Circulation:成人分散性主动脉瓣下狭窄预后特征分析

　　欧美学者的一项研究表明，分散性主动脉瓣下狭窄（DSS）术后生存情况良好，但因复发性DSS而再次手术的情况并非罕见。论文于2013年2月20日在线发表于《循环》（Circulation）。

　　此项回顾性多中心研究共纳入313例因DSS而接受手术治疗的成人患者。利用混合效应和联合模型评估术后DSS进展和主动脉瓣反流（AR）以及再手术情况。中位随访时间为12.9年，即随访5617患者-年。

　　结果显示，左心室流出道（LVOT）瞬时峰值梯度由术前75.7±28.0 mmHg降至术后15.1±14.1 mmHg（p<0.001），其后以1.31±0.16 mmHg/每年的速度而升高（P=0.001）。68%的受试者存在轻度AR，但通常未随时间推移而进展（(p=0.76）。术前LVOT梯度≥80 mmHg为术后进展为中度AR的预测因子。8例患者需至少一次的再次手术治疗（1.8/患者-年）。再次手术的预测因素包括女性和LVOT梯度进展。附加肌切除未能降低术后风险，但显著升高需起搏器植入的完全性心脏传导阻滞风险。

Surgical Outcome of Discrete Subaortic Stenosis in Adults: A Multicenter Study

Background—Discrete subaortic stenosis (DSS) is notable for its unpredictable hemodynamic progression in childhood and high re-operation rate, however data about adulthood are scarce.

Methods and Results—Adult patients who previously underwent surgery for DSS were included in this retrospective multicenter cohort study. Mixed-effects and joint models were used to assess postoperative progression of DSS and aortic regurgitation (AR), and re-operation. A total of 313 patients at 4 centers were included (age at baseline 20.2 years (Q1 to Q3, 18.4-31.0), 52% male). Median follow-up duration was 12.9 years (Q1 to Q3, 6.2-20.1), yielding 5617 patient-years. The peak instantaneous left ventricular outflow tract (LVOT) gradient decreased from 75.7±28.0 mmHg pre-operatively to 15.1±14.1 mmHg postoperatively (p<0.001), and thereafter increased over time at a rate of 1.31±0.16 mmHg per year (p=0.001). Mild AR was present in 68%, but generally did not progress over time (p=0.76). A pre-operative LVOT gradient ≥80 mmHg was a predictor for progression to moderate AR postoperatively. Eighty patients required at least one re-operation (1.8% per patient-year). Predictors for re-operation included female gender (HR=1.53, 95%CI 1.02-2.30) and LVOT gradient progression (HR=1.45, 95%CI 1.31-1.62). Additional myectomy did not reduce the risk for re-operation (p=0.92), but significantly increased the risk of a complete heart block requiring pacemaker implantation (8.1% versus 1.7%; p=0.005).

Conclusions—Survival is excellent after surgery for DSS, however reoperation for recurrent DSS is not uncommon. Over time the LVOT gradient slowly increases and mild AR is common, though generally nonprogressive over time. Myectomy does not show additional advantages and as it is associated with an increased risk of complete heart block, it should not be performed routinely.