發(fā)布時(shí)間：2018-08-22 12:58

【摘要】：摘要一高齡鈣化性主動脈瓣狹窄患者的臨床特點(diǎn)研究[目的]分析高齡(年齡≥75歲)鈣化性主動脈瓣狹窄患者的臨床特征,確立與死亡相關(guān)危險(xiǎn)因素。[方法】連續(xù)性收集2008年1月1日至2015年1月1日期間我院收治的所有年齡≥75歲且診斷為非風(fēng)濕性主動脈瓣狹窄的病歷共421例的臨床資料。根據(jù)主動脈瓣病變程度將患者分為輕度狹窄組、中度狹窄組、重度狹窄組。隨訪1年觀察全因及心源性死亡終點(diǎn)。采用Logistic回歸分析與死亡相關(guān)的獨(dú)立危險(xiǎn)因素。[結(jié)果】患者平均年齡為(79.1±3.5)歲(范圍75-94歲),男性57.7%。患者年齡75-80歲之間、80-85歲之間、大于85歲的比例分別為62.5%、29.2%、8.3%。其中二瓣化改變占7.4%,紐約心臟協(xié)會心功能(NYAH)Ⅲ-Ⅳ級占50.4%,58.2%合并冠心病,72%合并高血壓,23.8%合并糖尿病,8.6%合并腫瘤,17.6%合并慢性肺部疾病,22.6%合并腦血管病,16.9%合并腎功能不全,6.2%合并貧血。隨訪1年的總死亡率及心源性死亡率為94例(22.3%)和83例(19.7%)。三組間1年全因死亡率及心源性死亡率逐漸增加但組間均無統(tǒng)計(jì)學(xué)差異(16.8%,22.9%,24.9%, p=0.2409,13.3%,19.3%,23.1%, p=0.0997)。Logistic多因素回歸分析顯示,外周血管病變(OR=2.31,95% CI:1.215-4.392)、EF值(OR=0.966,95% CI:0.942-0.991)、NT-proBNP分組(OR=2.022,95% CI:1.14-3.586)是1年全因死亡的獨(dú)立危險(xiǎn)因素；糖尿病(OR=2.157,95% CI:1.213-3.836)、EF值(OR=0.975,95% CI:0.95-1)、NT-proBNP分組(OR=2.786,95% CI:1.449-5.356)、血磷(OR=5.755, 95% CI:1.462-22.657)是1年心源性死亡的獨(dú)立危險(xiǎn)因素。[結(jié)論]高齡鈣化性主動脈瓣輕度、中度、重度狹窄組組間1年全因死亡及心源性死亡率逐漸增加,但均無顯著性差異。外周血管病變、EF值及NT-proBNP分組是1年全因死亡的獨(dú)立危險(xiǎn)因素；而糖尿病、EF值、NT-proBNP分組、血磷是1年心源性死亡的預(yù)測因子。摘要二 左室收縮功能下降對高齡中重度主動脈瓣狹窄患者死亡率的影響【目的】評價(jià)左室射血分?jǐn)?shù)減低對于≥75歲中重度主動脈瓣狹窄(Aortic valve stenosis, AS)患者全因死亡的影響,以此明確此類患者臨床治療策略�！痉椒ā窟B續(xù)收集的2008年1月1日至2015年1月1日于阜外醫(yī)院住院治療的年齡≥75歲的非風(fēng)濕性主動脈瓣狹窄患者的病例,回顧性分析其中超聲心動圖證實(shí)狹窄程度為中重度患者共301例的臨床資料。301例患者均隨訪至2016年1月1日觀察全因死亡終點(diǎn)。根據(jù)超聲心動圖檢查的EF值是否減低分為EF正常組與EF減低組,比較兩組間死亡率差異。應(yīng)用不同EF界值共進(jìn)行5次兩組間比較,分別為EF60%組與EF≤60%組,EF55%組與EF≤55%組,EF50%組與EF≤50%組,EF45%組與EF≤45%組,EF40%組與EF≤40%組。應(yīng)用極限乘積法來估計(jì)生存率,使用Kaplan-Meier法估計(jì)和繪制生存曲線,使用log-rank檢驗(yàn)進(jìn)行組間生存率比較。最后選擇全因存在差異的最高EF界值作為正常組與EF減低組的分組條件,觀察兩組間不同治療方案藥物治療(D組)、TAVR治療(T組)、SAVR治療(S組)的預(yù)后差異�！窘Y(jié)果】301例≥75歲的中重度AS患者平均年齡為78.9±3.2歲,男性共179例占59.5%,全因死亡率為24.6%。應(yīng)用不同EF界值進(jìn)行5次組間比較：EF≤60%組(n=171)與EF60%組(n=130)之間全因死亡率無明顯差異(27.2% vs 21.2%,p=0.2187);EF≤55%組(n=101)與EF55%組(n=200)之間全因死亡率(33.5% vs20.1%,p=0.0055)存在統(tǒng)計(jì)學(xué)差異；EF≤50%組(n=65)與EF50%組(n=236)之間全因死亡率(42.2% vs 19.7%, p0.0001)存在明顯統(tǒng)計(jì)學(xué)差異；EF≤45%組(n=51)與EF45%組(n=250)之間全因死亡率(45.8% vs 20.2%, p0.0001)存在明顯統(tǒng)計(jì)學(xué)差異：EF≤40%組(n=37)與EF40%組(n=264)之間全因死亡率(48.9% vs 21.1%, p0.0001)也存在明顯統(tǒng)計(jì)學(xué)差異。比較EF≤55%組與EF55%組的基線情況,EF減低組合并急性心肌梗死、糖尿病、慢性肺病、腎功能不全、合并二尖瓣、三尖瓣聯(lián)合瓣膜病變的比例較高,NYHA分級Ⅳ級比例高、NT-proBNP數(shù)值明顯升高、合并室內(nèi)阻滯(LBBB/RBBB)比例高、左室舒張末期內(nèi)徑(LVDD)明顯增大,而兩組間藥物治療及TAVR、SAVR比例相當(dāng)p=0.2801。矯正年齡、性別、COPD、腦血管病、跨瓣壓差因素后進(jìn)行的多因素回歸分析顯示,當(dāng)EF55%時(shí),年齡≥75歲中重度AS患者的全因死亡率明顯下降[HR=0.568 (95% CI 0.34-0.947, p=0.03)]。D組在EF下降至55%或以下時(shí)全因死亡率明顯增加(p=0.0003)；而無論EF是否下降,年齡≥75歲中重度AS患者全因死亡率在T組、S組或T+S組均無明顯統(tǒng)計(jì)學(xué)差異(p0.05)。【結(jié)論】 當(dāng)EF下降至≤55%時(shí),年齡≥75歲中重度AS患者全因死亡率明顯升高,其中藥物治療組全因死亡率最高。而EF值下降不影響此類患者手術(shù)(TAVR或SAVR)干預(yù)治療的全因死亡率。摘要三高齡鈣性主動脈瓣重度狹窄患者不同治療方式的預(yù)后分析【目的】評價(jià)高齡鈣化性主動脈瓣重度狹窄患者的臨床特點(diǎn),不同影響因素對死亡率的影響。