Salemi Arash, De Micheli Andrea, Aftab Abdullah, Elmously Adham, Chang Regis, Wong S Chiu, Worku Berhane M
Department of Cardiothoracic Surgery, New York Presbyterian-Weill Cornell Medicine, New York, NY, USA.
Department of Cardiac Surgery, New York Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY, USA.
Interact Cardiovasc Thorac Surg. 2018 Dec 1;27(6):842-849. doi: 10.1093/icvts/ivy189.
Left atrial appendage thrombus (LAT) was an exclusion criterion in the seminal transcatheter aortic valve replacement (TAVR) trials; however, such patients do undergo TAVR in the 'real-world' setting. This study sought to analyse outcomes after TAVR in patients with LAT or spontaneous echo contrast (SEC).
All patients undergoing TAVR at our institution between March 2009 and December 2014 were prospectively analysed. The presence of LAT or SEC was determined via a retrospective chart review. Primary outcomes included 30-day and 1-year neurological events as well as mortality.
Of the 369 patients undergoing TAVR, 3.8% (14) were found to have LAT and 6.8% (25) were found to have SEC, and they were separately compared to patients who did not have LAT or SEC. Significant differences were noted between groups with regard to preoperative renal function, atrial fibrillation and ejection fraction. Preoperative atrial fibrillation was the only independent predictor of LAT. No perioperative complications were associated with the presence of LAT or SEC. Specifically, no patient with LAT or SEC experienced a postoperative neurological event. While neither LAT nor SEC was an independent predictor of 30-day mortality, LAT was an independent predictor of 1-year mortality (odds ratio 3.573, 95% confidence interval 1.040-12.28; P = 0.042).
The current study suggests that TAVR may be performed in patients with LAT and SEC with a low risk of embolic complications. While neither was an independent predictor of 30-day mortality, LAT was an independent predictor of 1-year mortality. Larger studies are needed to better study this phenomenon.
左心耳血栓（LAT）是开创性经导管主动脉瓣置换术（TAVR）试验中的一项排除标准；然而，这类患者在“现实世界”环境中确实会接受TAVR。本研究旨在分析LAT或自发回声增强（SEC）患者接受TAVR后的结局。
对2009年3月至2014年12月期间在本机构接受TAVR的所有患者进行前瞻性分析。通过回顾性病历审查确定LAT或SEC的存在。主要结局包括30天和1年的神经系统事件以及死亡率。
在369例接受TAVR的患者中，发现3.8%（14例）有LAT，6.8%（25例）有SEC，并将他们分别与没有LAT或SEC的患者进行比较。在术前肾功能、心房颤动和射血分数方面，各组之间存在显著差异。术前心房颤动是LAT的唯一独立预测因素。围手术期并发症与LAT或SEC的存在无关。具体而言，没有LAT或SEC的患者发生术后神经系统事件。虽然LAT和SEC都不是30天死亡率的独立预测因素，但LAT是1年死亡率的独立预测因素（比值比3.573，95%置信区间1.040 - 12.28；P = 0.042）。
当前研究表明，LAT和SEC患者可以接受TAVR，且栓塞并发症风险较低。虽然两者都不是30天死亡率的独立预测因素，但LAT是1年死亡率的独立预测因素。需要开展更大规模的研究以更好地研究这一现象。
