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ID naloge: 162 Letnik: 2003 Predmet: kirurgija
PREDOPERATIVNI DEJAVNIKI TVEGANJA ZA MENJAVO AORTNE ZAKLOPKE PRI STAROSTNIKIH
Avtor: Jure Dolenc
Mentor: prof. dr. Mirta Koželj
IZHODIŠCE: Zaradi staranja prebivalstva se povecuje število starostnikov z degenerativno stenozo aortne zaklopke. Posledica napredka v predoperativnem in pooperativnem zdravljenju je povecevanje števila bolnikov, starejših od 70 let, ki potrebujejo menjavo aortne zaklopke.
NAMEN: S pricujoco raziskavo skušamo dolociti pomembnost posameznih klinicnih, ehokardiografskih, invazivnih ter kirurških predoperativnih napovednih dejavnikov zgodnje in kasne pooperativne umrljivosti ter slabšega funkcijskega izhoda po menjavi aortne zaklopke.
HIPOTEZA: Slab pooperativen izid je odvisen od napredovalega stanja stenoze aortne zaklopke, socasnih bolezni ter zapletenosti kirurškega posega na srcu.
METODE: Zbrali smo podatke 235 zaporednih bolnikov starih 70 do 89 let (v povprecju 74,7 ± 3,3 leta, 120 žensk, 115 moških), ki so imeli opravljeno menjavo aortne zaklopke med 1. januarjem 1997 ter 31. decembrom 2001. Kot mogoce napovedne dejavnike pooperativnega izida smo obravnavali bolnikovo starost, spol, simptome, funkcijski razred po New York Heart Association (NYHA), znake srcnega popušcanja, socasne bolezni, srcni ritem, hipertrofijo levega prekata, ehokardiografske znacilnosti osnovne bolezni zaklopke, velikost levega prekata ter levega preddvora, iztisni delež levega prekata, obstoj mitralne regurgitacije ter pljucne hipertenzije, podatke predoperativne kateterizacije ter nujnost in vrsto kirurškega posega. Mogoci vpliv predoperativnih in operativnih spremenljivk na izide operacije smo iskali z bivariatnim testom ?2 ter multivariatno logisticno regresijo. Stopnje preživetja smo dolocali s Kaplan-Meierjevo metodo.
REZULTATI: V zgodnjem pooperativnem obdobju (< 30 dni) je umrlo 27 bolnikov (11,5 %). Z modelom logisticne regresije so se kot neodvisni napovedni dejavniki zgodnje umrljivosti izkazali kronicna ledvicna odpoved (p = 0,023), slab iztisni delež levega prekata (p = 0,039), pljucna hipertenzija (p = 0,001) ter kombiniran kirurški poseg (p = 0,005). Kasna pooperativna umrljivost je bila 8,5 %. Multivariatna napovedna dejavnika kasne umrljivosti sta bila kronicna ledvicna odpoved (p = 0,011) ter nujni poseg (p = 0,043). Slab dolgorocni izid smo ugotovili pri 27,2 % bolnikov. Z modelom logisticne regresije so se kot neodvisni napovedni dejavniki slabšega dolgorocnega izida izkazali znaki srcnega popušcanja (p = 0,032), pljucna hipertenzija (p = 0,001) ter kombinirani poseg (p = 0,023). Celokupni stopnji preživetja pri 1 in 3 letih sta bili 83 % in 79 %. Pomembni predoperativni napovedni dejavniki slabega preživetja so bili razred NYHA III-IV, znaki srcnega popušcanja, kronicna ledvicna odpoved, kronicna atrijska fibrilacija, hipertrofija levega prekata, slab iztisni delež levega prekata, povecan levi preddvor, mitralna regurgitacija, pljucna hipertenzija, ishemicna bolezen srca ter kombinirani kirurški poseg.
ZAKLJUCKI: Pri primerno izbranih starostnikih se menjava aortne zaklopke lahko opravi s sprejemljivo umrljivostjo, pri vecini bolnikov pa pride tudi do izboljšanja funkcijske zmožnosti. Rezultati raziskave kažejo, da je treba menjavo zaklopke opraviti še pred razvojem napredovalega stanja stenoze aortne zaklopke. Kombinirani kirurški posegi in hude socasne bolezni so slab napovedni dejavnik pooperativnega izida, zato jih je treba upoštevati, ko se odlocamo za operacijo pri starostniku.
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[Abstract / English version]
PREDOPERATIVNI DEJAVNIKI TVEGANJA ZA MENJAVO AORTNE ZAKLOPKE PRI STAROSTNIKIH
Author: Jure Dolenc
Mentor: prof. dr. Mirta Koželj
BACKGROUND: The number of elderly patients with degenerative aortic valve stenosis is increasing due to the ageing of the population. Advances in preoperative and postoperative care are reflected in a growing number of patients aged > 70 years undergoing aortic valve replacement (AVR).
AIM: The current study was undertaken to determine the significance of clinical, echocardiographic, invasive and surgical preoperative predictors of early and late postoperative mortality and of poor functional outcomes after AVR.
HYPOTHESIS: Poor postoperative outcome depends on the stage of aortic valve stenosis, co-morbidity and the complexity of surgical procedure.
METHODS: Data were reviewed for 235 consecutive patients, 120 women and 115 men, aged 70 to 89 years (mean age 74.7 ± 3.3) who underwent AVR between 1 January 1, 1997 and December 31, 2001. Patient age, gender, symptoms, New York Heart Association (NYHA) functional class, signs of congestive heart failure, concurrent diseases, cardiac rhythm, left ventricular hypertrophy, echocardiographic characteristics of native valve disease, left ventricular and left atrial dimensions, left ventricular ejection fraction, presence of mitral regurgitation and pulmonary hypertension, preoperative catheterization data, urgency and type of the surgical procedure were analysed as possible predictors of outcome. The influence of preoperative and operative variables on outcomes was determined using the bivariate ?2 tests and multivariate logistic regression. The survival rates were determined by the Kaplan-Meier method.
RESULTS: Early postoperative (< 30 days) mortality was 11.5 %. Multivariate logistic regression showed that chronic renal failure (p = 0.023), poor left ventricular ejection fraction (p = 0.039), pulmonary hypertension (p = 0.001) and combined surgery (p = 0.005) were independent predictors of early mortality. Late postoperative mortality was 8.5%. Multivariate predictors included chronic renal failure (p = 0.011) and urgent procedure (p = 0.043). Poor long-term outcome was established in 27.2 % of cases. Multivariate logistic regression showed that signs of congestive heart failure (p = 0.032), pulmonary hypertension (p = 0.001) and combined surgery (p = 0.023) were independent predictors of poor outcome after AVR. The overall actual survival rates at 1 and 3 years were 83 % and 79 %, respectively. Significant prognostic factors of poor preoperative survival included: NYHA class III-IV, signs of congestive heart failure, chronic renal failure, chronic atrial fibrillation, left ventricular hypertrophy, decreased left ventricular ejection fraction, enlarged left atrium, mitral regurgitation, pulmonary hypertension, ischemic heart disease and combined surgical procedure.
CONCLUSIONS: AVR done in selected elderly patients is associated with acceptable mortality and results in functional improvement in the majority of patients. The results of this study stress the importance of performing AVR at an early stage of aortic valve stenosis. Combined surgery and severe co-morbidity are unfavourable predictors of postoperative outcome, and they should be taken into consideration when considering AVR in older patients.
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