對比不同治療方案的預(yù)后,比較STS SCORE、EuroSCORE Ⅱ、 Logical EuroSCORE不同評分對于換瓣手術(shù)(TAVR或SAVR)結(jié)果的預(yù)測性及準(zhǔn)確性�！痉椒ā窟B續(xù)回顧性收集2008年1月1日至2015年1月1日年齡≥75歲住院診斷為非風(fēng)濕性主動脈瓣狹窄病變,且超聲心動圖證實(shí)狹窄程度為重度患者共226例的臨床資料。全部患者計(jì)算STS SCORE、EuroSCORE Ⅱ、Logical EuroSCORE。根據(jù)治療方案不同分為藥物治療組、經(jīng)皮球囊主動脈瓣成形術(shù)(PBAV組)、經(jīng)導(dǎo)管主動脈瓣置換術(shù)(TAVR組)及外科主動脈瓣置換術(shù)(SAVR組)�；颊呔S訪至2016年1月1日觀察全因死亡終點(diǎn)。[結(jié)果]226例高齡重度AS患者平均年齡為78.9±3.1歲,其中75歲-80歲占61.5%,≥80歲占38.5%,男性共93例占41.2%,BMI為23.7±3.7 kg/m2,近-半病人合并冠心病110例(48.9%),一半以上(69.4%)患者NY HA分級在Ⅲ-Ⅳ級,10.6%合并腫瘤,18.1%合并慢性肺病,21.7%合并腦血管病,17.7%合并腎功能不全。藥物治療99例、PBAV治療9例、TAVR治療56例、SAVR治療62例的死亡率分別為46.6%、44.4%、7.2%、6.5%。其中TAVR與SAVR組間無統(tǒng)計(jì)學(xué)差異(p=0.8963),TAVR、SAVR較藥物治療組死亡率均明顯減低(p0.0001)。TAVR組平均logistic EuroSCORE、EuroSCORE Ⅱ和STS SCORE為20.5±13.4、4.6±2.7和3.8±2.9;SAVR組平均logistic EuroSCORE、EuroSCORE 、和STS SCORE為14.1±1].0、3.7±2.5和3.3±1.4�！疶AVR組較SAVR組比較logistic EuroSCORE和EuroSCORE Ⅱ風(fēng)險(xiǎn)評分更高(p0.05),三種評分TAVR組與藥物組比較無明顯差異。TAVR組logistic EuroSCORE、EuroSCORE Ⅱ和STS SCORE ROC曲線下面積分別為0.843(95% CI 0.598-1.0)、0.855(95% CI 0.668-1.0)和0.899(95%C1 0.802-0.996),p均0.05。SAVR組logistic EuroSCORE、EuroSCORE Ⅱ和STS SCORE ROC曲線下面積分別為0.897(95% CI 0.800-0.993)、0.897(95% CI 0.774-1.0)和0.899(95% CI 0.687-1.0), p均0.05。Logistic多因素回歸分析顯示,糖尿病(OR=0.65,95% CI: 1.056-3.471)、EF值(OR=-0.036,95% CI:0.945-0.984)、合并二/三尖瓣病變(OR=0.742,95% CI:1.104-3.991)是1年全因死亡的獨(dú)立危險(xiǎn)因素。[結(jié)論]換瓣治療較藥物治療可明顯改善預(yù)后,TAVR與SAVR相比圍術(shù)期及1年死亡率無明顯差異;三個(gè)評分模型中Logical EuroSCORE過度的預(yù)測了短期AVR死亡風(fēng)險(xiǎn),而EuroSCORE Ⅱ和STS SCORE更接近真實(shí)死亡率;TAVR較SAVR可減少住院日時(shí)間,但圍術(shù)期起搏器及瓣周漏發(fā)生比例高；高齡重度主動脈瓣狹窄1年全因死亡的獨(dú)立危險(xiǎn)因素為糖尿病、EF值、合并二/三尖瓣疾病。
[Abstract]:[Objective] To analyze the clinical characteristics of elderly patients with calcified aortic stenosis (CAVS) and identify risk factors for death. The patients were divided into mild stenosis group, moderate stenosis group and severe stenosis group according to the severity of aortic stenosis. All-cause and cardiac death endpoints were observed after 1 year follow-up. The proportion of patients aged 75-80, 80-85 and over 85 was 62.5%, 29.2% and 8.3%, respectively. Divalvular changes accounted for 7.4%, NYAH class III-IV accounted for 50.4%, NYAH class III-IV accounted for 58.2%, CHD was associated with 72%, hypertension was associated with 23.8%, diabetes mellitus was associated with 8.6%, tumor was associated with 17.6%. The total mortality and cardiogenic mortality were 94 (22.3%) and 83 (19.7%) during the follow-up period of one year. 23.1%, P = 0.0997). Logistic regressianalysis showed that peripheralvascular lesions (OR = 2.31, 95% CI: 1.215-4.392, EF (OR = 0.966, 95% CI: 0.966, 95% CI: 0.942-0.942-0.991), NT-proBNP (OR = 2.022, 95% CI: 1.14-3.586) were independent risk factors for one-year all-cause morta; diabet (OR = 2.157, 95% CI: 1.157, 95% CI: 1.213-3.836, EF (OR = 0.966, 95% CI: 0.966, 95% CI: 0.942, 95% CI: 0.942-0.942-0.942-0.NT-proBNP Blood phosphorus (OR = 5.755, 