Clinic of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany.
Institute of Medical Statistics, Heinrich-Heine-University, Medical Faculty, Düsseldorf, Germany; German Diabetes Center, Leibniz Institute for Diabetes Research at Heinrich Heine University Düsseldorf, Institute for Biometry and Epidemiology, Düsseldorf, Germany.
J Thorac Cardiovasc Surg. 2018 Nov;156(5):1825-1834. doi: 10.1016/j.jtcvs.2018.04.104. Epub 2018 May 5.
Although transcatheter aortic valve implantation was the treatment of choice in inoperable and high-risk patients, the effect of transcatheter aortic valve implantation relative to conventional aortic valve replacement via ministernotomy in patients with moderate surgical risk remains unclear.
We consecutively enrolled patients who underwent minimally invasive aortic valve replacements via ministernotomy (n = 1929), transapical (n = 607), and transfemoral (n = 1273) aortic valve implantations from a single center during the period from July 2009 to July 2017. Of those, we conducted a 1:1:1 propensity score matching according to 23 preoperative risk factors.
We were able to find 177 triplets (n = 531). The median European System for Cardiac Operative Risk Evaluation II was 3.0% versus 3.4% versus 2.9%, and Society of Thoracic Surgeons Predicted Risk of Mortality was 3.2% versus 3.6% versus 3.4%, respectively. According to the Valve Academic Research Consortium 2 criteria, there were no significant periprocedural differences regarding 30-day mortality (2.3% minimally invasive aortic valve replacement vs 4.5% transapical transcatheter aortic valve implantation vs 1.7% transfemoral transcatheter aortic valve implantation, P = .34), stroke (1.1% minimally invasive aortic valve replacement vs 0.6% transapical transcatheter aortic valve implantation vs 1.7% transfemoral transcatheter aortic valve implantation, P = .84), or myocardial infarction (0.6% minimally invasive aortic valve replacement vs 0.0% transapical transcatheter aortic valve implantation vs 0.0% transfemoral transcatheter aortic valve implantation, P = .83). Both intensive care and hospitalization times were significantly longer in the transapical group. Regarding midterm survival, transapical transcatheter aortic valve implantation was associated with a tendency toward a less favorable outcome (hazard ratio, 1.48; 95% confidence interval, 0.95-2.31; P = .17) compared with minimally invasive aortic valve replacement.
In this real-world propensity score-matched minimally invasive aortic valve replacement, transapical transcatheter aortic valve implantation, transfemoral transcatheter aortic valve implantation cohort of intermediate-risk patients, early mortality was not significantly different, whereas the rates of periprocedural complications were different depending on the approach. During follow-up, there was a tendency in the transapical transcatheter aortic valve implantation group toward a less favorable survival outcome, although there was no significant difference among the 3 groups.
经导管主动脉瓣置换术已成为手术高危和极高危患者的首选治疗方法，但经胸骨下段小切口（ministernotomy）微创主动脉瓣置换术与经心尖(transapical)、经股动脉(transfemoral)途径行经导管主动脉瓣植入术（transcatheter aortic valve implantation，TAVI）在中危患者中的疗效比较仍不明确。
本研究连续纳入了 2009 年 7 月至 2017 年 7 月期间在单一中心接受微创主动脉瓣置换术（经胸骨下段小切口）（n=1929）、经心尖（n=607）和经股动脉（n=1273）途径行经导管主动脉瓣植入术的患者。根据 23 项术前风险因素，我们进行了 1:1:1 的倾向评分匹配。
我们成功匹配了 177 对患者（n=531）。欧洲心脏手术风险评估系统 II 中位数为 3.0%、3.4%和 2.9%，胸外科医生协会预测死亡率为 3.2%、3.6%和 3.4%。根据 Valve Academic Research Consortium 2 标准，30 天死亡率无显著差异（微创主动脉瓣置换术 2.3%，经心尖 TAVI 4.5%，经股动脉 TAVI 1.7%，P=0.34）、卒中发生率（微创主动脉瓣置换术 1.1%，经心尖 TAVI 0.6%，经股动脉 TAVI 1.7%，P=0.84）或心肌梗死发生率（微创主动脉瓣置换术 0.6%，经心尖 TAVI 0.0%，经股动脉 TAVI 0.0%，P=0.83）。心尖组的重症监护和住院时间明显更长。在中期生存方面，与微创主动脉瓣置换术相比，经心尖 TAVI 与较差的生存结局相关（风险比，1.48；95%置信区间，0.95-2.31；P=0.17）。
在本真实世界的倾向评分匹配微创主动脉瓣置换术、经心尖 TAVI、经股动脉 TAVI 中危患者队列中，早期死亡率无显著差异，而围手术期并发症发生率则因入路不同而不同。在随访期间，经心尖 TAVI 组的生存结局有较差的趋势，但 3 组间无显著差异。
