Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain.
Heart. 2018 May;104(10):814-820. doi: 10.1136/heartjnl-2017-312514. Epub 2018 Feb 13.
To evaluate the changes in transvalvular gradients and the incidence of valve haemodynamic deterioration (VHD) following transcatheter aortic valve replacement (TAVR), according to use of anticoagulation therapy.
This multicentre study included 2466 patients (46% men; mean age 81±7 years) who underwent TAVR with echocardiography performed at 12-month follow-up. Anticoagulation therapy was used in 707 patients (28.7%) following TAVR (AC group). A total of 663 patients received vitamin K antagonists, and 44 patients received direct oral anticoagulants. A propensity score matching analysis was performed to adjust for intergroup (AC vs non-AC post-TAVR) differences. A total of 622 patients per group were included in the propensity-matched analysis. VHD was defined as a ≥10 mm Hg increase in the mean transprosthetic gradient at follow-up (vs hospital discharge). The mean clinical follow-up was 29±18 months. The mean transvalvular gradient significantly increased at follow-up in the non-AC group within the global cohort (P=0.003), whereas it remained stable over time in the AC group (P=0.323). The incidence of VHD was significantly lower in the AC group (0.6%) compared with the non-AC group (3.7%, P<0.001), and these significant differences remained within the propensity-matched populations (0.6% vs 3.9% in the AC and non-AC groups, respectively, P<0.001). The occurrence of VHD did not associate with an increased risk of all-cause death (P=0.468), cardiovascular death (P=0.539) or stroke (P=0.170) at follow-up.
The lack of anticoagulation therapy post-TAVR was associated with significant increments in transvalvular gradients and a greater risk of VHD. VHD was subclinical in most cases and did not associate with major adverse clinical events. Future randomised trials are needed to determine if systematic anticoagulation therapy post-TAVR would reduce the incidence of VHD.
根据抗凝治疗的使用情况，评估经导管主动脉瓣置换术（TAVR）后跨瓣梯度的变化和瓣膜血流动力学恶化（VHD）的发生率。
这项多中心研究纳入了 2466 名（46%为男性；平均年龄 81±7 岁）接受 TAVR 并在 12 个月时进行超声心动图检查的患者。TAVR 后，707 名患者（28.7%）接受抗凝治疗（AC 组）。663 例患者接受维生素 K 拮抗剂，44 例患者接受直接口服抗凝剂。采用倾向评分匹配分析调整组间差异（AC 组 vs TAVR 后非 AC 组）。每组纳入 622 例患者进行倾向评分匹配分析。VHD 定义为随访时平均跨瓣梯度较出院时增加≥10mmHg。平均临床随访时间为 29±18 个月。在整个队列中，非 AC 组的跨瓣梯度在随访时显著增加（P=0.003），而 AC 组的跨瓣梯度随时间保持稳定（P=0.323）。AC 组的 VHD 发生率明显低于非 AC 组（0.6% vs 3.7%，P<0.001），这些显著差异在倾向评分匹配人群中仍然存在（AC 组和非 AC 组分别为 0.6%和 3.9%，P<0.001）。VHD 的发生与随访时全因死亡（P=0.468）、心血管死亡（P=0.539）或卒中（P=0.170）的风险增加无关。
TAVR 后缺乏抗凝治疗与跨瓣梯度显著增加和 VHD 风险增加相关。大多数情况下，VHD 为亚临床，与重大不良临床事件无关。需要进行未来的随机试验来确定 TAVR 后是否系统抗凝治疗会降低 VHD 的发生率。
