Muneretto Claudio, Bisleri Gianluigi, Moggi Annalisa, Di Bacco Lorenzo, Tespili Maurizio, Repossini Alberto, Rambaldini Manfredo
Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy.
Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy
Interact Cardiovasc Thorac Surg. 2015 Jan;20(1):90-5. doi: 10.1093/icvts/ivu340. Epub 2014 Oct 15.
Although the use of transcatheter aortic valve replacement (TAVR) has recently become an attractive strategy in extremely high-risk patients undergoing aortic valve replacement (AVR), the most appropriate treatment option in patients with an intermediate- to high-risk profile with conventional surgery (sAVR), TAVR or novel options, such as sutureless valves, has been widely debated.
One hundred and sixty-three consecutive patients with intermediate to high risk were prospectively enrolled and selected to undergo sAVR (Group 1: G1, n = 55), sutureless valve implantation (Group 2: G2, n = 53) or TAVR (Group 3: G3, n = 55) following a multidisciplinary evaluation including frailty, anatomy and degree of atherosclerotic disease of the aorta/peripheral vessels. The mean logistic EuroSCORE (G1 = 21.3 ± 12.7 vs G2 = 16 ± 11.7 vs G3 = 20.4 ± 12.7, P = 0.06) and preoperative demographics, such as age, gender and left ventricular ejection fraction, were similar: of note, chronic obstructive pulmonary disease was more frequent in TAVI patients (G1 = 27.2% vs G2 = 15.1% vs G3 = 47%; P <0.01). The Perceval S sutureless valve was used in Group 2, whereas TAVR was performed with a Corevalve prosthesis.
Post-procedural pacemaker implantation (G1 = 1.8% vs G2 = 2% vs G3 = 25.5%, P <0.001) and peripheral vascular complications (G1 = 0% vs G2 = 0% vs G3 = 14.5%, P <0.001) occurred more frequently in patients undergoing TAVR. Hospital mortality was similar among the groups (G1 = 0% vs G2 = 0% vs G3 = 1.8%, P = NS). At the 24-month follow-up, overall survival free from major adverse cardiac and cerebrovascular events and prosthetic regurgitation was better in patients who had undergone sAVR and sutureless valves than those who had undergone TAVR (G1 = 95.2 ± 3.3% vs G2 = 91.6 ± 3.8% vs G3 = 70.5 ± 7.6%; P = 0.015).
This preliminary study suggests that the use of TAVR in patients with an intermediate- to high-risk profile is associated with a higher rate of perioperative complications and decreased survival at the 24-month follow-up compared with the use of conventional surgery or sutureless valves.
尽管经导管主动脉瓣置换术（TAVR）最近已成为接受主动脉瓣置换术（AVR）的极高风险患者的一种有吸引力的策略，但对于具有中高风险特征的患者，最合适的治疗选择是传统手术（sAVR）、TAVR还是新型选择（如无缝合瓣膜），一直存在广泛争议。
连续纳入163例中高风险患者，经过包括虚弱程度、解剖结构以及主动脉/外周血管动脉粥样硬化疾病程度的多学科评估后，前瞻性地选择他们接受sAVR（第1组：G1，n = 55）、无缝合瓣膜植入（第2组：G2，n = 53）或TAVR（第3组：G3，n = 55）。平均逻辑欧洲心脏手术风险评估系统（EuroSCORE）（G1 = 21.3±12.7 vs G2 = 16±11.7 vs G3 = 20.4±12.7，P = 0.06）以及术前人口统计学特征，如年龄、性别和左心室射血分数，均相似：值得注意的是，慢性阻塞性肺疾病在TAVI患者中更为常见（G1 = 27.2% vs G2 = 15.1% vs G3 = 47%；P <0.01）。第2组使用Perceval S无缝合瓣膜，而TAVR使用Corevalve假体进行。
TAVR患者术后起搏器植入（G1 = 1.8% vs G2 = 2% vs G3 = 25.5%，P <0.001）和外周血管并发症（G1 = 0% vs G2 = 0% vs G3 = 14.5%，P <0.001）的发生率更高。各组间医院死亡率相似（G1 = 0% vs G2 = 0% vs G3 = 1.8%，P = 无显著性差异）。在24个月的随访中，接受sAVR和无缝合瓣膜治疗的患者无重大不良心脑血管事件和人工瓣膜反流的总体生存率优于接受TAVR的患者（G1 = 95.2±3.3% vs G2 = 91.6±3.8% vs G3 = 70.5±7.6%；P = 0.015）。
这项初步研究表明，与传统手术或无缝合瓣膜相比，在中高风险患者中使用TAVR与围手术期并发症发生率较高以及24个月随访时生存率降低相关。
