Medical City Dallas Hospital, Dallas, Texas, USA.
Ann Thorac Surg. 2010 Mar;89(3):758-67; discussion 767. doi: 10.1016/j.athoracsur.2009.12.033.
Previous coronary artery bypass grafting increases predicted operative risk for conventional valve replacement, according to the Society of Thoracic Surgeons risk algorithm. Additionally, the presence of coronary artery disease (CAD) has been demonstrated to increase procedural risk with conventional aortic valve replacement. Significant coexisting CAD requires preemptive percutaneous coronary intervention (PCI) in patients under consideration for transcatheter aortic valve implantation (TAVI). This study examined the impact of previous coronary artery bypass grafting or PCI on procedural outcomes and overall survival in patients having TAVI.
Two hundred and one high-risk patients were enrolled in two international feasibility studies from December 2005 to February 2008 for the treatment of aortic stenosis using TAVI. Thirty patients were excluded from analysis due to failure to successfully deploy the valve in the aortic annulus. Data were collected concurrently using an ad hoc database that included operative and long-term survival. Previous cardiovascular intervention prior to TAVI was used to identify the existence of concomitant CAD. Logistic regression along with Kaplan-Meier estimates were employed to establish the association between CAD and survival from TAVI.
Overall mortality after TAVI was significantly higher among the CAD group (35.7%) in contrast with the non-CAD patients (18.4%), p = 0.01. Logistic regression analysis found that patients who had CAD were 10.1 times more likely to die (95% confidence interval 2.1 to 174.8) within 30 days of the procedure than those who did not. Proportional hazards analysis established that the risk of dying at any point in time was 2.3 times higher among the patients with CAD (95% confidence interval 1.29 to 4.17). Kaplan-Meier survival curves demonstrate improved long-term survival among patients without CAD.
Coexisting coronary artery disease negatively impacts procedural outcomes and long-term survival in patients undergoing TAVI, and implies that risk assessment and anticipated outcomes might be inaccurate due to stratification as isolated aortic valve replacement rather than AVR+CABG. Comparison of procedural outcomes, based on operative approach without controlling for unequal distribution of CAD in the cohorts, are likely invalid.
根据胸外科医师学会风险算法，先前的冠状动脉旁路移植术会增加常规瓣膜置换术的预测手术风险。此外，已经证明冠状动脉疾病 (CAD) 的存在会增加常规主动脉瓣置换术的手术风险。在考虑行经导管主动脉瓣植入术 (TAVI) 的患者中，如果存在显著的并存 CAD，则需要预先进行经皮冠状动脉介入治疗 (PCI)。本研究探讨了先前的冠状动脉旁路移植术或 PCI 对接受 TAVI 治疗的患者的手术结果和总体生存率的影响。
2005 年 12 月至 2008 年 2 月，我们对 201 例高危患者进行了两项国际可行性研究，以使用 TAVI 治疗主动脉瓣狭窄。由于未能成功将瓣膜植入主动脉瓣环，30 例患者被排除在分析之外。使用专门的数据库同时收集数据，该数据库包括手术和长期生存数据。在 TAVI 之前进行的先前心血管介入用于确定是否存在并存 CAD。使用逻辑回归和 Kaplan-Meier 估计来确定 CAD 与 TAVI 后生存率之间的关系。
TAVI 后 CAD 组（35.7%）的总体死亡率明显高于非 CAD 患者（18.4%），p=0.01。逻辑回归分析发现，CAD 患者在手术后 30 天内死亡的可能性是无 CAD 患者的 10.1 倍（95%置信区间 2.1 至 174.8）。比例风险分析确定 CAD 患者在任何时间点死亡的风险是 CAD 患者的 2.3 倍（95%置信区间 1.29 至 4.17）。Kaplan-Meier 生存曲线表明无 CAD 的患者具有更好的长期生存率。
并存 CAD 会对接受 TAVI 的患者的手术结果和长期生存率产生负面影响，这表明由于分层为单纯主动脉瓣置换术而不是 AVR+CABG，风险评估和预期结果可能不准确。在不控制队列中 CAD 分布不均的情况下，基于手术方法比较手术结果可能是无效的。
