Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina; Division of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, North Carolina.
Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
JACC Cardiovasc Interv. 2019 Mar 25;12(6):569-578. doi: 10.1016/j.jcin.2018.12.012.
The aim of this study was to compare 1-year outcomes following transcatheter mitral valve (MV) repair in patients with and without atrial fibrillation (AF).
The development of AF in degenerative mitral regurgitation (MR) is considered a sign of MR progression and is associated with adverse clinical events. However, the impact of AF in patients undergoing transcatheter MV repair remains uncertain.
The TVT (Transcatheter Valve Therapy) Registry was used to identify patients undergoing transcatheter MV repair with the MitraClip between November 2013 and June 2016. Using Centers for Medicare and Medicaid Services-linked data, the 1-year rate of death, heart failure hospitalization, stroke, and bleeding following transcatheter MV repair was compared in patients with and without AF. Outcomes were analyzed using multivariate Cox regression modeling.
A total of 5,613 patients underwent commercial transcatheter MV repair in the United States during the study period, including 3,555 (63%) with pre-existing AF. Compared with patients without AF, patients with AF were older, were more likely to be male and Caucasian, had more comorbidities, and had higher Society of Thoracic Surgeons Predicted Risk of Mortality scores (median 7% vs. 5%; p < 0.0001). Acute procedural success (post-procedural ≥2+ MR, 37.4% vs. 35.0%; p = 0.20) and in-hospital mortality were similar, but length of hospital stay was longer for patients with AF (mean 4.91 days vs. 4.37 days; p = 0.0004). A total of 3,261 patients were linked to Centers for Medicare and Medicaid Services claims data. After adjustment, patients with AF had a higher 1-year rate of death or HF (hazard ratio [HR]: 1.27; 95% confidence interval [CI]: 1.11 to 1.44; p < 0.001). Patients with AF had higher rates of mortality (HR: 1.44; 95% CI: 1.22 to 1.70; p < 0.001), HF hospitalization (HR: 1.17; 95% CI: 1.00 to 1.36; p = 0.05), stroke (HR: 1.63; 95% CI: 1.01 to 2.64; p = 0.047), and bleeding (HR: 1.34; 95% CI: 1.10 to 1.64; p = 0.004) at 1 year as well. Among those with AF, the risk for stroke was lower (HR: 0.55; 95% CI: 0.32 to 0.93; p = 0.026) among those on anticoagulation.
In patients undergoing transcatheter MV repair, AF is common and is associated with worse clinical outcomes at 1 year despite similar acute procedural success. Further study is needed to investigate if early treatment of MR reduces the future risk for developing AF and to identify therapies that improve outcomes in these patients.
本研究旨在比较合并和不合并心房颤动（AF）的患者行经导管二尖瓣（MV）修复术后 1 年的结局。
退行性二尖瓣反流（MR）患者中 AF 的发生被认为是 MR 进展的标志，并与不良临床事件相关。然而，经导管 MV 修复术患者中 AF 的影响仍不确定。
使用 TVT（经导管瓣膜治疗）登记处，确定 2013 年 11 月至 2016 年 6 月期间接受 MitraClip 治疗的行经导管 MV 修复术的患者。利用医疗保险和医疗补助服务中心（Centers for Medicare and Medicaid Services）相关数据，比较了有和无 AF 的患者行经导管 MV 修复术后 1 年的死亡率、心力衰竭住院率、卒中和出血发生率。采用多变量 Cox 回归模型进行结果分析。
在研究期间，共有 5613 名患者在美国接受了商业性经导管 MV 修复术，其中 3555 名（63%）患者存在术前 AF。与无 AF 的患者相比，AF 患者年龄更大，更可能为男性和白种人，合并症更多，胸外科医生预测死亡率评分更高（中位数 7% vs. 5%；p<0.0001）。急性手术成功率（术后≥2+MR，37.4% vs. 35.0%；p=0.20）和院内死亡率相似，但 AF 患者的住院时间更长（平均 4.91 天 vs. 4.37 天；p=0.0004）。共有 3261 名患者与医疗保险和医疗补助服务中心索赔数据相关联。调整后，AF 患者 1 年死亡率或心力衰竭（HF）发生率更高（风险比[HR]：1.27；95%置信区间[CI]：1.11 至 1.44；p<0.001）。AF 患者死亡率（HR：1.44；95% CI：1.22 至 1.70；p<0.001）、HF 住院率（HR：1.17；95% CI：1.00 至 1.36；p=0.05）、卒中和出血发生率更高（HR：1.63；95% CI：1.01 至 2.64；p=0.047）。在 AF 患者中，抗凝治疗的卒中风险较低（HR：0.55；95% CI：0.32 至 0.93；p=0.026）。
在接受经导管 MV 修复术的患者中，尽管急性手术成功率相似，但 AF 很常见，并与 1 年时的临床结局更差相关。需要进一步研究以确定早期治疗 MR 是否会降低未来发生 AF 的风险，并确定改善这些患者结局的治疗方法。
