75岁以上钙化性主动脉瓣狭窄患者影响其预后的危险因素分析

摘要

目的：高龄（年龄≥75岁）钙化性主动脉瓣狭窄患者影响预后的危险因素分析,比较不同干预治疗方案的安全性。方法：回顾性分析2008-01-01至2015-01-01期间我院收治的所有年龄≥75岁且诊断为钙化性主动脉瓣狭窄的患者421例的临床资料，男性243例（57.7%），平均年龄为（79.1±3.5）岁。根据超声心动图检测的主动脉瓣口面积大小，将患者分为轻度狭窄组(n =112)、中度狭窄组(n =83)和重度狭窄组(n =226)。随访1年观察全因及心原性死亡终点。重度狭窄组患者比较不同治疗方案的死亡率的差异。采用Logistic回归分析与死亡相关的独立危险因素。结果：421例患者随访1年的全因及心原性死亡率分别为22.3%（94例）和19.7%（83例）。三组间1年全因死亡率及心原性死亡率比较差异均无统计学意义（P>0.05）。多因素Logistic回归分析显示，外周血管病变[比值比（OR）=2.31，95%可信区间（CI）：1.215~4.392]、左心室射血分数（LVEF，OR=0.966，95% CI：0.942~0.991）、不同氨基末端B型利钠肽原（NT-proBNP）水平（OR=2.022，95% CI：1.140~3.586）是1年全因死亡的独立危险因素；糖尿病（OR=2.157，95% CI：1.213~3.836）、 LVEF （OR=0.975，95% CI：0.950~1.000）、不同NT-proBNP水平（OR=2.786，95% CI：1.449~5.356）、血磷（OR=5.755，95% CI：1.462~22.657）是1年心原性死亡的独立危险因素。重度狭窄组的药物治疗、经皮球囊主动脉瓣成形术(PBAV)、经导管主动脉瓣置换术（TAVR）及外科主动脉瓣置换术（SAVR）的全因死亡率分别为43.6%、57.1%、7.3%、6.45%。TAVR、SAVR较药物治疗死亡率均明显降低（P<0.0001），TAVR与SAVR死亡率比较差异无统计学意义（P>0.05）。结论：高龄、不同程度的钙化性主动脉瓣狭窄患者的1年全因死亡及心原性死亡率随狭窄程度的加剧呈逐渐上升趋势，但死亡率与狭窄程度无关。外周血管病变和血磷是影响其预后的危险因素。重度狭窄患者行主动脉瓣膜置换术较药物治疗效果更佳，TAVR与SAVR疗效相当。%Objective: To analyze the risk factors affecting prognosis of calciifc aortic stenosis in patients elder than 75 years of age and to compare the safety among different treatments. Methods: A total of 421 consecutive aortic stenosispatients treated in our hospital from 2008-01-01 to 2015-01-01 were retrospectively studied. The patients were at the age of (79.1 ± 3.5) years and with 243 (57.7%) of male gender. According to echocardiography data, the patients were divided into 3 groups: Mild stenosis group,n=112, Moderate stenosis group,n=83 and Severe stenosis group,n=226. All patients were followed-up for 1 year to observe the end point of all cause and cardiac death. In Severe stenosis group, mortalities by different treatments were compared; the risk factors related to death were calculated by Logistic regression analysis. Results: The overall 1 year all cause and cardiac mortalities were 22.3% (94/421) and 19.7% (83/421) respectively, both all cause and cardiac mortalities were similar among 3 groups,P>0.05. Multivariate Logistic regression analysis indicated that peripheral vascular disease (OR=2.31, 95% CI 1.215-4.392), LVEF (OR=0.966, 95% CI 0.942-0.991) and NT-proBNP (OR=2.022, 95% CI 1.140-3.586) were the independent risk factors for 1 year all cause death; diabetes (OR=2.157, 95% CI 1.213-3.836), LVEF (OR=0.975, 95% CI 0.950-1.000), NT-proBNP (OR=2.786, 95% CI 1.449-5.356) and blood levels of phosphorus (OR=5.755, 95% CI 1.462-22.657) were the independent risk factors for 1 year cardiac death. In Severe stenosis group, the all cause mortalities by medication, PBAV, TAVR and SAVR were 43.6%, 57.1%, 7.3% and 6.45% respectively, the patients with TAVR, SAVR had the lower mortality than those with medication, P<0.0001, while the mortality was similar between the patients with TAVR and SAVR, P>0.05. Conclusion: All cause and cardiac mortalities within 1 year were increasing with the age accordingly, while aortic stenosis grade was not related to mortality in elder patients with calcific aortic stenosis. Peripheral vascular disease and blood levels of phosphorus were the risk factors affecting prognosis. TAVR and SAVR had better effect for treating the patients with severe aortic stenosis.