JAMA:中老年人主动脉瓣置换术中生物瓣膜略优于机械瓣膜

2014-10-02 MedSci译 MedSci原创

主动脉瓣置换术中,选择生物瓣膜还是机械瓣膜,一直存在争议。一般认为机械瓣膜更结实,因此不容易损坏,再手术率低。但是金属机械瓣膜毕竟是异物,需要终生抗凝治疗,因此出血风险高。但对于中老年年人来说,选择哪种瓣膜呢?最新一期JAMA在2014年10月1日公布一项大型的回顾性研究分析,比较生物瓣膜与机械瓣膜在主动脉瓣置换术后长期随访结果,比较患者长期生存状况,以及主要致死情况。研究选择年龄50-69岁之间

主动脉瓣置换术中,选择生物瓣膜还是机械瓣膜,一直存在争议。一般认为机械瓣膜更结实,因此不容易损坏,再手术率低。但是金属机械瓣膜毕竟是异物,需要终生抗凝治疗,因此出血风险高。但对于中老年年人来说,选择哪种瓣膜呢?


最新一期JAMA在2014年10月1日公布一项大型的回顾性研究分析,比较生物瓣膜与机械瓣膜在主动脉瓣置换术后长期随访结果,比较患者长期生存状况,以及主要致死情况。

研究选择年龄50-69岁之间接受主动脉瓣置换术的患者,本队列共收集从1997年到2004年4253位50-69岁之间的首次接受主动脉瓣置换术患者。中位随访时间为10.8年(平均0-16.9年),致死情况最后随访时间为2013年11月。同时对其中的1001位患者进行倾向得分匹配分析。
主要结局指标为全因死亡,次要结局指标为卒中,再手术和大出血状况。

结果发现,两组患者在生存或卒中发生率方面没有显著性差异。15年随访中,生物瓣膜组有60.6%(95% CI, 56.3%-64.9%)存活,而机械瓣膜组为 62.1% (95% CI, 58.2%-66.0%) ,两组相比HR:0.97[95% CI, 0.83-1.14]。15年累积的卒中发生率在生物瓣膜组为7.7%(95% CI, 5.7%-9.7%) ,在机械瓣膜组为8.6% (95% CI, 6.2%-11.0%),两者相比HR:1.04 (95% CI, 0.75-1.43)。15年累积再手术在生物瓣膜组更高为12.1% [95% CI, 8.8%-15.4%],在机械瓣膜组仅为 6.9% [95% CI, 4.2%-9.6%]; 两组相比HR:0.52 [95% CI, 0.36-0.75]。而15年累积大出血事件在机械瓣膜组更高13.0% [95% CI, 9.9%-16.1%] ,而生物瓣膜组仅为 6.6% [95% CI, 4.8%-8.4%],两组相比HR: 1.75 [95% CI, 1.27-2.43]。卒中后30天内致死率为18.7%,再手术为9.0%,大出血为13.2%。

通过倾向得分匹配分析发现,两组在15年生存状况和卒中状况方面均没有显著性差异。但是生物瓣膜组有更高的再手术率,但大出血可能更低。因此,从整体来说,在50-69岁人群中,主动脉置换术中,更推荐使用生物瓣膜。

MedSci认为这个研究结果与预期是相似的。不过本组研究还有很多特色,其一将人群拓宽为50岁以上人群进行对比,将来还希望有更细致针对不同年龄人群进行对比研究。其二,采用倾向得分匹配进一步验证,结果是相似的。这也是这篇回顾性研究能发表在JAMA上的重要原因之一。

