高危严重主动脉瓣狭窄伴左心室射血分数降低患者行药物治疗或 TAVI 的临床转归。

Clinical outcome of high-risk patients with severe aortic stenosis and reduced left ventricular ejection fraction undergoing medical treatment or TAVI.

机构信息

Department of Cardiology, Swiss Cardiovascular Center, Bern University Hospital, Bern, Switzerland.

出版信息

PLoS One. 2011;6(11):e27556. doi: 10.1371/journal.pone.0027556. Epub 2011 Nov 10.

INTRODUCTION

Reduced left ventricular function in patients with severe symptomatic valvular aortic stenosis is associated with impaired clinical outcome in patients undergoing surgical aortic valve replacement (SAVR). Transcatheter Aortic Valve Implantation (TAVI) has been shown non-inferior to SAVR in high-risk patients with respect to mortality and may result in faster left ventricular recovery.

METHODS

We investigated clinical outcomes of high-risk patients with severe aortic stenosis undergoing medical treatment (n = 71) or TAVI (n = 256) stratified by left ventricular ejection fraction (LVEF) in a prospective single center registry.

RESULTS

Twenty-five patients (35%) among the medical cohort were found to have an LVEF≤30% (mean 26.7±4.1%) and 37 patients (14%) among the TAVI patients (mean 25.2±4.4%). Estimated peri-interventional risk as assessed by logistic EuroSCORE was significantly higher in patients with severely impaired LVEF as compared to patients with LVEF>30% (medical/TAVI 38.5±13.8%/40.6±16.4% versus medical/TAVI 22.5±10.8%/22.1±12.8%, p <0.001). In patients undergoing TAVI, there was no significant difference in the combined endpoint of death, myocardial infarction, major stroke, life-threatening bleeding, major access-site complications, valvular re-intervention, or renal failure at 30 days between the two groups (21.0% versus 27.0%, p = 0.40). After TAVI, patients with LVEF≤30% experienced a rapid improvement in LVEF (from 25±4% to 34±10% at discharge, p = 0.002) associated with improved NYHA functional class at 30 days (decrease ≥1 NYHA class in 95%). During long-term follow-up no difference in survival was observed in patients undergoing TAVI irrespective of baseline LVEF (p = 0.29), whereas there was a significantly higher mortality in medically treated patients with severely reduced LVEF (log rank p = 0.001).

CONCLUSION

TAVI in patients with severely reduced left ventricular function may be performed safely and is associated with rapid recovery of systolic left ventricular function and heart failure symptoms.

简介

严重症状性主动脉瓣狭窄患者的左心室功能降低与接受主动脉瓣置换术（SAVR）的患者临床结局受损相关。经导管主动脉瓣植入术（TAVI）在死亡率方面已被证明不劣于高危患者的 SAVR，并且可能导致更快的左心室恢复。

方法

我们在一项前瞻性单中心登记研究中，根据左心室射血分数（LVEF）对接受药物治疗（n=71）或 TAVI（n=256）的高危严重主动脉瓣狭窄患者的临床结局进行分层。

结果

药物治疗组中有 25 名患者（35%）的 LVEF≤30%（平均 26.7±4.1%），TAVI 患者中有 37 名患者（14%）的 LVEF≤30%（平均 25.2±4.4%）。用逻辑 EuroSCORE 评估的围手术期估计风险在严重 LVEF 受损的患者中明显高于 LVEF＞30%的患者（药物治疗/TAVI 38.5±13.8%/40.6±16.4%比药物治疗/TAVI 22.5±10.8%/22.1±12.8%，p＜0.001）。在接受 TAVI 的患者中，两组在 30 天的死亡、心肌梗死、大卒中、危及生命的出血、主要入路并发症、瓣膜再介入或肾功能衰竭的联合终点方面无显著差异（21.0%比 27.0%，p=0.40）。TAVI 后，LVEF≤30%的患者 LVEF 迅速改善（从 25±4%到出院时的 34±10%，p=0.002），30 天时 NYHA 心功能分级改善（95%的患者 NYHA 心功能分级至少改善 1 级）。在长期随访中，无论基线 LVEF 如何，接受 TAVI 的患者的生存率均无差异（p=0.29），而接受药物治疗且 LVEF 严重降低的患者死亡率明显更高（log rank p=0.001）。