Nwaejike Nnamdi, Mills Keith, Stables Rod, Field Mark
Thoracic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK.
Interventional Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK.
Interact Cardiovasc Thorac Surg. 2015 Mar;20(3):429-35. doi: 10.1093/icvts/ivu398. Epub 2014 Dec 8.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, in patients with severe aortic stenosis, can balloon valvuloplasty be used as a bridge to aortic valve replacement? Altogether 463 papers were found using the reported search, of which 11 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that balloon aortic valvuloplasty is recommended as a bridge to aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI) in patients with severe symptomatic aortic stenosis. Institutional practices, local and logistic factors can affect patient selection and management approaches to severe aortic stenosis, but having the facility to offer balloon aortic valvuloplasty (especially in the TAVI era) provides another management option for patients who would otherwise have been considered unacceptably high risk for aortic valve surgery. The increased incidence of balloon aortic valvuloplasty mirrors the increase in the use of TAVI with a sharp increase in activity from 2006. Success rates for bridging from balloon aortic valvuloplasty to definite surgical intervention are in the range 26.3-74%, with AVR or TAVI occurring within 8 weeks to 7 months. Complications from balloon aortic valvuloplasty such as aortic regurgitation (AR) can be managed successfully. Up to 40% of patients selected by balloon aortic valvuloplasty to have TAVI or AVR do not have these procedures within 2 years. While most of these patients are excluded for objective clinical reasons such as terminal disease/malignancy or other persistent contraindication, some patients refuse definitive treatment and others die while on the waiting list. Outcomes in patients bridged to AVR/TAVI are better than in patients treated with balloon aortic valvuloplasty only. Owing to the high mortality of patients in this cohort without destination therapy, delays to progression to TAVI or AVR should be avoided in selected patients. A discussion with the patient about expectations, mortality and morbidity risks with all management options will aid decision-making.
一篇心脏外科的最佳证据主题文章是按照结构化方案撰写的。所探讨的问题是，在重度主动脉瓣狭窄患者中，球囊瓣膜成形术能否用作主动脉瓣置换术的过渡治疗？通过报告的检索共找到463篇论文，其中11篇论文代表了回答该临床问题的最佳证据。这些论文的作者、期刊、发表日期和国家、所研究的患者群体、研究类型、相关结局和结果都列成了表格。我们得出结论，对于有症状的重度主动脉瓣狭窄患者，推荐球囊主动脉瓣成形术作为主动脉瓣置换术（AVR）或经导管主动脉瓣植入术（TAVI）的过渡治疗。机构惯例、当地和后勤因素会影响重度主动脉瓣狭窄患者的选择和管理方法，但具备开展球囊主动脉瓣成形术的条件（尤其是在TAVI时代）为那些原本被认为主动脉瓣手术风险高得不可接受的患者提供了另一种管理选择。球囊主动脉瓣成形术的发生率增加反映了TAVI使用的增加，自2006年起活动量急剧上升。从球囊主动脉瓣成形术过渡到确定性手术干预的成功率在26.3%至74%之间，AVR或TAVI在8周至7个月内进行。球囊主动脉瓣成形术的并发症，如主动脉瓣反流（AR），可以得到成功处理。通过球囊主动脉瓣成形术选择进行TAVI或AVR的患者中，高达40%在2年内未进行这些手术。虽然这些患者中的大多数因终末期疾病/恶性肿瘤或其他持续存在的禁忌证等客观临床原因被排除，但一些患者拒绝确定性治疗，另一些患者在等待名单上死亡。过渡到AVR/TAVI的患者的结局优于仅接受球囊主动脉瓣成形术治疗的患者。由于该队列中未接受目标治疗的患者死亡率高，应避免在选定患者中延迟进展至TAVI或AVR。与患者讨论所有管理选项的预期、死亡率和发病率风险将有助于决策。
