背景:新主动脉根部扩张和瓣膜反流是动脉转换手术(ASO)后后期出现的问题。我们试图评估ASO后新主动脉根部或瓣膜再手术的患病率和结果。
方法:在1983年至2015年期间接受ASO的所有双心室循环患者均纳入单一机构。
结果:在我们782名晚期ASO幸存者的队列中,中位随访时间为18.1年(四分位距[IQR],11.3-25.6年)。随访期间,47例患者(6.0%)在新主动脉瓣/根部进行了60次再次手术。第一次新主动脉瓣/根部再手术的中位数为15.2年(IQR,7.8-18.4年)在ASO之后。操作包括机械Bentall(31.9%;n=15),主动脉瓣修复术(25.5%;n=12),机械主动脉瓣置换术(AVR)(21.3%;n=10),保留瓣膜的根部置换(19.1%;n=9),和罗斯程序(2.1%;n=1)。有1例晚期死亡(2.1%)。新主动脉瓣/根部再手术的多变量预测因素是二尖瓣(危险比[HR],4.8;95%置信区间[CI],2.1-10.7;P<.001),Taussig-Bing异常(HR,3.0;95%CI,1.2-7.4;P<.02),先前的肺动脉带(HR,2.8;95%CI,1.2-6.3;P<0.01)和ASO前左心室流出道梗阻(HR,2.4;95%CI,1.0-5.8;P<.04)。10年时,新主动脉瓣或根部再手术的自由度为98.0%(95%CI,96.7%-98.8%),20年为93.3%(95%CI,90.8%-95.2%),ASO后30年为88.5%(95%CI,84.1%-91.8%)。在47例接受新主动脉再手术的患者中,10年AVR的自由度为82.3%(95%CI,67.7%-90.7%),20年58.0%(95%CI,41.8%-71.2%),ASO后25年为43.2%(95%CI,27.0%-58.3%)。
结论:ASO后30年,新主动脉瓣或根部再手术的需求超过10%。对新主动脉瓣关闭不全的机制和新主动脉瓣修复技术的不断了解可能会减少对AVR的需求。
BACKGROUND: Neo-aortic root dilatation and valve regurgitation are emerging problems late after arterial switch operation (ASO). We sought to evaluate the prevalence and outcomes of neo-aortic root or valve reoperation after ASO.
METHODS: All patients with biventricular circulation who underwent an ASO between 1983 and 2015 were included at a single institution.
RESULTS: In our cohort of 782 late ASO survivors, the median duration of follow-up was 18.1 years (interquartile range [IQR], 11.3-25.6 years). During follow-up, 47 patients (6.0%) underwent 60 reoperations on the neo-aortic valve/root. The first neo-aortic valve/root reoperation occurred at a median of 15.2 years (IQR, 7.8-18.4 years) after ASO. Operations included mechanical Bentall (31.9%; n = 15), aortic valve repair (25.5%; n = 12), mechanical aortic valve replacement (AVR) (21.3%; n = 10), valve-sparing root replacement (19.1%; n = 9), and the Ross procedure (2.1%; n = 1). There was 1 late death (2.1%). Multivariable predictors of neo-aortic valve/root reoperation were bicuspid valve (hazard ratio [HR], 4.8; 95% confidence interval [CI], 2.1-10.7; P < .001), Taussig-Bing anomaly (HR, 3.0; 95% CI, 1.2-7.4; P < .02), previous pulmonary artery band (HR, 2.8; 95% CI, 1.2-6.3; P < .01) and left ventricular outflow tract obstruction before ASO (HR, 2.4; 95% CI, 1.0-5.8; P < .04). Freedom from neo-aortic valve or root reoperation was 98.0% (95% CI, 96.7%-98.8%) at 10 years, 93.3% (95% CI, 90.8%-95.2%) at 20 years, and 88.5% (95% CI, 84.1%-91.8%) at 30 years after ASO. Among the 47 patients who underwent neo-aortic reoperation, freedom from AVR was 82.3% (95% CI, 67.7%-90.7%) at 10 years, 58.0% (95% CI, 41.8%-71.2%) at 20 years, and 43.2% (95% CI, 27.0%-58.3%) at 25 years after ASO.
CONCLUSIONS: The need for neo-aortic valve or root reoperation surpasses 10% by 30 years post-ASO. Evolving understanding of the mechanisms of neo-aortic valve insufficiency and techniques of neo-aortic valve repair may decrease the need for AVR.