Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
J Thorac Cardiovasc Surg. 2018 Sep;156(3):1028-1034. doi: 10.1016/j.jtcvs.2018.03.125. Epub 2018 Apr 7.
Calcification of the ascending aorta complicates aortic valve replacement. Transcatheter aortic valve replacement is an alternative procedure in this situation, but it requires manipulation through the hostile area in the ascending aorta. We reviewed our transcatheter aortic valve insertion experience to better understand the surgical mortality risk of valve insertion in patients with extensive calcification of the ascending aorta.
We retrospectively reviewed the records of 665 consecutive patients who received transcatheter aortic valve insertion from November 2008 through December 2015. We defined a hostile ascending aorta on the basis of preoperative computed tomography scan documenting significant aortic calcification that the surgeon believed precluded safe aortic cross-clamp application. There were 36 patients (5%) who met our definition of a hostile ascending aorta (hostile aorta group) and 629 (95%) who did not (control group).
Surgical mortality occurred in 2 patients (6%) in the hostile aorta group and in 18 (3%) in the control group (P = .296). There were no strokes in the hostile aorta group, whereas there were 15 (2%) in the control group (P = 1.00). There was no difference in mortality at 3 years for patients in the hostile aorta (48.5% ± 9.0%) and control groups (35.9% ± 2.3%; P = .484). Alternative access was associated with an increased risk of mortality (hazard ratio, 1.41; 95% confidence interval, 1.09-1.82; P = .009).
Transcatheter aortic valve insertion can be performed with low procedure-related morbidity and mortality in patients with hostile calcification of the ascending aorta. Our data support a transfemoral-first paradigm in this patient population.
升主动脉钙化会使主动脉瓣置换复杂化。在这种情况下，经导管主动脉瓣置换是一种替代手术，但需要通过升主动脉的敌对区域进行操作。我们回顾了经导管主动脉瓣置入术的经验，以更好地了解在广泛升主动脉钙化的患者中，瓣膜置入的手术死亡率风险。
我们回顾性地分析了 2008 年 11 月至 2015 年 12 月期间接受经导管主动脉瓣置换术的 665 例连续患者的记录。我们根据术前计算机断层扫描（CT）扫描定义敌对性升主动脉，即外科医生认为存在主动脉夹闭应用风险的显著主动脉钙化。有 36 例（5%）患者符合我们的敌对性升主动脉定义（敌对主动脉组），629 例（95%）患者不符合（对照组）。
敌对主动脉组中有 2 例（6%）患者发生手术死亡，对照组中有 18 例（3%）（P=0.296）。敌对主动脉组无卒中发生，而对照组有 15 例（2%）（P=1.00）。敌对主动脉组和对照组患者在 3 年时的死亡率无差异（敌对主动脉组 48.5%±9.0%，对照组 35.9%±2.3%；P=0.484）。替代入路与死亡率升高相关（风险比，1.41；95%置信区间，1.09-1.82；P=0.009）。
经导管主动脉瓣置换术可在升主动脉严重钙化的患者中安全进行，且与低手术相关发病率和死亡率相关。我们的数据支持在这类患者人群中采用经股动脉入路的首选方法。
