Department of Cardiovascular Surgery, Mayo Clinic Rochester, Minnesota.
Department of Cardiovascular Surgery, Mayo Clinic Rochester, Minnesota.
Ann Thorac Surg. 2019 Aug;108(2):424-430. doi: 10.1016/j.athoracsur.2019.03.084. Epub 2019 May 2.
This study directly compared outcomes of transcatheter aortic valve-in-valve insertion (TAVI-in-valve) with repeat surgical aortic valve replacement (SAVR) for failing stented aortic biological prostheses.
We retrospectively reviewed the records of 350 consecutive patients who underwent repeat aortic valve replacement of failing stented aortic biological valve prostheses at our institution between November 2008 and May 2018. Operations included TAVI-in-valve in 90 patients (26%) and repeat SAVR in 260 patients (74%).
Patient age was 74 years (interquartile range [IQR], 65-79 years), 100 patients (29%) were women, aortic valve internal diameter was 21 mm (IQR, 19-22), Society of Thoracic Surgeons predicted operative mortality risk was 4.1% (IQR, 2.3%-6.8%), and the interval to repeat operation was 7 years (IQR, 5-11 years). A 23-mm or smaller valve was inserted in 57 patients (63%) in the TAVI-in-valve group and in 170 (65%) in the SAVR group (P = .725). Aortic root enlargement was done in 45 patients (17%) in the SAVR group. Procedure-related complications were less in the TAVI-in-valve group (23% vs SAVR 59%, P < .001), whereas operative mortality was similar in both groups (2.2% vs SAVR 2.6%, P = 1.000). Severe patient-to-prosthesis mismatch was more common after TAVI-in-valve (44% vs SAVR 12%, P < .001). Median duration of follow-up was 2.1 years (IQR, 1.2-4.2 years). Multivariable analysis demonstrated no association between TAVI-in-valve and intermediate-term mortality (hazard ratio, 1.18; 95% confidence interval, 0.62 to 2.22; P = .612).
TAVI-in-valve and repeat SAVR can be done with similar operative and intermediate-term mortality. SAVR results in better hemodynamic function and thus appears the preferred option.
本研究直接比较了经导管主动脉瓣置入术（TAVI-in-valve）与再次行主动脉瓣置换术（SAVR）治疗主动脉瓣支架生物瓣衰败的效果。
我们回顾性分析了 2008 年 11 月至 2018 年 5 月在我院因主动脉瓣支架生物瓣衰败再次行主动脉瓣置换术的 350 例连续患者的记录。手术包括 TAVI-in-valve 90 例（26%）和再次 SAVR 260 例（74%）。
患者年龄为 74 岁（四分位距[IQR]，65-79 岁），100 例（29%）为女性，主动脉瓣内径为 21mm（IQR，19-22mm），胸外科医师协会预测的手术死亡率为 4.1%（IQR，2.3%-6.8%），再次手术的间隔时间为 7 年（IQR，5-11 年）。在 TAVI-in-valve 组，57 例（63%）患者植入 23mm 或更小的瓣膜，在 SAVR 组，170 例（65%）患者植入 23mm 或更小的瓣膜（P=0.725）。在 SAVR 组，45 例（17%）患者行主动脉根部扩张术。TAVI-in-valve 组的手术相关并发症发生率低于 SAVR 组（23%比 SAVR 组 59%，P<0.001），而两组的手术死亡率相似（2.2%比 SAVR 组 2.6%，P=1.000）。TAVI-in-valve 后严重的患者-瓣膜不匹配更为常见（44%比 SAVR 组 12%，P<0.001）。中位随访时间为 2.1 年（IQR，1.2-4.2 年）。多变量分析显示 TAVI-in-valve 与中期死亡率之间无关联（风险比，1.18；95%置信区间，0.62 至 2.22；P=0.612）。
TAVI-in-valve 和再次 SAVR 可获得相似的手术死亡率和中期死亡率。SAVR 可获得更好的血流动力学功能，因此似乎是首选方案。
