Quebec Heart and Lung Institute, Laval University, Quebec city, QC, Canada.
St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
Eur Heart J. 2014 Oct 7;35(38):2685-96. doi: 10.1093/eurheartj/ehu175. Epub 2014 May 5.
The aim of this study was to determine the effects of advanced chronic kidney disease (CKD) on early and late outcomes after transcatheter aortic valve implantation (TAVI), and to evaluate the predictive factors of poorer outcomes in such patients.
This was a multicentre study including a total of 2075 consecutive patients who had undergone TAVI. Patients were grouped according the estimated glomerular filtration rate as follows: CKD stage 1-2 (≥60 mL/min/1.73 m(2); n = 950), stage 3 (30-59 mL/min/1.73 m(2); n = 924), stage 4 (15-29 mL/min/1.73 m(2); n = 134) and stage 5 (<15 mL/min/1.73 m² or dialysis; n = 67). Clinical outcomes were evaluated at 30-days and at follow-up (median of 15 [6-29] months) and defined according to the VARC criteria. Advanced CKD (stage 4-5) was an independent predictor of 30-day major/life-threatening bleeding (P = 0.001) and mortality (P = 0.027), and late overall, cardiovascular and non-cardiovascular mortality (P < 0.01 for all). Pre-existing atrial fibrillation (HR: 2.29, 95% CI: 1.47-3.58, P = 0.001) and dialysis therapy (HR: 1.86, 95% CI: 1.17-2.97, P = 0.009) were the predictors of mortality in advanced CKD patients, with a mortality rate as high as 71% at 1-year follow-up in those patients with these 2 factors. Advanced CKD patients who had survived at 1-year follow-up exhibited both a significant improvement in NYHA class (P < 0.001) and no deterioration in valve hemodynamics (P = NS for changes in mean gradient and valve area over time).
Advanced CKD was associated with a higher rate of early and late mortality and bleeding events following TAVI, with AF and dialysis therapy determining a higher risk in these patients. The mortality rate of patients with both factors was unacceptably high and this should be taken into account in the clinical decision-making process in this challenging group of patients.
本研究旨在探讨慢性肾脏病（CKD）晚期对经导管主动脉瓣植入术（TAVI）后早期和晚期结局的影响，并评估此类患者预后较差的预测因素。
这是一项多中心研究，共纳入 2075 例连续接受 TAVI 的患者。根据估计肾小球滤过率（eGFR）将患者分为以下几组：CKD 1-2 期（≥60 mL/min/1.73 m²；n = 950）、3 期（30-59 mL/min/1.73 m²；n = 924）、4 期（15-29 mL/min/1.73 m²；n = 134）和 5 期（<15 mL/min/1.73 m²或透析；n = 67）。根据 VARC 标准，在 30 天和随访时（中位数 15[6-29]个月）评估临床结局。晚期 CKD（4-5 期）是 30 天内主要/危及生命出血（P = 0.001）和死亡率（P = 0.027）的独立预测因素，也是晚期全因、心血管和非心血管死亡率的独立预测因素（P < 0.01）。存在既往心房颤动（HR：2.29，95%CI：1.47-3.58，P = 0.001）和透析治疗（HR：1.86，95%CI：1.17-2.97，P = 0.009）是晚期 CKD 患者死亡的预测因素，这些患者中有这两个因素的患者在 1 年随访时的死亡率高达 71%。在 1 年随访时存活的晚期 CKD 患者，纽约心脏协会（NYHA）心功能分级明显改善（P < 0.001），且瓣膜血流动力学无恶化（平均梯度和瓣口面积随时间的变化，P = NS）。
晚期 CKD 与 TAVI 后早期和晚期死亡率及出血事件的发生率较高相关，房颤和透析治疗使这些患者的风险增加。同时存在这两个因素的患者死亡率高得令人无法接受，这在对这组具有挑战性的患者进行临床决策时应予以考虑。
