超越学习曲线：经心尖与经股动脉经导管主动脉瓣置换术治疗重度主动脉瓣狭窄
Beyond the learning curve: transapical versus transfemoral transcatheter aortic valve replacement in the treatment of severe aortic valve stenosis.
作者信息
Greason Kevin L, Suri Rakesh M, Nkomo Vuyisile T, Rihal Charanjit S, Holmes David R, Mathew Verghese
机构信息
Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
出版信息
J Card Surg. 2014 May;29(3):303-7. doi: 10.1111/jocs.12323. Epub 2014 Mar 7.
BACKGROUND
Most studies comparing transapical and transfemoral transcatheter aortic valve replacement include the center's early operative experience, which may negatively impact the outcomes. This study reports our experience beyond the learning curve with transapical and transfemoral transcatheter aortic valve replacement.
METHODS
A total of 303 patients underwent transcatheter aortic valve replacement from November 2008 through August 2013. There were 153 patients (50.5%) who received transfemoral valve replacement, 130 (42.9%) received transapical valve replacement, and 20 (6.6%) received transaortic valve replacement. We retrospectively reviewed the outcomes of the most recent 100 consecutive patients each from the transfemoral and transapical valve replacement groups.
RESULTS
The median age was 82 years (range, 54 to 95) and 110 patients (55%) were male; STS predicted risk of mortality was 8.1% (0.7 to 27.8) and was similar between groups (p = 0.256). Operative complications occurred in 49 patients (49%) in the transapical replacement group and in 43 (43%) in the transfemoral group (p = 0.478). Vascular complications occurred only in the transfemoral group and included nine patients (9%; p = 0.003). Paravalvular regurgitation at discharge of grade mild-moderate occurred in 23 patients (24.2%) in the transapical group in comparison to 40 (43.5%) in the transfemoral group (p = 0.006). Operative mortality occurred in two patients (2%) in the transapical group and in five (5%) in the transfemoral group (p = 0.445).
CONCLUSIONS
Transapical transcatheter aortic valve replacement is associated with less prevalence of vascular complications and mild-moderate paravalvular regurgitation in comparison to the transfemoral approach. Further study is necessary to determine if the transapical technique is the preferred option. doi: 10.1111/jocs.12323 (J Card Surg 2014;29:303-307).
背景
大多数比较经心尖与经股动脉经导管主动脉瓣置换术的研究纳入了中心的早期手术经验，这可能对结果产生负面影响。本研究报告了我们在经心尖与经股动脉经导管主动脉瓣置换术学习曲线之后的经验。
方法
2008年11月至2013年8月期间，共有303例患者接受了经导管主动脉瓣置换术。其中153例（50.5%）接受经股动脉瓣膜置换术，130例（42.9%）接受经心尖瓣膜置换术，20例（6.6%）接受经主动脉瓣膜置换术。我们回顾性分析了经股动脉和经心尖瓣膜置换术组最近连续100例患者的结果。
结果
患者的中位年龄为82岁（范围54至95岁），110例（55%）为男性；胸外科医师协会（STS）预测的死亡风险为8.1%（0.7至27.8），两组之间相似（p = 0.256）。经心尖置换术组49例（49%）发生手术并发症，经股动脉组43例（43%）发生手术并发症（p = 0.478）。血管并发症仅发生在经股动脉组，包括9例患者（9%；p = 0.003）。经心尖组出院时轻度至中度瓣周反流发生率为23例（24.2%），经股动脉组为40例（43.5%）（p = 0.006）。经心尖组2例患者（2%）发生手术死亡，经股动脉组5例患者（5%）发生手术死亡（p = 0.445）。
结论
与经股动脉途径相比，经心尖经导管主动脉瓣置换术的血管并发症和轻度至中度瓣周反流发生率较低。有必要进行进一步研究以确定经心尖技术是否为首选方案。doi: 10.1111/jocs.12323（《心血管外科杂志》2014年；29:303 - 307）
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