 Blais C,Dumesnil JG,Baillot R,et al.Impact of prosthesis-patient mismatch on short-term mortality after aortic valve replacement.Circulation.2003;108:983-988.
25 Mohty-Euhahidi D,Girard SE,MaloufJF,etal..Impact of prosthesis-patient mismatch on long-term survival in patients with small St Jude mechanical prosthesis in the aortic position.Circulation.2006;113:420-426.
26 Ruel M,Rubens FD,Masters RG,et al..Late incidence and predictors of persistent or recurrent heart failure in patients with aortic prosthetic valves.J Thorac Cardiovas Surg.2004;127:149-159.
27 Tasca G,Brunelli F,Cirillo M,et al..Impact of valve prosthesis-patient mismatch on left ventricular mass regression following aortic valve replacement.Ann Thorac Surg.2005;79:505-510.
28 Botzenhardt F,Eichinger WB,Bleiziffer S,et al.Hemodynamic comparison of bioprostheses for complete supra-annular position in patients with small aortic annulus.J Am Coll Cardiol.2005;45:2054-2060.
29 Tasca G Brunelli F,Cirillo M,et al..Impact of the improvement of valve area achieved with aortic valve replacement on the regression of left ventricular hypertrophy in patients with pure aortic stenosis.Ann Thorac Surg.2005;79:1291-1296.
30 Rahimtoola SH.The problem of valve prosthesis-patient mismatch.Circulation.1978;58:20-24.
31 Connolly HM,Oh JK,Schaff HV,et al..Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction (result of aortic valve replacement in 52 patients).Circulation.2000;101:1940-1946.
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33 Blais C,Dumesnil JG,Baillot R,et al.Impact of valve prosthesis-patient mismatch on short-term mortality after aortic valve replacement.Circulation.2003;108:983-988.
34 Bridges CR,Cleveland JC,Savage EB,et al.Effect of patient and prosthesis size on operative mortality after aortic valve replacement.Paper presented at:Annual Meeting of the American Association for Thoracic Surgery;April 10-13,2005;San Francisco,Calif
35 Blackstone EH,Cosgrove DM,Jamieson WR,Birkmeyer NJ,Lemmer JH Jr,Miller DC,Butchart EG,Rizzoli G,Yacoub M,Chai A.Prosthesis size and long-term survival after aortic valve replacement.J Thorac Cardiovasc Surg.2003;126:783-796.
36 Hanayama N,Christakis GT,Mallidi HR,Joyner CD,Fremes SE,Morgan CD,Mitoff PR,Goldman BS.Patient prosthesis mismatch is rare after aortic valve replacement:valve size may be irrelevant.Ann Thorac Surg.2002;73:1822-1829
37 Rao V,Jamieson WR,Ivanov J,Armstrong S,David TE.Prosthesis-patient mismatch affects survival after aortic valve replacement.Circulation.2000;102 (suppl Ⅲ):Ⅲ-5-Ⅲ-9.
38 Adams DH,Chen RH,Kadner A,et al.Impact of small prosthetic valve size on operative mortality in elderly patients after aortic valve replacement for aortic stenosis:does gender matter?J Thorac Cardiovasc Surg.1999;118:815-822.
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43 Fuster RG,Montero Argudo JA,Albarova OG,et al.Patient-prosthesis mismatch in aortic valve replacement:really tolerable? Eur J Cardiothorac Surg.2005;27:441-449.
44 Medalion B,Blackstone EH,Lytle BW,et al.Cosgrove DM.Aortic valve replacement (is valve size important?).J Thorac Cardiovasc Surg.2000;119:963-974.
45 Hanayama N,Christakis GT,Mallidi HR,et al..Patient prosthesis mismatch is rare after aortic valve replacement (valve size may be irrelevant).Ann Thorac Surg.2002;73:1822-1829.
46 Blackstone EH,Cosgrove DM,Jamieson WRE,et al..Prosthesis size and long-term survival after aortic valve replacement.J Thorac Cardiovasc Surg.2003;126:783-793.