机械瓣是由碳材料、金属及人造织物制造的。它的优点有几个。第一是结实,就是耐久性好,不会因磨损而损坏。在试验台上模拟工作,机械瓣可以承受超过100年的磨损。第二是小口径(19毫米及以下)的机械瓣,其几何瓣口面积相对较大,尤其是新一代的机械瓣,对某些主动脉根部细小的病人来说,其应用是不易被取代的。第三是瓣膜的高度低,适合某些特殊情况。临床数据已经证明,双叶瓣的瓣膜血栓发生率低于倾碟型机械瓣。但是,机械瓣膜需要病人终身接受抗凝治疗,有抗凝治疗禁忌症的病人不能使用。抗凝治疗有发生致死性并发症--出血和栓塞--的危险。在中国汉族人群中,出血的比例较高。另外,植入机械瓣膜后的病人,在怀孕、接受其他手术时有一定的麻烦,需要阶段性的肝素替代华法林治疗,但是很多地方的医院目前无此类情况的处治经验。女性病人还可能有月经增多的问题。尽管医生强调规范抗凝治疗的重要性,病人也按照医生的要求去做了,但是,总体上看,仍有一定比例的病人因为抗凝治疗的并发症而致死、致残。另一个麻烦是非瓣膜结构性人工瓣膜功能障碍,简单地说就是人工瓣膜机械障碍。这是因为植入的人工瓣膜周围的组织增生过度,干扰到了瓣叶的活动,使瓣叶启闭异常。人工机械瓣膜功能障碍是瓣膜病人进行再次手术的主要原因之一。

生物瓣是用其他动物的心包或主动脉瓣加上一些人工支架和织物制成的。其中又分支架生物瓣和无支架生物瓣。生物瓣膜的优点是形状、血流方式与人体瓣膜十分相似。生物瓣被植入人体后,其表面会被沉积的纤维蛋白和血管内皮等组织覆盖,避免了激活血液的凝血反应。因此,生物瓣的优点是手术后只需要抗凝半年即可,以后不需要持续抗凝治疗。与瓣膜相关的并发症如血栓形成、血栓栓塞的发生率也较机械瓣膜低。这里特别要注意的一点是,生物瓣膜植入手术后持续房颤的病人,必须抗凝治疗。美国心脏病协会的指南建议,对于无瓣膜疾病、仅仅是单纯持续房颤的病人,都必须进行华法林抗凝治疗。单纯房颤如此,何况你还有人工瓣膜呢。当然,生物瓣缺点显而易见,就是耐久性不好,使用时间长了会坏,医学上称为损毁。二尖瓣位支架生物瓣膜损毁出现在第五年,主动脉瓣位第八年,第十年后损毁率迅速上升,以致对生存率产生影响。

生物瓣坏了只能再换新的。再次手术时的风险也是必须考虑的因素之一。使用生物瓣后,当其中的任何一个瓣膜损坏(不是在手术后早期),除非有非常明确的手术技术原因,一般均须将心脏内的全部生物瓣同期进行更换。无论在国内还是国外,再次手术替换两个或三个人工瓣膜,其手术风险都是很大的。所以,病人预计需要植入两个或三个人工瓣膜时,如果其预期寿命还较长,这个因素很值得考虑。

基于上述道理,当存在病人年龄较大(特别是65岁以上),窦性心律,单瓣膜疾病,经济情况好,有抗凝治疗禁忌症,不合并慢性肾功能衰竭等情况时,医生倾向于建议病人选择生物瓣膜。手术后想生孩子的女性病人也可以考虑生物瓣。如果病人年轻,术前持续房颤,多瓣膜病变,主动脉根部细小等情况下,医生则更支持机械瓣膜的选择。

