经心尖经导管主动脉瓣置换术与左心室功能障碍患者的心脏死亡率增加相关：来自 PARTNER I 试验的见解。
Transapical Transcatheter Aortic Valve Replacement Is Associated With Increased Cardiac Mortality in Patients With Left Ventricular Dysfunction: Insights From the PARTNER I Trial.
机构信息
Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Baim Institute for Clinical Research, Boston, Massachusetts.
Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.
出版信息
JACC Cardiovasc Interv. 2017 Dec 11;10(23):2414-2422. doi: 10.1016/j.jcin.2017.09.023.
OBJECTIVES
The authors sought to evaluate the impact of transapical (TA) transcatheter aortic valve replacement (TAVR) on mortality, left ventricular (LV) ejection fraction (LVEF) improvement, and functional recovery in patients with LV dysfunction.
BACKGROUND
LV injury inherent to TA access for structural heart disease interventions may be particularly detrimental to the LV, functional recovery, and survival in patients with LV dysfunction.
METHODS
The study included patients enrolled within the PARTNER I (Placement of Aortic Transcatheter Valves) trial that underwent transfemoral (TF) or TA TAVR. Analyses of clinical outcomes were stratified by the presence of baseline LV dysfunction (LVEF<50%) and adjusted for the propensity of receiving TA TAVR.
RESULTS
Of 2,084 subjects, 1,057 underwent TA TAVR. TA access was associated with increased 2-year all-cause mortality in those with (adjusted hazard ratio [HR]: 1.52; 95% confidence interval [CI]: 1.12 to 2.07; p = 0.008) and without (HR: 1.38; 95% CI: 1.10 to 1.74; p = 0.006) LV dysfunction. TA TAVR portended increased 2-year cardiac mortality in subjects with LVEF<50% (HR: 1.92; 95% CI: 1.21 to 3.05; p = 0.006), but not with LVEF≥50% (HR: 1.29; 95% CI: 0.87 to 1.90; p = 0.21). In those with LVEF<50%, greater improvements in LVEF (TF-TA difference +4.04%, 95% CI: 2.39% to 5.69%; p < 0.0001) and 6-min walk distance (TF-TA difference +45.1 m, 95% CI: 18.4 to 71.9 m; p = 0.001) occurred within 30 days after TF versus TA TAVR.
CONCLUSIONS
Compared with TF TAVR, TA TAVR is associated with a disproportionate risk of cardiac mortality in patients with LV dysfunction and with delayed and less robust improvement in LV function and overall functional status. Caution is warranted when considering TA access for structural heart disease interventions, particularly in patients with LV dysfunction. (Placement of Aortic Transcatheter Valves [PARTNER]; NCT00530894).
目的
作者旨在评估经心尖（TA）经导管主动脉瓣置换术（TAVR）对左心室（LV）功能障碍患者死亡率、左心室射血分数（LVEF）改善和功能恢复的影响。
背景
结构性心脏病介入治疗的 TA 通路固有的 LV 损伤可能对 LV、功能恢复和 LV 功能障碍患者的生存特别有害。
方法
该研究纳入了 PARTNER I 试验中的患者，这些患者接受了经股（TF）或 TA TAVR。根据基线时 LV 功能障碍（LVEF<50%）对临床结局进行分析，并根据接受 TA TAVR 的倾向进行了调整。
结果
在 2084 名受试者中，有 1057 名接受了 TA TAVR。TA 通路与伴有（调整后的 HR：1.52；95%置信区间[CI]：1.12 至 2.07；p=0.008）和不伴有（HR：1.38；95% CI：1.10 至 1.74；p=0.006）LV 功能障碍患者的 2 年全因死亡率增加相关。LVEF<50%的患者接受 TA TAVR 预示着 2 年心脏死亡率增加（HR：1.92；95% CI：1.21 至 3.05；p=0.006），但 LVEF≥50%的患者则不然（HR：1.29；95% CI：0.87 至 1.90；p=0.21）。在 LVEF<50%的患者中，在接受 TF 与 TA TAVR 后 30 天内，LVEF（TF-TA 差值+4.04%，95%CI：2.39%至 5.69%；p<0.0001）和 6 分钟步行距离（TF-TA 差值+45.1 m，95%CI：18.4 至 71.9 m；p=0.001）的改善更为显著。
结论
与 TF TAVR 相比，TA TAVR 与 LV 功能障碍患者的心脏死亡率不成比例地增加相关，并导致 LV 功能和整体功能状态的改善延迟且不那么明显。在考虑结构性心脏病介入治疗的 TA 通路时应谨慎，特别是在 LV 功能障碍患者中。（主动脉瓣经导管置换术[PARTNER]；NCT00530894）。
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