Bleiziffer Sabine, Ruge Hendrik, Mazzitelli Domenico, Hutter Andrea, Opitz Anke, Bauernschmitt Robert, Lange Rüdiger
Clinic for Cardiovascular Surgery, German Heart Center Munich, Lazarettstrasse 36, Munich, Germany.
J Thorac Cardiovasc Surg. 2009 Nov;138(5):1073-80. doi: 10.1016/j.jtcvs.2009.07.031. Epub 2009 Sep 17.
Recently, suspicion had been expressed that survival might be impaired after antegrade transapical as opposed to retrograde transfemoral valve implantation in high-risk patients with aortic stenosis. We analyzed survival in patients undergoing transcatheter aortic valve implantation with special emphasis on the access site for implantation.
Between June 2007 and February 2009, 203 high-risk patients (EuroSCORE, 22% +/- 14%; mean age, 81 +/- 7 years) underwent transcatheter aortic valve implantation via a transapical (n = 50) or transfemoral (n = 153) access. The transapical implantation technique was chosen only in patients who had no access through diseased femoral arteries.
Thirty-day survival was 88.8% after transfemoral versus 91.7% after transapical implantation (P = .918). The transapical group had a significantly higher preoperative brain natriuretic peptide value and a significantly higher incidence of peripheral vessel, cerebrovascular, and coronary heart disease. Death within 30 days was valve related in 25% (transapical) and 31% (transfemoral), cardiac in 25% and 13%, and noncardiac in 50% and 56%, respectively (no significant difference). Complications specific to the access site (peripheral vessel injury or apex complications) occurred in both groups, whereas neurologic events did not occur in the transapical group (P = .041).
Our patient and access site selection process, with the transfemoral technique considered the access site of first choice, results in comparable survival and morbidity for either transfemoral or transapical transcatheter aortic valve implantation. Both techniques are associated with certain access site-specific complications that require highly qualified management. The neurologic risk profile of the patients should be included in the decision-making process before transcatheter aortic valve implantation, inasmuch as neurologic events may be reduced with the transapical access.
最近，有人怀疑在高危主动脉瓣狭窄患者中，经心尖顺行瓣膜植入术后的生存率可能低于经股动脉逆行瓣膜植入术。我们分析了接受经导管主动脉瓣植入术患者的生存率，并特别关注植入的入路部位。
2007年6月至2009年2月，203例高危患者（欧洲心脏手术风险评估系统评分，22%±14%；平均年龄，81±7岁）接受了经心尖（n = 50）或经股动脉（n = 153）入路的经导管主动脉瓣植入术。仅在无法通过病变股动脉入路的患者中选择经心尖植入技术。
经股动脉植入术后30天生存率为88.8%，经心尖植入术后为91.7%（P = 0.918）。经心尖组术前脑钠肽值显著更高，外周血管、脑血管和冠心病的发生率也显著更高。30天内死亡与瓣膜相关的比例分别为25%（经心尖）和31%（经股动脉），与心脏相关的比例分别为25%和13%，非心脏相关的比例分别为50%和56%（无显著差异）。两组均发生了特定入路部位的并发症（外周血管损伤或心尖并发症），而经心尖组未发生神经系统事件（P = 0.041）。
我们的患者和入路部位选择过程中，将经股动脉技术视为首选入路，经股动脉或经心尖经导管主动脉瓣植入术的生存率和发病率相当。两种技术都与特定入路部位的并发症相关，需要高水平的管理。在经导管主动脉瓣植入术前的决策过程中应考虑患者的神经风险状况，因为经心尖入路可能会降低神经系统事件的发生。
