McCarthy Fenton H, Desai Nimesh D, Herrmann Howard C, Kobrin Dale, Vallabhajosyula Prashanth, Fox Zachary, Menon Rohan, Augoustides John G, Giri Jay S, Anwaruddin Saif, Li Robert H, Jagasia Dinesh H, Bavaria Joseph E, Szeto Wilson Y
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Ann Thorac Surg. 2014 Oct;98(4):1267-73. doi: 10.1016/j.athoracsur.2014.05.075. Epub 2014 Aug 19.
Recent studies have suggested that transcatheter aortic valve replacement (TAVR) may have superior outcomes compared with aortic valve replacement (AVR) for high-risk patients with significant mitral regurgitation (MR). Considering significant MR is frequently addressed with a mitral valve repair or replacement (MVR) at the time of open aortic valve replacement, this study compares TAVR and AVR/MVR in propensity-matched pairs of patients with significant MR.
We evaluated all patients presenting with moderate or greater MR undergoing either TAVR or AVR/MVR at a single institution from 2002 to 2012. Patients who underwent other cardiac operations or had preoperative endocarditis were excluded. Of 306 patients in the AVR/MVR group and 147 patients in the TAVR group, propensity analysis matched 40 pairs of patients. Standard univariate, logistic regression, and propensity matching techniques were used.
There was no significant difference between TAVR patients and AVR/MVR patients, respectively, in preoperative average age (76 ± 7.4 versus 78 ± 6.9 years, p = 0.68), ejection fraction (53 ± 15 versus 51 ± 17, p = 0.68), The Society of Thoracic Surgeons score (9.9 ± 3.1 versus 9.3 ± 3.4, p = 0.61), or 30-day mortality (7.5% versus 2.5%, p = 0.6). Postoperative MR was significantly improved for both TAVR and AVR/MVR, but AVR/MVR showed significantly greater improvement (-2.33 ± 1.23 versus -0.88 ± 0.79, p < 0.001). Among 30-day survivors, midterm survival was significantly better in the AVR/MVR group compared with the TAVR group (log rank p = 0.04).
In a propensity-matched analysis of patients with significant MR, AVR/MVR and TAVR had equivalent perioperative outcomes, but AVR/MVR had more reduction in MR and may have superior midterm survival when compared with TAVR among 30-day survivors.
近期研究表明，对于伴有严重二尖瓣反流（MR）的高危患者，经导管主动脉瓣置换术（TAVR）可能比主动脉瓣置换术（AVR）有更好的预后。鉴于在进行开放性主动脉瓣置换时，严重的MR通常通过二尖瓣修复或置换（MVR）来解决，本研究比较了倾向评分匹配的伴有严重MR患者中TAVR与AVR/MVR的情况。
我们评估了2002年至2012年在单一机构接受TAVR或AVR/MVR治疗的所有中度或更严重MR患者。排除接受其他心脏手术或术前有感染性心内膜炎的患者。在AVR/MVR组的306例患者和TAVR组的147例患者中，倾向分析匹配了40对患者。使用了标准单变量、逻辑回归和倾向匹配技术。
TAVR患者和AVR/MVR患者在术前平均年龄（76±7.4岁对78±6.9岁，p = 0.68）、射血分数（53±15对51±17，p = 0.68）、胸外科医师协会评分（9.9±3.1对9.3±3.4，p = 0.61）或30天死亡率（7.5%对2.5%，p = 0.6）方面均无显著差异。TAVR和AVR/MVR术后MR均有显著改善，但AVR/MVR改善更显著（-2.33±1.23对-0.88±0.79，p < 0.001）。在30天幸存者中，AVR/MVR组的中期生存率显著优于TAVR组（对数秩检验p = 0.04）。
在对伴有严重MR患者的倾向评分匹配分析中，AVR/MVR和TAVR围手术期结局相当，但AVR/MVR对MR的降低更多，且在30天幸存者中与TAVR相比可能有更好的中期生存率。