47 Knez I,Rienmuller R,Maier R,et al..Left ventricular architecture after valve replacement due to critical aortic stenosis (an approach to dis-/qualify the myth of valve prosthesis-patient mismatch?).Eur J Cardiothorac Surg.2001;19:797-805.
48 Freed DH,Tam JW,Moon MC,et al.Nineteen-millimeter prosthetic aortic valves allow normalization of left ventricular mass in elderly women.Ann Thorac Surg.2002;74:2022-2025.
49 Koch CG,Khandwala F,Estafanous FG,et al.Impact of prosthesis-patient size on functional recovery after aortic valve replacement.Circulation.2005;111:3221-3229.
50 Rahimtoola SH.The problem of valve prosthesis-patient mismatch.Circulation.1978;58:20-24.
51 Dumesnil JG,Honos GN,Lemieux M,et al.Validation and applications of indexed aortic prosthetic valve areas calculated by Doppler echocardiography.J Am Coll Cardiol.1990;16:637-643.
52 Niskanen M,Ruokonen E,Takala J,et al:Quality of life after prolonged intensive care.CritCare Med 1999;27:1132-1139.
53 Nielsen D,Sellgren J,Ricksten SE:Quality of life after cardiac surgery complicated by multiple organ failure.Crit Care Med 1997;25:52-57.
54 Hunt SM,McEwen J,McKenna SP:Measuring health status:A new tool for clinicians and epidemiologist.J R Coll Gen Pract 1985;35:185-188.
55 Stewart AL,Hays RD,Ware JE,et al:The MOS short form general health survey.Med Care 1988;26:724-735
56 Chocron S,Etievent JPH,Viel JF,et al:Preoperative quality of life as a predictive factor of 3-year survival after open heart operations.Ann Thorac Surg 2000;69:722-727.
57 Harwood J:Cardiac surgery in the elderly.Heart 1999;82:119-120
58 Rumsfeld JS,McWhinney S,McCarthy M Jr:Health related quality of life as a predictor of mortality following coronary artery bypass graft surgery.Participants of the Department of Veteran Affairs cooperative study group on processes,structures.And outcomes of care in cardiac surgery.J Am Med Assoc 1999;281:1298-1303.
59 Falcoz PE,Chocron S,Mercier M,et al:Comparison of the Nottingham health profile and the 36-item health survey questionnaires in cardiac surgery.Ann Thorac Surg 2002;73:1222-1228.
60 Garcia LF,Peres BD,De Cubber M,et al:Long-term outcome in ICU patients:What about quality of life? Intensive Care Med 2003;29:1286-1293
61 Johnston G,Goss JR,Malmgren JA,et al:Health status and social risk correlates of extended length of stay following coronary artery bypass surgery.Ann Thorac Surg 2004;77:557-562
62 Holmes L,Loughhead K,Treasure T,et al:Which patients will not benefit from further intensive care after cardiac surgery? Lancet 1994;344:1200-1202.
63 S.Aziz and F.L.Grover,Cardiovascular surgery in the elderly.Cardiol Clin 17 (1999),pp.213-231
64 Sedrakyan A,Vaccarino V,Paltiel AD,et al.Age does not limit quality of life improvement in cardiac valve surgery.J Am Coll Cardiol 2003;42:1208-14
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16 Del Rizzo DF,Abdoh A,Cartier P,et al.Factors affecting left ventricular mass regression after aortic valve replacement with stentless valves.Semin Thorac Cardiovasc Surg.1999;11:114-120
17 Blackstone EH,Cosgrove DM,Jamieson WR.Prosthesis size and long-term survival after aortic valve replacement.J Thorac Cardiovasc Surg.2003;126:783-796
18 Pibarot P,Honos GN,Durand LG,et al.The effect of patient-prosthesis mismatch on aortic bioprosthetic valve hemodynamic performance and patient clinical status.Can J Cardiol.1996;12:379-387
19 Pibarot P,Dumesnil JG,Lemieux M,et al.Impact of prosthesis-patient mismatch on hemodynamic and symptomatic status,morbidity,and mortality after aortic valve replacement with a bioprosthetic heart valve.J Heart Valve Dis.1998;7:211-218.
