Ad Niv, Holmes Sari D, Shuman Deborah J, Rongione Anthony J, Massimiano Paul S, Speir Alan M, Pritchard Graciela, Yazdani Shahram, Raybuck Bryan D
Inova Heart and Vascular Institute, Falls Church, Virginia.
Inova Heart and Vascular Institute, Falls Church, Virginia.
Semin Thorac Cardiovasc Surg. 2016;28(2):353-360. doi: 10.1053/j.semtcvs.2016.02.005. Epub 2016 Feb 15.
We assessed the effect of a transcatheter aortic valve replacement (TAVR) program and Heart Team concept on our approach to severe isolated symptomatic aortic stenosis (AS) with regard to surgical practice, patient selection, perioperative outcomes, 1-year survival, and AVR volume. TAVR program began in August 2011. Patients having isolated surgical AVR between January 2008 and August 2011, when the program began (n = 282, 42 months), were compared with those after the program began until February 2015 (n = 344, surgical AVR and n = 126, TAVR, 42 months). Isolated surgical AVR accounted for 21% of all valve procedures (isolated and concomitant) before and after the TAVR program. However, the volume of all isolated AVR (surgical and transcatheter) increased to 27% of all valve procedures (isolated and concomitant) after the TAVR program implementation. Mean Society Of Thoracic Surgeons (STS)-predicted mortality risk was similar among patients who had surgical AVR pre-TAVR and post-TAVR implementation (2.3% vs 2.1%, P = 0.227), but addition of patients who had TAVR (STS risk = 7.1%) increased STS-predicted risk for all isolated AVR (surgical and transcatheter) procedures (2.3% vs 3.4%, P < 0.001). A similar trend was found for age, including a slight decrease in octogenarians for surgical AVR post-TAVR (18% vs 13%, P = 0.084). Operative mortality for isolated surgical AVR was similar in pre-TAVR and post-TAVR (2.1% vs 1.8%, P = 0.798), as were observed/expected (O/E) ratios (0.91 vs 0.82). For all isolated AVR, O/E ratio was 0.91 pre-TAVR and 0.82 post-TAVR (n = 470), including O/E = 0.79 for patients who had TAVR. No changes were found in proportion of isolated surgical AVR cases or patient risk and outcomes after introduction of TAVR program and Heart Team. However, volume of patients with severe AS treated increased significantly post-TAVR. Our results reflect growing awareness of TAVR availability and accompanying increases in patients referred to our Heart Team for AS treatment.
我们评估了经导管主动脉瓣置换术（TAVR）项目和心脏团队理念对我们处理严重孤立性症状性主动脉瓣狭窄（AS）的方法在外科手术实践、患者选择、围手术期结局、1年生存率和主动脉瓣置换术数量方面的影响。TAVR项目于2011年8月开始。将2008年1月至2011年8月该项目开始时（n = 282，42个月）接受孤立性外科主动脉瓣置换术的患者与项目开始后至2015年2月（n = 344，外科主动脉瓣置换术；n = 126，TAVR，42个月）的患者进行比较。在TAVR项目前后，孤立性外科主动脉瓣置换术占所有瓣膜手术（孤立性和合并性）的21%。然而，在实施TAVR项目后，所有孤立性主动脉瓣置换术（外科和经导管）的数量增加到所有瓣膜手术（孤立性和合并性）的27%。胸外科医师协会（STS）预测的平均死亡风险在TAVR术前和术后接受外科主动脉瓣置换术的患者中相似（2.3%对2.1%，P = 0.227），但加入接受TAVR的患者（STS风险 = 7.1%）后，所有孤立性主动脉瓣置换术（外科和经导管）手术的STS预测风险增加（2.3%对3.4%，P < 0.001）。年龄方面也发现了类似趋势，包括TAVR术后接受外科主动脉瓣置换术的八旬老人比例略有下降（18%对13%，P = 0.084）。孤立性外科主动脉瓣置换术的手术死亡率在TAVR术前和术后相似（2.1%对1.8%，P = 0.798），观察/预期（O/E）比值也相似（0.91对0.82）。对于所有孤立性主动脉瓣置换术，TAVR术前O/E比值为0.91，术后为0.82（n = 470），其中接受TAVR的患者O/E = 0.79。在引入TAVR项目和心脏团队后，孤立性外科主动脉瓣置换术病例的比例、患者风险和结局均未发现变化。然而，TAVR术后治疗的严重AS患者数量显著增加。我们的结果反映了对TAVR可及性的认识不断提高，以及转诊至我们心脏团队接受AS治疗的患者随之增加。
