经导管主动脉瓣置换术在老年患者中的替代入路：来自法国和美国的合作研究。
Alternative access for transcatheter aortic valve replacement in older adults: A collaborative study from France and United States.
机构信息
Beverly and Jerome Fine Cardiac Valve Center, Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, Maryland.
Division of Cardiology, Johns Hopkins University, Baltimore, Maryland.
出版信息
Catheter Cardiovasc Interv. 2018 Nov 15;92(6):1182-1193. doi: 10.1002/ccd.27690. Epub 2018 Jul 3.
BACKGROUND
We examined the outcomes of older adults undergoing nontrans-femoral (non-TF) transcatheter aortic valve replacement (TAVR) procedures including trans-apical (TA), trans-aortic (TAo), trans-subclavian (TSub), and trans-carotid (TCa) techniques.
METHODS AND RESULTS
This is an observational study of all consecutive older patients who underwent non-TF TAVR for symptomatic severe AS with Edwards Sapien (ES), Medtronic CoreValve, ES3 or Lotus Valve at three centers in France and the United States from 04/2008 to 02/2017. Baseline characteristics and clinical outcomes were defined according to VARC-2 criteria. Of 857 patients who received TAVR, 172 (20%) had an alternative access procedure. Of these, 45 (26%) were TA, 67 (39%) TAo, 17 (10%) TSub, and 43 (25%) TCa procedures. The preference for non-TF access site was different between the two countries (US: TA 39%, TAo 52%, TSub 9%; TCa 0% vs. France: TA 9%, TAo 23%, TSub 11%, and TCa 57%, P-value < .001). Most patients who underwent TAo TAVR were older women (median age: TA 82, TAo 84, TSub 81, TCa 81, P-value = 0.043; female gender: TA 32 (27%), TAo 30 (55%), TSub 10 (41%), TCa 27 (37%), P-value = .021). The predicted Society of Thoracic Surgery risk of mortality was similar among groups (TA 7%, TAo 7%, TSub 6%, TCa 7%, P-value= .738). No differences were observed in the frequency of para-valvular leak, intra-procedural bleeding, vascular complications, conversion to open-heart surgery, or development of acute kidney injury. The highest in-hospital mortality was observed in the TAo group (TA 2%, TAo 15%, TSub 0%, TCa 2%, P-value = .014). However, hospital length of stay, one-month, and one-year mortality were similar among non-TF techniques.
CONCLUSION
Although regional differences exist in the choice of alternative access techniques, centers with high technical expertise can provide a safe alternative to traditional TF TAVR. TAo TAVR was associated with higher in-hospital mortality than other non-TF approaches, and this may have reflected patient rather than procedural factors. All alternative access techniques had similar mortality rates and clinical outcomes at one-year follow-up. Trans-carotid access is safe and feasible compared to other non-TF access techniques.
背景
我们研究了接受非经股（非 TF）经导管主动脉瓣置换术（TAVR）的老年患者的结局，包括经心尖（TA）、经主动脉（TAo）、经锁骨下（TSub）和经颈动脉（TCa）技术。
方法和结果
这是一项在法国和美国的三个中心进行的连续观察性研究，纳入了因有症状的重度主动脉瓣狭窄而接受非 TF TAVR 的所有老年患者，使用的瓣膜为 Edwards Sapien（ES）、Medtronic CoreValve、ES3 或 Lotus 瓣膜。根据 VARC-2 标准定义基线特征和临床结局。在接受 TAVR 的 857 名患者中，有 172 名（20%）采用了替代入路方法。其中，45 名（26%）采用 TA 入路，67 名（39%）采用 TAo 入路，17 名（10%）采用 TSub 入路，43 名（25%）采用 TCa 入路。两国之间非 TF 入路部位的选择偏好不同（美国：TA 39%、TAo 52%、TSub 9%、TCa 0%；法国：TA 9%、TAo 23%、TSub 11%、TCa 57%，P 值<.001）。大多数接受 TAo TAVR 的患者为老年女性（中位年龄：TA 82 岁、TAo 84 岁、TSub 81 岁、TCa 81 岁，P 值=0.043；女性：TA 32（27%）、TAo 30（55%）、TSub 10（41%）、TCa 27（37%），P 值=0.021）。各组预测的胸外科协会死亡率相似（TA 7%、TAo 7%、TSub 6%、TCa 7%，P 值=0.738）。瓣周漏、术中出血、血管并发症、转为开胸手术或急性肾损伤的发生率无差异。TAo 组的院内死亡率最高（TA 2%、TAo 15%、TSub 0%、TCa 2%，P 值=0.014）。然而，非 TF 技术的住院时间、一个月和一年的死亡率相似。
结论
尽管替代入路技术的选择存在地域差异，但技术水平较高的中心可以为传统 TF TAVR 提供安全的替代方案。与其他非 TF 方法相比，TAo TAVR 与更高的院内死亡率相关，这可能反映了患者而非手术因素。所有替代入路技术在一年随访时的死亡率和临床结局相似。与其他非 TF 入路技术相比，经颈动脉入路安全且可行。
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