Hayek Salim S, Corrigan Frank E, Condado Jose F, Lin Shuang, Howell Sharon, MacNamara James P, Spilias Nikolaos, Zheng Shuai, Keegan Patricia, Thourani Vinod, Babaliaros Vasilis C, Lerakis Stamatios
Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
Division of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia.
J Am Soc Echocardiogr. 2017 Jun;30(6):533-540. doi: 10.1016/j.echo.2017.02.002. Epub 2017 Apr 6.
Transcatheter aortic valve replacement (TAVR) is increasingly being performed in cardiac catheterization laboratories using transthoracic echocardiography (TTE) to guide valve deployment. The risk of paravalvular regurgitation (PVR) remains a concern.
We retrospectively reviewed 454 consecutive patients (mean age, 82 ± 8; 58% male) who underwent transfemoral TAVR at Emory Healthcare from 2007 to 2014. Two hundred thirty-four patients underwent TAVR in the cardiac catheterization laboratory with TTE guidance (TTE-TAVR; mean Society of Thoracic Surgeons score, 10%), while 220 patients underwent the procedure in the hybrid operating room with transesophageal echocardiography (TEE) guidance (TEE-TAVR; mean Society of Thoracic Surgeons score, 11%). All patients received an Edwards valve (SAPIEN 55%, SAPIEN-XT 45%). Clinical and procedural characteristics, echocardiographic parameters, and incidence of PVR were compared.
The incidence of at least mild PVR at discharge was comparable between TTE-TAVR and TEE-TAVR (33% vs 38%, respectively; P = .326) and did not differ when stratified by valve type. However, in the TTE-TAVR group, there was a higher incidence of second valve implantation (7% vs 2%; P = .026) and postdilation (38% vs 17%; P < .001) during the procedure. Although not independently associated with PVR at discharge (odds ratio = 1.12; 95% CI, 0.69-1.79), TTE-TAVR was associated with PVR-related events: the combined outcome of mild PVR at discharge, intraprocedural postdilation, and second valve insertion (odds ratio = 1.58; 95% CI, 1.01-2.46). There were no significant differences in PVR at 30 days, 6 months, and 1 year between the two groups.
TTE-TAVR in a high-risk group of patients was associated with increased incidence of intraprocedure PVR-related events, although it was not associated with higher rates of PVR at follow-up. Multicenter randomized trials are required to confirm the cost-effectiveness and safety of TTE-TAVR.
经导管主动脉瓣置换术（TAVR）越来越多地在心脏导管实验室中使用经胸超声心动图（TTE）来指导瓣膜植入。瓣周反流（PVR）的风险仍然是一个关注点。
我们回顾性分析了2007年至2014年在埃默里医疗中心接受经股动脉TAVR的454例连续患者（平均年龄82±8岁；58%为男性）。234例患者在心脏导管实验室接受TTE引导下的TAVR（TTE-TAVR；胸外科医师协会平均评分10%），而220例患者在杂交手术室接受经食管超声心动图（TEE）引导下的该手术（TEE-TAVR；胸外科医师协会平均评分11%）。所有患者均接受爱德华兹瓣膜（SAPIEN占55%，SAPIEN-XT占45%）。比较了临床和手术特征、超声心动图参数以及PVR的发生率。
出院时至少轻度PVR的发生率在TTE-TAVR组和TEE-TAVR组之间相当（分别为33%和38%；P = 0.326），按瓣膜类型分层时也无差异。然而，在TTE-TAVR组中，术中二次瓣膜植入（7%对2%；P = 0.026）和后扩张（38%对17%；P < 0.001）的发生率更高。虽然TTE-TAVR与出院时的PVR无独立相关性（优势比 = 1.12；95%可信区间，0.69 - 1.79），但与PVR相关事件有关：出院时轻度PVR、术中后扩张和二次瓣膜植入的联合结果（优势比 = 1.58；95%可信区间，1.01 - 2.46）。两组在30天、6个月和1年时的PVR无显著差异。
高危患者群体中的TTE-TAVR与术中PVR相关事件的发生率增加有关，尽管随访时与较高的PVR发生率无关。需要多中心随机试验来证实TTE-TAVR的成本效益和安全性。
