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心脏瓣膜病的病因存在显著的地域差异，中低收入国家以风湿性疾病为主，高收入国家中则以退行性病因更为常见。《柳叶刀》发表的评论指出，建议将心脏瓣膜病患者及早转诊至由多学科团队组成的专科心脏诊疗网络。“终身管理”意味着，当患者需要接受侵入性治疗时，应把握住首次干预，做到及早治疗、正确治疗。识别文中二维码或点击文末阅读原文，查阅原文。


心脏瓣膜病是导致死亡与残疾的重要原因，随着全球人口老龄化，其发病率持续上升[1]。心脏瓣膜病的病因存在显著的地域差异：中低收入国家以风湿性疾病为主，高收入国家中则以退行性病因更为常见。目前，大多数患者在得到确诊并转送治疗时，治疗干预往往被定位为发挥姑息性效果而非根治作用[2]，而且重症患者若不进行心脏介入治疗，其生存率甚至低于某些恶性肿瘤（如前列腺癌、膀胱癌以及结直肠癌）[3]。全球范围内，不同国家和地区的心脏瓣膜病治疗的可及性同样差异悬殊，且高质量治疗技术服务的供应仍显不足[4][5]。近几十年来，结构性心脏病的新型经导管介入治疗技术取得了重大进展，为患者提供了相较于外科手术更为微创的治疗选项[1][6]。临床医生提出了“终身管理”理念，涉及到外科手术与介入治疗的不同组合方案。


现有证据表明，尽早将心脏瓣膜病患者转诊到接受治疗的医院，最有可能使患者生存率提升至接近普通人群水平[7][8]。然而，英美研究均显示，符合转诊指征的心脏瓣膜病（尤其是二尖瓣和三尖瓣反流）患者中，实际转诊并接受侵入性治疗的人数比例不足25% [4][5][9]。这一所谓的“转诊惰性”（referral inertia）可能与治疗风险的相关认识有关：首先，患者常将瓣膜病症状（如气短、疲惫）归因于衰老的表现而不寻求帮助；其次，全科医生和较为保守的心脏科医生可能会认为，介入治疗的风险实际高于临床研究记载；最后，尽管外科手术与经导管介入治疗的短期死亡率相当[10]，医患双方均仍普遍认为手术的风险更高。实际上，即使经导管介入治疗的确呈现出低于手术治疗的短期死亡率，但当患者及早被转诊接受治疗时，这一差异也不再存在[11][12]。当前中低风险的临床试验存有明显局限，既缺乏可靠的长期数据，又存在常见于随机试验的多种偏倚（如偏离所分配治疗、合并干预影响，以及终点指标相关性等问题）[13]。欧美多项真实世界注册研究显示，接受外科手术治疗的患者在调整其自身风险之后的长期死亡率显著降低（降幅超40%）[14]，这一层面难以单纯用偏倚加以解释。尽管存在以上数据支持，美国与德国的临床实践中，经导管介入治疗的使用率仍持续攀升[15]，而同期的外科手术量呈相关性递减，可能危及患者获得最佳治疗的机会。


因此，我们建议将心脏瓣膜病患者及早转诊至由多学科团队组成的专科心脏诊疗网络。诊疗团队可综合评估每位患者，定制最适合终身管理的个性化治疗决策，从首次干预起，综合权衡短期与长期预后。我们提议，心脏诊疗网络可参照肿瘤专家委员会进行设计，使介入心脏科医生、外科医生、心衰专科医生、影像学专科医生以及转诊医生能够及早交流，为患者定制最佳治疗方案。诊疗网络可采用线上会诊形式开展协作，推动患者由全科医生向专科团队及早转诊。主动脉瓣、二尖瓣以及三尖瓣治疗领域的文献研究表明，在恰当的时间为适宜患者匹配最佳治疗策略，不仅能够改善个体预后，长期来看还可为医疗体系节约成本[7][16][17]。目前已实现二尖瓣及三尖瓣修复术[18]、Ross手术[19]以及需较低抗凝程度的新型机械瓣膜[20]等技术进步，心脏外科领域正不断改善患者的长期预后。我们主张，心脏诊疗网络（类似于肿瘤专家委员会）需综合评估患者的早期与长期预后。我们呼吁参与心脏瓣膜病管理的临床医生尽早将患者转送至心脏诊疗团队；心脏诊疗团队则应构建更广泛的诊疗网络，进而确定风险最低、疗效最持久的治疗方案。所谓的“终身管理”意味着，当患者需要接受侵入性治疗时，应把握住首次干预，做到及早治疗、正确治疗。END

Torsten Doenst, Maurice Enriquez Sarano, Hristo Kirov, Tulio Caldonazo, Joanna Chikwe, Julien Dreyfus, Joseph Zacharias

 

Competing Interests

TD received lecture honoraria from Edwards Lifesciences and Abbott. MES received consulting fees from HighLife and holds patent US 11.896.482 B2. JD received consulting fees from Abbott and Edwards Lifesciences. JZ received consulting fees from Cambridge Medical Robotics, lecture honoraria from Edwards Lifesciences, Medtronic, Abbott, Terumo, Corcym, and Intuitive Surgery, travel support from LSI Solutions, declares advisory board involvement with Artivion, and lists he is secretary of the Endoscopic Cardiac Surgeons Club. All other authors declare no competing interests.

 

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中文翻译仅供参考，所有内容以英文原文为准。

DOI: 10.1016/S0140-6736(25)00989-4 


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