Department of Medicine, Division of Cardiology, Sub-division of Interventional Cardiology, New York-Presbyterian Hospital, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York; Department of Medicine, Division of Cardiology, Rabin Medical Center, Petah Tikva, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Department of Medicine, Division of Cardiology, Sub-division of Interventional Cardiology, New York-Presbyterian Hospital, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York.
Ann Thorac Surg. 2018 Apr;105(4):1215-1222. doi: 10.1016/j.athoracsur.2017.10.055. Epub 2018 Feb 15.
Transcatheter aortic valve replacement (TAVR) provides therapy for patients with severe aortic stenosis at extreme, high, or intermediate surgical risk. Transfemoral access has been the preferred access route; however, this approach is not suitable for many TAVR candidates. A suprasternal approach may allow for earlier ambulation and shorter hospital stay as compared with other, nontransfemoral approaches.
A total of 11 patients with unsuitable transfemoral access underwent suprasternal TAVR. Propensity matching was used to compare suprasternal patients to patients undergoing transaortic, transapical, and trans-subclavian TAVR.
Groups were well matched for baseline characteristics. A self-expanding valve device was used in 6 (54.5%) and a balloon-expandable valve in 5 (45.5%) of the 11 patients treated by the suprasternal route. Suprasternal and trans-subclavian patients were able to ambulate earlier than patients treated by the transaortic route, a median 1.6 days (interquartile range [IQR]: 0.9 to 1.8), 1.6 days (IQR: 0.9 to 2.7), and 3.9 days (IQR: 1.9 to 4.5) after the procedure for suprasternal, trans-subclavian, and transaortic patients, respectively (p = 0.001). Length of hospitalization was shorter for patients treated by suprasternal or trans-subclavian access in comparison with patients treated by the transaortic or transapical approach: median 4 days (IQR: 3 to 8) and 4 days (IQR: 4 to 8) versus 8 days (IQR: 6 to 14) and 6 days (IQR: 7 to 11) for suprasternal and trans-subclavian versus transaortic and transapical, respectively (p = 0.01).
Suprasternal and trans-subclavian access are associated with earlier ambulation and shorter hospitalization than other nontransfemoral TAVR routes, without an increase in complications. Further study is required to determine if suprasternal is the alternative access of choice for TAVR patients with poor transfemoral vasculature.
经导管主动脉瓣置换术（TAVR）为极高危、高危或中危的严重主动脉瓣狭窄患者提供了治疗方法。经股动脉入路一直是首选的入路方式，但该方法并不适用于许多 TAVR 候选者。胸骨上入路与其他非经股动脉入路相比，可能允许更早的活动和更短的住院时间。
共有 11 名经股动脉入路不合适的患者接受了胸骨上 TAVR。采用倾向评分匹配法比较胸骨上组与经主动脉瓣、经心尖和经锁骨下入路 TAVR 的患者。
两组基线特征匹配良好。6 例（54.5%）患者采用自膨式瓣膜装置，5 例（45.5%）患者采用球囊扩张瓣膜。胸骨上和经锁骨下入路患者较经主动脉瓣入路患者更早能下地活动，分别为术后中位数 1.6 天（四分位距 [IQR]：0.9 至 1.8）、1.6 天（IQR：0.9 至 2.7）和 3.9 天（IQR：1.9 至 4.5）（p=0.001）。与经主动脉瓣或经心尖入路相比，胸骨上或经锁骨下入路患者的住院时间更短：中位数 4 天（IQR：3 至 8）和 4 天（IQR：4 至 8）与胸骨上和经锁骨下入路分别为 8 天（IQR：6 至 14）和 6 天（IQR：7 至 11）（p=0.01）。
与其他非经股动脉 TAVR 途径相比，胸骨上和经锁骨下入路与更早的活动和更短的住院时间相关，而不增加并发症。需要进一步研究以确定胸骨上入路是否是股动脉血管条件差的 TAVR 患者的替代入路选择。