20 Del Rizzo DF,Abdoh A,Cartier P,et al.Factors affecting left ventricular mass regression after aortic valve replacement with stentless valves.Semin Thorac Cardiovasc Surg.1999;11:114- 120.
21 Pibarot P,DumesnilJG Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention.J Am Coll Cardiol.2000;36:1131-1141
22 Rao V,Jamieson WRE,Ivanov J,Armstrong S,et al.Prosthesis-patient mismatch affects survival following aortic valve replacement.Circulation.2000;102(suppl Ⅲ):Ⅲ5-Ⅲ9.
23 Milano AD,De Carlo M,Mecozzi G,et al..Clinical outcome in patients with 19-mm and 21-mm St.Jude aortic prostheses (comparison at long-term follow-up).Ann Thorac Surg.2002;73:37-43.
24 Blais C,Dumesnil JG,Baillot R,et al.Impact of prosthesis-patient mismatch on short-term mortality after aortic valve replacement.Circulation.2003;108:983-988.
25 Mohty-Euhahidi D,Girard SE,MaloufJF,etal..Impact of prosthesis-patient mismatch on long-term survival in patients with small St Jude mechanical prosthesis in the aortic position.Circulation.2006;113:420-426.
26 Ruel M,Rubens FD,Masters RG,et al..Late incidence and predictors of persistent or recurrent heart failure in patients with aortic prosthetic valves.J Thorac Cardiovas Surg.2004;127:149-159.
27 Tasca G,Brunelli F,Cirillo M,et al..Impact of valve prosthesis-patient mismatch on left ventricular mass regression following aortic valve replacement.Ann Thorac Surg.2005;79:505-510.
28 Botzenhardt F,Eichinger WB,Bleiziffer S,et al.Hemodynamic comparison of bioprostheses for complete supra-annular position in patients with small aortic annulus.J Am Coll Cardiol.2005;45:2054-2060.
29 Tasca G Brunelli F,Cirillo M,et al..Impact of the improvement of valve area achieved with aortic valve replacement on the regression of left ventricular hypertrophy in patients with pure aortic stenosis.Ann Thorac Surg.2005;79:1291-1296.
30 Rahimtoola SH.The problem of valve prosthesis-patient mismatch.Circulation.1978;58:20-24.
31 Connolly HM,Oh JK,Schaff HV,et al..Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction (result of aortic valve replacement in 52 patients).Circulation.2000;101:1940-1946.
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33 Blais C,Dumesnil JG,Baillot R,et al.Impact of valve prosthesis-patient mismatch on short-term mortality after aortic valve replacement.Circulation.2003;108:983-988.
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36 Hanayama N,Christakis GT,Mallidi HR,Joyner CD,Fremes SE,Morgan CD,Mitoff PR,Goldman BS.Patient prosthesis mismatch is rare after aortic valve replacement:valve size may be irrelevant.Ann Thorac Surg.2002;73:1822-1829
37 Rao V,Jamieson WR,Ivanov J,Armstrong S,David TE.Prosthesis-patient mismatch affects survival after aortic valve replacement.Circulation.2000;102 (suppl Ⅲ):Ⅲ-5-Ⅲ-9.
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43 Fuster RG,Montero Argudo JA,Albarova OG,et al.Patient-prosthesis mismatch in aortic valve replacement:really tolerable? Eur J Cardiothorac Surg.2005;27:441-449.
44 Medalion B,Blackstone EH,Lytle BW,et al.Cosgrove DM.Aortic valve replacement (is valve size important?).J Thorac Cardiovasc Surg.2000;119:963-974.
