Ichibori Yasuhiro, Li Jun, Patel Toral, Lipinski Jerry, Ladas Thomas, Saric Petar, Kobe Daniel, Tsushima Takahiro, Peters Matthew, Patel Sandeep, Davis Angela, Markowitz Alan H, Bezerra Hiram G, Costa Marco A, Kalra Ankur, Attizzani Guilherme F
Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106 USA.
J Invasive Cardiol. 2019 Feb;31(2):E30-E36. doi: 10.25270/jic/18.00221.
Urgent transcatheter aortic valve replacement (TAVR) is associated with worse short-term outcomes compared with elective TAVR; however, little is known about long-term outcomes or the safety of the minimalist strategy in this setting. This study investigated the short-term and long-term outcomes of urgent TAVR compared with elective TAVR under a minimalist strategy (transfemoral [TF] approach with conscious sedation and no transesophageal echocardiography guidance).
After excluding 2 emergent patients requiring immediate procedures, a total of 474 consecutive patients underwent elective TF-TAVR (396 patients; 83.6%) or urgent TF-TAVR (78 patients; 16.4%). Urgent TAVR was defined as a procedure performed in the same hospitalization in patients emergently admitted due to cardiac arrest, severe acute decompensated heart failure, acute coronary syndrome, or repeated syncopal episodes.
A minimalist approach was used in 77 patients (98.7%) undergoing urgent TAVR and in 392 patients (99.0%) undergoing elective TAVR (P=.59). Urgent TAVR had similar procedure-related complications, such as stroke, myocardial infarction, bleeding or vascular complications, and in-hospital mortality compared with elective TAVR (mortality, 1.3% vs 0.8%; P=.51) with no intraprocedural cross-over from conscious sedation to general anesthesia. However, 30-day and 1-year survival rates were reduced in patients undergoing urgent TAVR. After adjustment with baseline and procedural factors, urgent TAVR remained significantly predictive of 1-year mortality (adjusted hazard ratio, 2.26; 95% confidence interval, 1.16-4.23; P=.01).
Urgent minimalist TAVR can be safely performed with favorable in-hospital outcomes, while increased 30-day and 1-year mortality rates suggest the importance of appropriate diagnosis and timely treatment of severe aortic stenosis.
与择期经导管主动脉瓣置换术（TAVR）相比，紧急TAVR的短期预后较差；然而，对于这种情况下的长期预后或极简策略的安全性知之甚少。本研究调查了在极简策略（清醒镇静下经股动脉[TF]入路且无经食管超声心动图引导）下，紧急TAVR与择期TAVR的短期和长期预后。
排除2例需要立即手术的急诊患者后，共有474例连续患者接受了择期TF-TAVR（396例患者；83.6%）或紧急TF-TAVR（78例患者；16.4%）。紧急TAVR定义为因心脏骤停、严重急性失代偿性心力衰竭、急性冠状动脉综合征或反复晕厥发作而紧急入院的患者在同一住院期间进行的手术。
77例（98.7%）接受紧急TAVR的患者和392例（99.0%）接受择期TAVR的患者采用了极简入路（P = 0.59）。与择期TAVR相比，紧急TAVR有相似的手术相关并发症，如中风、心肌梗死、出血或血管并发症以及住院死亡率（死亡率，1.3%对0.8%；P = 0.51），且术中无从清醒镇静转为全身麻醉的情况。然而，接受紧急TAVR的患者30天和1年生存率降低。在对基线和手术因素进行调整后，紧急TAVR仍然是1年死亡率的显著预测因素（调整后的风险比，2.26；95%置信区间，1.16 - 4.23；P = 0.01）。
紧急极简TAVR可以安全进行，住院结局良好，而30天和1年死亡率增加表明对严重主动脉瓣狭窄进行适当诊断和及时治疗的重要性。