95% CI: 1.462-22.657) was an independent risk factor for one-year cardiac death. [Conclusion] All-cause mortality and cardiac mortality increased gradually in mild, moderate and severe calcified aortic valve stenosis groups, but there was no significant difference in peripheral vascular disease, EF value and NT-proBNP. Diabetes mellitus, EF, NT-proBNP, and serum phosphorus were independent risk factors for one-year all-cause mortality. [Methods] From January 1, 2008 to January 1, 2015, patients with non-rheumatic aortic stenosis (>75 years of age) hospitalized in Fuwai Hospital were retrospectively analyzed, and echocardiographically confirmed cases were retrospectively analyzed. 301 patients with moderate or severe stenosis were followed up until January 1, 2016 to observe the all-cause endpoint. According to whether the EF value of echocardiographic examination was reduced to normal EF group and low EF group, the mortality difference between the two groups was compared. Group F < 60%, group EF55% and group EF < 55%, group EF50% and group EF < 50%, group EF45% and group EF < 45%, group EF40% and group EF < 40%. The prognosis of 301 patients with moderate to severe AS (> 75 years old) was 78.9 (+ 3.2 years old), 179 males (59.5%) and 24.6% of all-cause mortality. There was no significant difference in all-cause mortality between EF < 60% group (n = 171) and EF 60% group (n = 130) (27.2% vs 21.2%, P = 0.2187); there was significant difference in all-cause mortality between EF < 55% group (n = 101) and EF 55% group (n = 200) (33.5% vs 20.1%, P = 0.0055); there was significant difference in all-cause mortality between EF < 50% group (n = 65) and EF 50% group (n = 236) (42.2% vs 19.7%, P 0.0001). There were significant differences in all-cause mortality (45.8% vs 20.2%, P 0.0001) between EF < 45% group (n = 51) and EF 45% group (n = 250). There were significant differences in all-cause mortality (48.9% vs 21.1%, P 0.0001) between EF < 40% group (n = 37) and EF 40% group (n = 264). Acute myocardial infarction, diabetes mellitus, chronic pulmonary disease, renal insufficiency, mitral valve, tricuspid valve disease, NYHA grade IV, NT-proBNP, LBBB / RBBB, LVDD, TAVR and SAVR were higher in patients with acute myocardial infarction, diabetes mellitus, chronic pulmonary disease, and renal insufficiency. Corrected age, sex, COPD, cerebrovascular disease, and transvalvular pressure difference, multivariate regression analysis showed that the all-cause mortality of moderate to severe AS patients aged over 75 decreased significantly when EF was 55% [HR = 0.568 (95% CI 0.34-0.947, P = 0.03)]. Whether EF decreased or not, there was no significant difference in all-cause mortality between group T and group S or group T+S (p All-cause mortality after surgical intervention (TAVR or SAVR) in elderly patients with severe calcified aortic stenosis ORE, EuroSCORE II, and Logical