45 Hanayama N,Christakis GT,Mallidi HR,et al..Patient prosthesis mismatch is rare after aortic valve replacement (valve size may be irrelevant).Ann Thorac Surg.2002;73:1822-1829.
46 Blackstone EH,Cosgrove DM,Jamieson WRE,et al..Prosthesis size and long-term survival after aortic valve replacement.J Thorac Cardiovasc Surg.2003;126:783-793.
47 Knez I,Rienmuller R,Maier R,et al..Left ventricular architecture after valve replacement due to critical aortic stenosis (an approach to dis-/qualify the myth of valve prosthesis-patient mismatch?).Eur J Cardiothorac Surg.2001;19:797-805.
48 Freed DH,Tam JW,Moon MC,et al.Nineteen-millimeter prosthetic aortic valves allow normalization of left ventricular mass in elderly women.Ann Thorac Surg.2002;74:2022-2025.
49 Koch CG,Khandwala F,Estafanous FG,et al.Impact of prosthesis-patient size on functional recovery after aortic valve replacement.Circulation.2005;111:3221-3229.
50 Rahimtoola SH.The problem of valve prosthesis-patient mismatch.Circulation.1978;58:20-24.
51 Dumesnil JG,Honos GN,Lemieux M,et al.Validation and applications of indexed aortic prosthetic valve areas calculated by Doppler echocardiography.J Am Coll Cardiol.1990;16:637-643.
52 Niskanen M,Ruokonen E,Takala J,et al:Quality of life after prolonged intensive care.CritCare Med 1999;27:1132-1139.
53 Nielsen D,Sellgren J,Ricksten SE:Quality of life after cardiac surgery complicated by multiple organ failure.Crit Care Med 1997;25:52-57.
54 Hunt SM,McEwen J,McKenna SP:Measuring health status:A new tool for clinicians and epidemiologist.J R Coll Gen Pract 1985;35:185-188.
55 Stewart AL,Hays RD,Ware JE,et al:The MOS short form general health survey.Med Care 1988;26:724-735
56 Chocron S,Etievent JPH,Viel JF,et al:Preoperative quality of life as a predictive factor of 3-year survival after open heart operations.Ann Thorac Surg 2000;69:722-727.
57 Harwood J:Cardiac surgery in the elderly.Heart 1999;82:119-120
58 Rumsfeld JS,McWhinney S,McCarthy M Jr:Health related quality of life as a predictor of mortality following coronary artery bypass graft surgery.Participants of the Department of Veteran Affairs cooperative study group on processes,structures.And outcomes of care in cardiac surgery.J Am Med Assoc 1999;281:1298-1303.
59 Falcoz PE,Chocron S,Mercier M,et al:Comparison of the Nottingham health profile and the 36-item health survey questionnaires in cardiac surgery.Ann Thorac Surg 2002;73:1222-1228.
60 Garcia LF,Peres BD,De Cubber M,et al:Long-term outcome in ICU patients:What about quality of life? Intensive Care Med 2003;29:1286-1293
61 Johnston G,Goss JR,Malmgren JA,et al:Health status and social risk correlates of extended length of stay following coronary artery bypass surgery.Ann Thorac Surg 2004;77:557-562
62 Holmes L,Loughhead K,Treasure T,et al:Which patients will not benefit from further intensive care after cardiac surgery? Lancet 1994;344:1200-1202.
63 S.Aziz and F.L.Grover,Cardiovascular surgery in the elderly.Cardiol Clin 17 (1999),pp.213-231
64 Sedrakyan A,Vaccarino V,Paltiel AD,et al.Age does not limit quality of life improvement in cardiac valve surgery.J Am Coll Cardiol 2003;42:1208-14
65 J.Ware and M.Kosinski,SF-36 Physical and Mental Health Summary Scales:A Manual for Users of Version 1.(2nd edition ed.)? QualityMetric Inc.,Lincoln,RI (2001).
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