Mechanisms of Recurrent Aortic Regurgitation After Aortic Valve Repair Predictive Value of Intraoperative Transesophageal Echocardiography
Mechanisms of Recurrent Aortic Regurgitation After Aortic Valve Repair Predictive Value of Intraoperative Transesophageal Echocardiography
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DOI：
10.1016/j.jcmg.2009.04.013
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发表时间：
2009-08-01
影响因子：
14
通讯作者：
Vanoverschelde, Jean-Louis J.
中科院分区：
文献类型：
--
作者：
de Waroux, Jean-Benoit le Polain;Pouleur, Anne-Catherine;Vanoverschelde, Jean-Louis J.
目的探讨术中超声心动图特征与主动脉瓣修复术后复发的重度主动脉瓣反流(AR)的关系。背景：外科瓣膜修补术治疗AR具有明显的优势，但对其失败的预测因素和机制知之甚少。方法我们盲目地回顾了186例连续10年的AR患者的临床、术前、术中和随访的经食道超声心动图资料。中位随访18个月后，41例复发3+AR，23例残留1+~2+AR，122例无AR或轻微AR。在复发的3+AR患者中，复发的原因是心包补片破裂3例，残留瓣叶脱垂26例，瓣叶运动受限9例，主动脉夹层2例，感染性心内膜炎1例。结果术前3组患者的主动脉根部大小和二尖瓣发生率相似(37%)。复发的AR患者术前更容易出现马凡综合征或3型功能障碍。另一方面，随访时接受可控性AR修复的患者在术前更有可能发生II型功能障碍。体外循环后，较短的吻合长度、心尖滚滚程度、较低的吻合水平(相对于瓣环)、较大的主动脉环和窦管交界处直径、残余AR的存在及其收缩静脉的宽度与随访时AR的存在有关。多变量COX分析显示，吻合长度较短(优势比[OR]：0.8，p=0.05)、主动脉环水平以下的吻合(OR：7.9，p=0.01)、较大的主动脉环(OR：1.2，p=0.01)和残余的主动脉瓣关闭不全(OR：5.3，p=0.01)是修复失败的危险因素。(J Am Coll Hearol IMG 2009；2：931-9)(C)美国心脏病学会基金会2009
OBJECTIVES The aim of the present study was to examine the intraoperative echocardiographic features associated with recurrent severe aortic regurgitation (AR) after an aortic valve repair surgery.BACKGROUND Surgical valve repair for AR has significant advantages over valve replacement, but little is known about the predictors and mechanisms of its failure.METHODS We blindly reviewed all clinical, pre-operative, intraoperative, and follow-up transesophageal echocardiographic data of 186 consecutive patients who underwent valve repair for AR during a 10-year period and in whom intraoperative and follow-up echo data were available. After a median follow-up duration of 18 months, 41 patients had recurrent 3+ AR, 23 patients presented with residual 1+ to 2+ AR, and 122 had no or trivial AR. In patients with recurrent 3+ AR, the cause of recurrent AR was the rupture of a pericardial patch in 3 patients, a residual cusp prolapse in 26 patients, a restrictive cusp motion in 9 patients, an aortic dissection in 2 patients, and an infective endocarditis in 1 patient.RESULTS Pre-operatively, all 3 groups were similar for aortic root dimensions and prevalence of bicuspid valve (overall 37%). Patients with recurrent AR were more likely to display Marfan syndrome or type 3 dysfunction pre-operatively. At the opposite end, patients with continent AR repair at follow-up were more likely to have type 2 dysfunction pre-operatively. After cardiopulmonary bypass, a shorter coaptation length, the degree of cusp billowing, a lower level of coaptation (relative to the annulus), a larger diameter of the aortic annulus and the sino-tubular junction, the presence of a residual AR, and the width of its vena contracta were associated with the presence of AR at follow-up. Multivariate Cox analysis identified a shorter coaptation length (odds ratio [OR]: 0.8, p = 0.05), a coaptation occurring below the level of the aortic annulus (OR: 7.9, p = 0.01), a larger aortic annulus (OR: 1.2, p = 0.01), and residual aortic regurgitation (OR: 5.3, p = 0.01) as risk factors of repair failure.CONCLUSIONS Our results demonstrate that intraoperative transesophageal echocardiography can be used to identify patients undergoing AR repair who are at increased risk for late repair failure. (J Am Coll Cardiol Img 2009;2:931-9) (C) 2009 by the American College of Cardiology Foundation