EuroSCORE scores were used to predict the outcome of valve replacement surgery (TAVR or SAVR). [Methods] A total of 226 patients with severe stenosis confirmed by echocardiography who were hospitalized from January 1, 2008 to January 1, 2015 and aged over 75 years were retrospectively collected. STS SCORE, EuroSCORE II, and Logical EuroSCORE were calculated in all patients. The patients were divided into three groups according to different treatment schemes: drug therapy group, percutaneous balloon aortic valvuloplasty (PBAV group), transcatheter aortic valve replacement (TAVR group) and surgical aortic valve replacement (SAVR group). [Results] The average age of 226 elderly patients with severe AS was 78.9 (+ 3.1 years). Among them, 61.5% were 75-80 years old, 38.5% were over 80 years old, 93 cases were male (41.2%), BMI was 23.7 (+ 3.7 kg/m2), 110 cases (48.9%) were near-half patients with coronary heart disease, more than half (69.4%) were NY HA grade III-IV, 10.6% with tumor, 18.1% with chronic lung disease, and 21.7% with chronic lung disease. There were 99 cases treated with drug, 9 cases treated with PBAV, 56 cases treated with TAVR, and 62 cases treated with SAVR. The mortality rates were 46.6%, 44.4%, 7.2% and 6.5% respectively. There was no significant difference between TAVR and SAVR (p = 0.8963). The mortality rates of TAVR and SAVR were significantly lower than those of drug treatment group (p 0.0001). SCORE II and STS CORE were 20.5+13.4, 4.6+2.7 and 3.8+2.9; the mean logistic EuroSCORE, EuroSCORE, and STS CORE were 14.1+1]. The sub-curves of EuroSCORE, EuroSCORE II, and STSCORE ROC were 0.843 (95% CI 0.598-1.0), 0.855 (95% CI 0.668-1.0) and 0.899 (95% CI 0.668-1.0) and 0.899 (95% C1 0.802-0.802-0.996), respectively, P 0.05. The sub-curves of logistic EuroSCORE, EuroSCORE II and STSCORE ROC were 0.897 (95% CI 0.800-0.993), 0.855 (95% CI 0.668-1.0) and 0.899 (95% CI 0.802-0.802-0.802-0.996) and 0.89899 (95% CI 0.687-1). Multivariate logistic regression analysis showed that diabetes mellitus (OR = 0.65, 95% CI: 1.056-3.471), EF (OR = - 0.036, 95% CI: 0.945-0.984) and mitral/tricuspid valve disease (OR = 0.742, 95% CI: 1.104-3.991) were independent risk factors for one-year all-cause mortality. There was no significant difference between the first and second-year mortality rates; Logical EuroSCORE excessively predicted the risk of short-term AVR mortality in the three scoring models, while EuroSCORE II and STS SCORE were closer to the true mortality rates; TAVR reduced the length of hospital stay than SAVR, but the incidence of perioperative pacemaker and pericardial leak was higher; severe aortic stenosis in the elderly was all-cause death for one year. The independent risk factor was diabetes, EF, combined with two / three cusp disease.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R542.5

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