Hirji Sameer A, Ramirez-Del Val Fernando, Kolkailah Ahmed A, Ejiofor Julius I, McGurk Siobhan, Chowdhury Ritam, Lee Jiyae, Shah Pinak B, Sobieszczyk Piotr S, Aranki Sary F, Pelletier Marc P, Shekar Prem S, Kaneko Tsuyoshi
Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Center for Surgery and Public Health (CSPH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Ann Cardiothorac Surg. 2017 Sep;6(5):453-462. doi: 10.21037/acs.2017.08.01.
Contemporary options for aortic valve replacement (AVR) include transcatheter and surgical approaches (TAVR and SAVR). As evidence accrues for TAVR in high and intermediate risk patients, some clinicians advocate that all patients aged over 80 years should only receive TAVR. Our aim was to investigate the utility of SAVR and minimally invasive AVR (mAVR) among octogenarians in the current era of TAVR.
From 2002 to 2015, 1,028 octogenarians underwent isolated AVR; 306 TAVR and 722 SAVR, of which 378 patients underwent mAVR. Logistic regression and Cox modeling were used to evaluate overall operative mortality and mid-term survival, respectively. Patients were stratified based on procedural approaches (mAVR or full sternotomy for SAVR, and transfemoral or alternate access for TAVR). Median follow-up was 35 [interquartile range (IQR) 14-65] months.
Compared to SAVR patients, TAVR patients were relatively older (86.2 versus 84.2 years) with co-morbidities such as chronic kidney disease (CKD), diabetes mellitus (DM), cerebrovascular disease (CVD), and prior myocardial infarction (MI), all P<0.05. The mean STS-PROM for the TAVR group was statistically higher, 6.81 versus 5.58 for the SAVR group (P<0.001). The median in-hospital LOS was statistically higher for the SAVR group (P<0.05). Cox proportional hazard modeling, adjusted for temporal differences in procedure and patient selection, identified age, New York Heart Association (NYHA) class III/IV, preoperative creatinine, severe chronic lung disease, prior cardiac surgery as significant predictors of decreased survival (all P<0.05), while type of intervention (approach) was non-contributory. Adjusted operative mortality stratified by procedure approaches was similar between full sternotomy SAVR and mAVR, and between alternative access and transfemoral TAVR.
After adjusting for confounders, TAVR (regardless of approach), SAVR, and mAVR had comparable operative mortality and mid-term survival. Treatment decisions should be individualized with consensus from a multi-disciplinary heart team, taking into account patient co morbidities, frailty, and quality of life. We believe certain patient groups will still benefit from SAVR even in this elderly population.
当代主动脉瓣置换术（AVR）的选择包括经导管和外科手术方法（经导管主动脉瓣置换术和外科主动脉瓣置换术）。随着经导管主动脉瓣置换术在高危和中危患者中的证据不断积累，一些临床医生主张所有80岁以上的患者都应仅接受经导管主动脉瓣置换术。我们的目的是在当前经导管主动脉瓣置换术时代，研究80岁以上老人中外科主动脉瓣置换术和微创主动脉瓣置换术（mAVR）的效用。
2002年至2015年，1028名80岁以上老人接受了单纯主动脉瓣置换术；306例行经导管主动脉瓣置换术，722例行外科主动脉瓣置换术，其中378例患者接受了微创主动脉瓣置换术。分别采用逻辑回归和Cox模型评估总体手术死亡率和中期生存率。根据手术方法（微创主动脉瓣置换术或外科主动脉瓣置换术的全胸骨切开术，以及经股动脉或其他入路的经导管主动脉瓣置换术）对患者进行分层。中位随访时间为35[四分位间距（IQR）14 - 65]个月。
与外科主动脉瓣置换术患者相比，经导管主动脉瓣置换术患者年龄相对较大（86.2岁对84.2岁），伴有慢性肾病（CKD）、糖尿病（DM）、脑血管疾病（CVD）和既往心肌梗死（MI）等合并症，所有P<0.05。经导管主动脉瓣置换术组的平均胸外科医师协会预测死亡率（STS-PROM）在统计学上更高，经导管主动脉瓣置换术组为6.81，外科主动脉瓣置换术组为5.58（P<0.001）。外科主动脉瓣置换术组的中位住院时间在统计学上更高（P<0.05）。Cox比例风险模型在对手术和患者选择的时间差异进行调整后，确定年龄、纽约心脏协会（NYHA）III/IV级、术前肌酐、严重慢性肺病、既往心脏手术是生存率降低的显著预测因素（所有P<0.05），而干预类型（方法）无显著影响。按手术方法分层的调整后手术死亡率在全胸骨切开术的外科主动脉瓣置换术和微创主动脉瓣置换术之间，以及其他入路和经股动脉经导管主动脉瓣置换术之间相似。
在对混杂因素进行调整后，经导管主动脉瓣置换术（无论采用何种方法）、外科主动脉瓣置换术和微创主动脉瓣置换术的手术死亡率和中期生存率相当。治疗决策应个体化，由多学科心脏团队达成共识，同时考虑患者的合并症、虚弱程度和生活质量。我们认为，即使在这个老年人群中，某些患者群体仍将从外科主动脉瓣置换术中获益。
