经导管主动脉瓣置换术改善了既往冠状动脉旁路移植术后单纯主动脉瓣置换术的短期预后，但中期预后相似。
Transcatheter aortic valve replacement has improved short-term but similar midterm outcomes in isolated aortic valve replacement after prior coronary artery bypass grafting.
作者信息
Nguyen Tom C, Babaliaros Vasilis C, Razavi Seyed Amirhossein, Kilgo Patrick D, Devireddy Chandan M, Leshnower Brad G, Mavromatis Kreton, Guyton Robert A, Kanitkar Mihir, Lerakis Stam, Merlino John, Chen Edward P, Thourani Vinod H
机构信息
Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Texas.
Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
出版信息
Ann Thorac Surg. 2014 Oct;98(4):1316-24. doi: 10.1016/j.athoracsur.2014.05.081. Epub 2014 Aug 20.
BACKGROUND
An increasing number of patients with prior coronary artery bypass grafting (CABG) now present with severe aortic stenosis. The proposed benefit of surgical (SAVR) vs transcatheter aortic valve replacement (TAVR) is unknown. The objective of this study was to compare short-term and midterm outcomes of patients undergoing isolated SAVR vs TAVR in those with prior CABG.
METHODS
A retrospective analysis was performed of 255 patients who underwent isolated SAVR after prior CABG from January 2002 to February 2013 at Emory University. Outcomes of 148 patients undergoing SAVR (2002 to 2013) and 107 undergoing TAVR (2007 to 2013) were compared using multivariable logistic regression and analysis of variance techniques, adjusting for The Society of Thoracic Surgeons (STS) risk score. Kaplan-Meier plots were used to determine survival rates, and midterm survival between groups was compared using the Cox proportional hazards model.
RESULTS
TAVR patients were older (79.8 ± 7.9 years vs 72.5 ± 8.8 years, p < 0.001) but were gender equivalent (female: 24% vs 22%, p = 0.61). The preoperative ejection fraction was similar between groups (TAVR: 0.433 ± 0.131 vs SAVR: 0.469 ± 0.148%, p = 0.60). The TAVR group had a significantly higher the STS risk scores (11.8% vs 7.1%, p < 0.001). All-cause 30-day mortality was 1.9% for TAVR and 4.1% for SAVR (p = 0.32), a result that marginally favors TAVR after risk adjustment (adjusted odds ratio, 0.19; p = 0.07). Postoperative morbidity and resource utilization was significantly higher in the SAVR patients. Midterm survival was similar between the two groups after adjustment (adjusted hazard ratio, 0.78, p = 0.46).
CONCLUSIONS
Excellent outcomes can be achieved in SAVR or TAVR after prior CABG. Although TAVR improves short-term outcomes and resource utilization compared with SAVR, midterm mortality outcomes are similar.
背景
越来越多曾接受冠状动脉旁路移植术（CABG）的患者现出现严重主动脉瓣狭窄。外科主动脉瓣置换术（SAVR）与经导管主动脉瓣置换术（TAVR）相比的潜在获益尚不清楚。本研究的目的是比较在曾接受CABG的患者中，接受单纯SAVR与TAVR患者的短期和中期结局。
方法
对2002年1月至2013年2月在埃默里大学接受单纯SAVR的255例曾接受CABG的患者进行回顾性分析。使用多变量逻辑回归和方差分析技术，比较148例接受SAVR（2002年至2013年）和107例接受TAVR（2007年至2013年）患者的结局，并根据胸外科医师协会（STS）风险评分进行调整。采用Kaplan-Meier曲线确定生存率，并使用Cox比例风险模型比较两组之间的中期生存率。
结果
TAVR组患者年龄更大（79.8±7.9岁 vs 72.5±8.8岁，p<0.001），但性别相当（女性：24% vs 22%，p = 0.61）。两组术前射血分数相似（TAVR组：0.433±0.131 vs SAVR组：0.469±0.148%，p = 0.60）。TAVR组的STS风险评分显著更高（11.8% vs 7.1%，p<0.001）。TAVR组30天全因死亡率为1.9%，SAVR组为4.1%（p = 0.32），风险调整后这一结果略微有利于TAVR（调整后的优势比为0.19；p = 0.07）。SAVR患者术后发病率和资源利用率显著更高。调整后两组中期生存率相似（调整后的风险比为0.78，p = 0.46）。
结论
曾接受CABG后行SAVR或TAVR均可取得良好结局。虽然与SAVR相比，TAVR改善了短期结局和资源利用率，但中期死亡率结局相似。
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