Agha Ali M, Burt Jeremy R, Beetler Danielle, Tran Tri, Parente Ryan, Sensakovic William, Du Yuan, Siddiqui Usman
Department of Internal Medicine, The McGovern Medical School at UT Houston, Houston, TX, USA.
Department of Radiology, AdventHealth Orlando, Orlando, FL, USA.
Cardiol Ther. 2019 May 23;8(2):357-364. doi: 10.1007/s40119-019-0137-2.
Transcatheter aortic valve replacement (TAVR) has become a widely accepted treatment option for patients with severe aortic stenosis (AS) who are considered intermediate- and high-risk surgical candidates. The purpose of this study was to test the hypothesis that trans-apical TAVR would be associated with increased risk of new-onset intraventricular conduction delay (LBBB or RBBB).
We conducted a retrospective observational study of consecutive patients undergoing TAVR at a large, single institution. The incidence of new LBBB or RBBB was compared between femoral and apical TAVR patients. Multivariate analysis was performed to account for confounding variables, which included age, gender, CAD, PAD, hypertension, and diabetes.
A total of 467 TAVR patients were included in the study, with 283 (60.6%) femoral approach and 184 (39.4%) apical approach. In univariate analysis, the apical approach (when compared to the femoral approach) was associated with a higher incidence of both new-onset LBBB (12.79 vs. 3.40%, p = 0.0002) and RBBB (5.49 vs. 0.81%, p = 0.0039). After controlling for potential confounding variables, the apical approach continued to be associated with a higher incidence of both new-onset LBBB (p = 0.0010) and RBBB (p = 0.0115). There was also a trend towards an association between diabetes and new-onset LBBB (p = 0.0513) in apical TAVR patients. In subgroup analysis, LBBB/RBBB occurring as a result of transapical TAVR was associated with more frequent hospitalizations > 30 days after TAVR, compared to transfemoral TAVR. Other post-procedural complications noted more frequently among patients undergoing transapical TAVR include arrhythmias including atrial fibrillation, peri-procedural myocardial infarction (within 72 h), mortality from unknown cause, and mortality from non-cardiac cause.
Relative to transfemoral TAVR, patients undergoing transapical TAVR are at increased risk for new-onset bundle branch block, peri-procedural myocardial infarction, rehospitalization, TAV-in-TAV deployment, and all-cause mortality at 1 year. Interventional cardiologists and cardiothoracic surgeons alike should take these findings into consideration when choosing which approach is most suitable for patients undergoing TAVR for severe aortic stenosis.
经导管主动脉瓣置换术（TAVR）已成为被广泛接受的治疗选择，适用于那些被认为是中高危手术候选者的严重主动脉瓣狭窄（AS）患者。本研究的目的是检验经心尖TAVR会增加新发室内传导延迟（左束支传导阻滞或右束支传导阻滞）风险这一假设。
我们对在一家大型单一机构连续接受TAVR的患者进行了一项回顾性观察研究。比较了经股动脉和经心尖TAVR患者中新发左束支传导阻滞或右束支传导阻滞的发生率。进行多变量分析以考虑混杂变量，这些变量包括年龄、性别、冠心病、外周动脉疾病、高血压和糖尿病。
本研究共纳入467例TAVR患者，其中283例（60.6%）采用经股动脉途径，184例（39.4%）采用经心尖途径。在单变量分析中，经心尖途径（与经股动脉途径相比）与新发左束支传导阻滞（12.79%对3.40%，p = 0.0002）和右束支传导阻滞（5.49%对0.81%，p = 0.0039）的较高发生率相关。在控制潜在混杂变量后，经心尖途径继续与新发左束支传导阻滞（p = 0.0010）和右束支传导阻滞（p = 0.0115）的较高发生率相关。在经心尖TAVR患者中，糖尿病与新发左束支传导阻滞之间也存在关联趋势（p = 0.0513）。在亚组分析中，与经股动脉TAVR相比，经心尖TAVR导致的左束支传导阻滞/右束支传导阻滞与TAVR后>30天更频繁的住院相关。在接受经心尖TAVR的患者中更频繁出现的其他术后并发症包括心律失常，包括心房颤动、围手术期心肌梗死（72小时内）、不明原因死亡和非心脏原因死亡。
相对于经股动脉TAVR，接受经心尖TAVR的患者发生新发束支传导阻滞、围手术期心肌梗死、再次住院、TAV-in-TAV植入以及1年全因死亡的风险增加。介入心脏病学家和心胸外科医生在选择最适合严重主动脉瓣狭窄患者进行TAVR的方法时应考虑这些发现。
