Seppelt Philipp Christian, Zappel Jessica, Weiler Helge, Mas-Peiró Silvia, Papadopoulos Nestoras, Walther Thomas, Zeiher Andreas Michael, Fichtlscherer Stephan, Vasa-Nicotera Mariuca
Division of Cardiology, Department of Medicine III, Goethe University, Frankfurt, Germany.
Department of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt, Frankfurt, Germany.
Catheter Cardiovasc Interv. 2020 Jan;95(1):54-64. doi: 10.1002/ccd.28319. Epub 2019 Apr 29.
The treatment of aortic stenosis has been revolutionized by transcatheter aortic valve replacement (TAVR), but the experience in patients with liver disease is limited. To address this open question, we report the outcome of patients with liver disease undergoing surgical aortic valve replacement (SAVR), transapical (TA), and transfemoral (TF) TAVR.
Between January 2004 and August 2016, 4,394 patients received aortic valve replacement at our institution. We identified 85 patients (mean follow-up 504 ± 733 days, age 73.4 ± 9.2 years, 44.7% female) with preexisting liver disease (median model of end-stage liver disease score 11, MELD-Na), who underwent TF-TAVR (n = 30), TA-TAVR (n = 13), or SAVR (n = 42). Baseline Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) and of Mortality and Morbidity (STS-PROMM) were the lowest in SAVR patients (related to TF- and TA-TAVR, both p < 0.01). Operative mortality (18.8%) was high, but no procedure showed superior short-term outcome. Need for renal replacement therapy (31.5% vs. 10.3%, p = 0.046) and reoperation occurred more frequently after SAVR than after TF-TAVR (26.6% vs. 6.7%, p = 0.021). Moreover, TF-TAVR patients had superior long-term survival compared to SAVR (log-rank test p = 0.048 and Cox regression adjusted for MELD and STS-PROM, p = 0.01, HR 0.25, CI95 0.09-0.71). Baseline MELD-Na (p = 0.013) and STS PROMM (p = 0.01) were predictors for operative mortality (ROC-analysis).
Our results indicate increased perioperative risks for patients with liver disease undergoing AVR, but favorable long-term survival after TF-TAVR compared to SAVR. For baseline risk, stratification in patients with liver disease undergoing AVR, MELD-Na and STS-PROMM are valuable predictors.
经导管主动脉瓣置换术（TAVR）彻底改变了主动脉瓣狭窄的治疗方式，但在肝病患者中的经验有限。为解决这一未决问题，我们报告了接受外科主动脉瓣置换术（SAVR）、经心尖（TA）和经股动脉（TF）TAVR的肝病患者的治疗结果。
2004年1月至2016年8月期间，4394例患者在我院接受了主动脉瓣置换术。我们确定了85例（平均随访504±733天，年龄73.4±9.2岁，44.7%为女性）患有肝病（终末期肝病模型评分中位数11，MELD-Na）的患者，他们接受了TF-TAVR（n = 30）、TA-TAVR（n = 13）或SAVR（n = 42）。胸外科医师协会预测的死亡风险（STS-PROM）和死亡与并发症风险（STS-PROMM）在SAVR患者中最低（与TF-TAVR和TA-TAVR相比，p均<0.01）。手术死亡率较高（18.8%），但没有一种手术显示出更好的短期结果。SAVR术后需要肾脏替代治疗的比例（31.5%对10.3%，p = 0.046）和再次手术的发生率高于TF-TAVR（26.6%对6.7%，p = 0.021）。此外，与SAVR相比，TF-TAVR患者具有更好的长期生存率（对数秩检验p = 0.048，Cox回归经MELD和STS-PROM校正后，p = 0.01，HR 0.25，CI95 0.09-0.71）。基线MELD-Na（p = 0.013）和STS PROMM（p = 0.01）是手术死亡率的预测指标（ROC分析）。
我们的结果表明，肝病患者接受AVR的围手术期风险增加，但与SAVR相比，TF-TAVR后的长期生存率良好。对于接受AVR的肝病患者的基线风险分层，MELD-Na和STS-PROMM是有价值的预测指标。
