Department of Cardiac Surgery, Cardiocentro Ticino, Lugano, Switzerland.
Department of Cardiology, Swiss Cardiovascular Center, Bern University Hospital, Bern, Switzerland.
Eur J Cardiothorac Surg. 2019 Jul 1;56(1):55-63. doi: 10.1093/ejcts/ezy471.
The SwissTAVI Registry includes all consecutive patients undergoing transcatheter aortic valve implantation (TAVI) and valve-in-valve (VinV) procedures for a failed bioprosthesis in Switzerland. We report the real world, all-comers, 30-day and 1-year outcomes of patients undergoing VinV and standard TAVI procedures.
Prospectively collected data from the 2 groups (VinV and standard TAVI patients) were retrospectively analysed. In an adjusted analysis, in-hospital and 1-year outcomes of VinV patients were compared with those of patients undergoing TAVI for native aortic valve disease in the same registry. A subanalysis of VinV procedures in stenotic or regurgitant bioprosthesis was also performed.
Between February 2011 and December 2016, 4599 and 157 consecutive patients underwent TAVI in native aortic valves and VinV procedures in degenerate bioprosthesis, respectively. VinV patients were younger (78 ± 9.1 years vs 82.2 ± 6.3 years; P < 0.001) but at a higher risk for surgery (the logistic EuroSCORE: 28.48 ± 15.3% vs 18.2 ± 13.6%; P < 0.001; the Society of Thoracic Surgery (STS) score: 6.4 ± 5% vs 5.5 ± 4.3%; P = 0.008). Valve predilatation was less frequently performed during VinV procedures (22.9% vs 69.1%; P < 0.001), and the hospital stay was shorter after VinV procedure (8.46 ± 4.2 days vs 9.83 ± 6 days; P = 0.005). VinV patients showed higher predischarge transvalvular mean gradients (14.14 ± 7.9 mmHg vs 8.42 ± 5.0 mmHg; P < 0.001), smaller mean valve surface area (1.54 ± 0.7 cm2 vs 1.83 ± 0.5 cm2; P < 0.001) and a lower risk of moderate/severe paravalvular leak (1.3% vs 5%). Post-procedural kidney injury (1.3% vs 4.8%; P = 0.06) and new pacemakers for conduction abnormalities (3.3% vs 18.5%; P < 0.001) were higher after TAVI. All-cause mortality and cardiovascular mortality at 30 days were similar between the 2 groups (1.9% vs 3.8%; P = 0.242 and 1.9% vs 3.4%; P = 0.321), whereas after 1 year, all-cause mortality was lower for VinV patients (6.8% vs 13%; P = 0.035). The bioprosthetic valve size correlated inversely with postoperative gradients after VinV procedures.
VinV aortic procedures showed favourable 30-day and 1-year clinical outcomes compared with TAVI procedures for the native aortic valve disease. Despite higher transvalvular mean gradients following VinV implants, this appears not to impact the early clinical outcomes.
瑞士经导管主动脉瓣植入术（TAVI）注册研究包括了所有在瑞士因生物瓣衰败而行 TAVI 或瓣中瓣（VinV）手术的连续患者。我们报告了所有接受 VinV 和标准 TAVI 手术患者的真实世界、所有患者、30 天和 1 年的结果。
回顾性分析了两组（VinV 和标准 TAVI 患者）前瞻性收集的数据。在调整分析中，将 VinV 患者的院内和 1 年结果与同一注册研究中因原发性主动脉瓣疾病而行 TAVI 的患者进行了比较。还对狭窄或反流生物瓣的 VinV 手术进行了亚组分析。
2011 年 2 月至 2016 年 12 月，分别有 4599 名和 157 名患者因原发性主动脉瓣疾病而行 TAVI 和因生物瓣衰败而行 VinV 手术。VinV 患者年龄较小（78±9.1 岁比 82.2±6.3 岁；P<0.001），但手术风险较高（Logistic EuroSCORE：28.48±15.3%比 18.2±13.6%；P<0.001；STS 评分：6.4±5%比 5.5±4.3%；P=0.008）。VinV 手术中瓣膜预扩张的频率较低（22.9%比 69.1%；P<0.001），且 VinV 手术后住院时间较短（8.46±4.2 天比 9.83±6 天；P=0.005）。VinV 患者出院前跨瓣平均梯度较高（14.14±7.9mmHg 比 8.42±5.0mmHg；P<0.001），平均瓣口面积较小（1.54±0.7cm2 比 1.83±0.5cm2；P<0.001），且中度/重度瓣周漏的风险较低（1.3%比 5%）。TAVI 后肾损伤（1.3%比 4.8%；P=0.06）和因传导异常新植入起搏器（3.3%比 18.5%；P<0.001）的发生率较高。两组患者 30 天的全因死亡率和心血管死亡率相似（1.9%比 3.8%；P=0.242；1.9%比 3.4%；P=0.321），但 1 年后，VinV 组的全因死亡率较低（6.8%比 13%；P=0.035）。瓣中瓣术后跨瓣梯度与生物瓣的大小呈负相关。
与因原发性主动脉瓣疾病而行 TAVI 手术相比，VinV 主动脉瓣手术在 30 天和 1 年的临床结果均较好。尽管 VinV 术后跨瓣平均梯度较高，但这似乎并未影响早期临床结果。