目前,某些心脏外科领域内的人员对生物瓣瓣膜(尤其是支架生物膜)的耐久性提供了不完全客观的相关数据。他们将支架生物瓣在某些特定病人获得的良好结果宣传为一般人群的预期结果。1.  将一些年龄较大的(65岁以上甚至是70岁的病人)接受主动脉瓣替换的病人瓣膜衰败的免除率泛化为此瓣膜在各个年龄层次的预计值(病人接受生物瓣膜植入的年龄越大,与瓣膜耐久性相关的数据就越好)。2. 用病人因人工瓣膜衰败接受再次瓣膜替换手术的免除率来代表人工瓣膜衰败的免除率(瓣膜发生衰败后部分病人因为种种原因未能接受再次手术,故瓣膜衰败后接受再次手术的病人数量肯定少于发生瓣膜衰败病人的数量)。3. 在文章中提供病人实际(actual)瓣膜衰败数量而不是应该在统计学上使用的精算值(actuarial,如果病人因为其他原因死亡于瓣膜发生衰败前,瓣膜就没有衰败,但假定这个瓣膜用在了一个年轻病人身上,此瓣膜仍然有可能发生衰败,故病人越年轻,预期生存时间越长,上述两个数值差距越大)。4. 用临床应用后短时间(5至8年)内的结果代表最终的耐久性数值(当任何一种新的人工瓣膜开始临床应用后,有关其耐久性的数据要等到此瓣膜大规模应用于临床足够长的时间(10至15年)后发生足够数量的衰败后才能得出,这个时间通常是20年左右).

原始出处:
Chiang YP, Chikwe J, Moskowitz AJ, Itagaki S, Adams DH, Egorova NN.Survival and long-term outcomes following bioprosthetic vs mechanical aortic valve replacement in patients aged 50 to 69 years. JAMA. 2014 Oct 1;312(13):1323-9.

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objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=61265, encryptionId=a31661265fd, topicName=机械瓣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7db99, createdName=chg121, createdTime=Fri Jul 10 23:08:00 CST 2015, time=2015-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1332361, encodeId=5eea133236131, content=<a href='/topic/show?id=1dd6231822d' target=_blank style='color:#2F92EE;'>#主动脉瓣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23182, encryptionId=1dd6231822d, topicName=主动脉瓣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dc4b2500077, createdName=hittouch, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1367067, encodeId=7336136e067b4, content=<a href='/topic/show?id=b6222320322' target=_blank style='color:#2F92EE;'>#主动脉瓣置换术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23203, encryptionId=b6222320322, topicName=主动脉瓣置换术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0b24249, createdName=medsci246, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1399080, encodeId=4469139908000, content=<a href='/topic/show?id=49dd69399c2' target=_blank style='color:#2F92EE;'>#生物瓣膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69399, encryptionId=49dd69399c2, topicName=生物瓣膜)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SicjCIAeTxGf3PibxsFPgEb3xtbibdR8KpjNN5V3XkiatR1BXv2o9YPVhSnazedCHtUUh9KJyUmqYnmS3fRlyJZ4Dw/132, createdBy=5c342186905, createdName=liao1620, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1414981, encodeId=8645141498140, content=<a href='/topic/show?id=04812314540' target=_blank style='color:#2F92EE;'>#主动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23145, encryptionId=04812314540, topicName=主动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=77603112682, createdName=circumcision, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=)]
    2015-07-10 yydlt

    不错!可以!

    0

  3. 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encryptionId=83a3693965d, topicName=生物瓣)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ddce22497218, createdName=396094184_42047362, createdTime=Fri Sep 18 00:08:00 CST 2015, time=2015-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1923750, encodeId=ef4b1923e50ab, content=<a href='/topic/show?id=56a522389f9' target=_blank style='color:#2F92EE;'>#中老年#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22389, encryptionId=56a522389f9, topicName=中老年)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ca6a2500099, createdName=more is better!, createdTime=Sat May 09 05:08:00 CST 2015, time=2015-05-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2078751, encodeId=905b20e875188, content=<a href='/topic/show?id=a31661265fd' target=_blank style='color:#2F92EE;'>#机械瓣#</a>, beContent=null, 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content=<a href='/topic/show?id=b6222320322' target=_blank style='color:#2F92EE;'>#主动脉瓣置换术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23203, encryptionId=b6222320322, topicName=主动脉瓣置换术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0b24249, createdName=medsci246, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1399080, encodeId=4469139908000, content=<a href='/topic/show?id=49dd69399c2' target=_blank style='color:#2F92EE;'>#生物瓣膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69399, encryptionId=49dd69399c2, topicName=生物瓣膜)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SicjCIAeTxGf3PibxsFPgEb3xtbibdR8KpjNN5V3XkiatR1BXv2o9YPVhSnazedCHtUUh9KJyUmqYnmS3fRlyJZ4Dw/132, createdBy=5c342186905, createdName=liao1620, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1414981, encodeId=8645141498140, content=<a href='/topic/show?id=04812314540' target=_blank style='color:#2F92EE;'>#主动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23145, encryptionId=04812314540, topicName=主动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=77603112682, createdName=circumcision, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=)]
    2015-07-09 yxch48
  4. 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  5. 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objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=61265, encryptionId=a31661265fd, topicName=机械瓣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7db99, createdName=chg121, createdTime=Fri Jul 10 23:08:00 CST 2015, time=2015-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1332361, encodeId=5eea133236131, content=<a href='/topic/show?id=1dd6231822d' target=_blank style='color:#2F92EE;'>#主动脉瓣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23182, encryptionId=1dd6231822d, topicName=主动脉瓣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dc4b2500077, createdName=hittouch, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1367067, encodeId=7336136e067b4, 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createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SicjCIAeTxGf3PibxsFPgEb3xtbibdR8KpjNN5V3XkiatR1BXv2o9YPVhSnazedCHtUUh9KJyUmqYnmS3fRlyJZ4Dw/132, createdBy=5c342186905, createdName=liao1620, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1414981, encodeId=8645141498140, content=<a href='/topic/show?id=04812314540' target=_blank style='color:#2F92EE;'>#主动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23145, encryptionId=04812314540, topicName=主动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=77603112682, createdName=circumcision, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=)]
  6. [GetPortalCommentsPageByObjectIdResponse(id=1771296, encodeId=15c21e7129685, content=<a href='/topic/show?id=9ced223904c' target=_blank style='color:#2F92EE;'>#中老年人#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22390, encryptionId=9ced223904c, topicName=中老年人)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=71df38244151, createdName=gjsgj, createdTime=Fri Jun 19 19:08:00 CST 2015, time=2015-06-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=32207, encodeId=9f603220ecb, content=不错!可以!, beContent=null, objectType=article, channel=null, level=null, likeNumber=94, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLCEEr4dM45RatXXGAkFCicnNYiasFiaRicicO1YWsIeTFOhgapauqib8Z8TChNB3ttVC5RqNHptDvAxA72Q/0, createdBy=a82a1611288, createdName=yydlt, createdTime=Fri Jul 10 09:35:00 CST 2015, time=2015-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1742305, encodeId=4e9c1e4230532, content=<a href='/topic/show?id=39cae96626f' target=_blank style='color:#2F92EE;'>#置换#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79662, encryptionId=39cae96626f, topicName=置换)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3a7c35056336, createdName=yxch48, createdTime=Thu Jul 09 21:08:00 CST 2015, time=2015-07-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1635539, encodeId=9ac816355399b, content=<a href='/topic/show?id=83a3693965d' target=_blank style='color:#2F92EE;'>#生物瓣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69396, encryptionId=83a3693965d, topicName=生物瓣)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ddce22497218, createdName=396094184_42047362, createdTime=Fri Sep 18 00:08:00 CST 2015, time=2015-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1923750, encodeId=ef4b1923e50ab, content=<a href='/topic/show?id=56a522389f9' target=_blank style='color:#2F92EE;'>#中老年#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22389, encryptionId=56a522389f9, topicName=中老年)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ca6a2500099, createdName=more is better!, createdTime=Sat May 09 05:08:00 CST 2015, time=2015-05-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2078751, encodeId=905b20e875188, content=<a href='/topic/show?id=a31661265fd' target=_blank style='color:#2F92EE;'>#机械瓣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=61265, encryptionId=a31661265fd, topicName=机械瓣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7db99, createdName=chg121, createdTime=Fri Jul 10 23:08:00 CST 2015, time=2015-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1332361, encodeId=5eea133236131, content=<a href='/topic/show?id=1dd6231822d' target=_blank style='color:#2F92EE;'>#主动脉瓣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23182, encryptionId=1dd6231822d, topicName=主动脉瓣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dc4b2500077, createdName=hittouch, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1367067, encodeId=7336136e067b4, content=<a href='/topic/show?id=b6222320322' target=_blank style='color:#2F92EE;'>#主动脉瓣置换术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23203, encryptionId=b6222320322, topicName=主动脉瓣置换术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0b24249, createdName=medsci246, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1399080, encodeId=4469139908000, content=<a href='/topic/show?id=49dd69399c2' target=_blank style='color:#2F92EE;'>#生物瓣膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69399, encryptionId=49dd69399c2, topicName=生物瓣膜)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SicjCIAeTxGf3PibxsFPgEb3xtbibdR8KpjNN5V3XkiatR1BXv2o9YPVhSnazedCHtUUh9KJyUmqYnmS3fRlyJZ4Dw/132, createdBy=5c342186905, createdName=liao1620, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1414981, encodeId=8645141498140, content=<a href='/topic/show?id=04812314540' target=_blank style='color:#2F92EE;'>#主动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23145, encryptionId=04812314540, topicName=主动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=77603112682, createdName=circumcision, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=)]
    2015-07-10 chg121
  7. 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encryptionId=83a3693965d, topicName=生物瓣)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ddce22497218, createdName=396094184_42047362, createdTime=Fri Sep 18 00:08:00 CST 2015, time=2015-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1923750, encodeId=ef4b1923e50ab, content=<a href='/topic/show?id=56a522389f9' target=_blank style='color:#2F92EE;'>#中老年#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22389, encryptionId=56a522389f9, topicName=中老年)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ca6a2500099, createdName=more is better!, createdTime=Sat May 09 05:08:00 CST 2015, time=2015-05-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2078751, encodeId=905b20e875188, content=<a href='/topic/show?id=a31661265fd' target=_blank style='color:#2F92EE;'>#机械瓣#</a>, beContent=null, 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content=<a href='/topic/show?id=b6222320322' target=_blank style='color:#2F92EE;'>#主动脉瓣置换术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23203, encryptionId=b6222320322, topicName=主动脉瓣置换术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0b24249, createdName=medsci246, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1399080, encodeId=4469139908000, content=<a href='/topic/show?id=49dd69399c2' target=_blank style='color:#2F92EE;'>#生物瓣膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69399, encryptionId=49dd69399c2, topicName=生物瓣膜)], attachment=null, authenticateStatus=null, 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  8. 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objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=61265, encryptionId=a31661265fd, topicName=机械瓣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7db99, createdName=chg121, createdTime=Fri Jul 10 23:08:00 CST 2015, time=2015-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1332361, encodeId=5eea133236131, content=<a href='/topic/show?id=1dd6231822d' target=_blank style='color:#2F92EE;'>#主动脉瓣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23182, encryptionId=1dd6231822d, topicName=主动脉瓣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dc4b2500077, createdName=hittouch, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1367067, encodeId=7336136e067b4, content=<a href='/topic/show?id=b6222320322' target=_blank style='color:#2F92EE;'>#主动脉瓣置换术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23203, encryptionId=b6222320322, topicName=主动脉瓣置换术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0b24249, createdName=medsci246, createdTime=Sat Oct 04 12:08:00 CST 2014, time=2014-10-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1399080, encodeId=4469139908000, content=<a href='/topic/show?id=49dd69399c2' target=_blank style='color:#2F92EE;'>#生物瓣膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69399, encryptionId=49dd69399c2, topicName=生物瓣膜)], attachment=null, authenticateStatus=null, 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  9. 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