Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
J Thorac Cardiovasc Surg. 2021 Aug;162(2):539-547.e1. doi: 10.1016/j.jtcvs.2019.11.139. Epub 2020 Jan 12.
Despite the rapid adoption of transcatheter aortic valve replacement (TAVR) and worldwide interest in its implantation, TAVR valve explantation has not been well described.
We retrospectively reviewed 1442 consecutive patients who underwent a TAVR procedure between 2011 and 2019, in which TAVR explantation was performed in 15 patients (1.0%). In addition, 2 patients from outside institutions also underwent TAVR explantation at our institution. We reviewed the clinical details of these 17 patients.
The frequency of TAVR explant increased over time from 0 to 1 during the period from 2011 to 2015 to 6 in 2019. The mean age was 73.0 ± 9.3 years. The majority of patients (88.2%) were in New York Heart Association functional class IV heart failure. The Society of Thoracic Surgeons Predicted Risk of Mortality score was significantly higher at the time of explantation than at the time of the original TAVR (3.5% vs 9.9%; P < .001). The indication for explantation included structural valve degeneration (23.5%), severe paravalvular leak (41.2%), TAVR procedure-related complications (23.5%), endocarditis (5.9%), and bridge-to-definitive surgery (5.9%). Neoendothelialization of the TAVR valve into the aortic wall requiring intense aortic endarterectomy was noted in all 5 of the TAVR valves older than 1 year, in which 2 (40%) required unplanned aortic root repair. There were 2 (11.8%) in-hospital mortalities.
Surgical TAVR valve explant is increasing and may become common in the near future. The clinical effects of explanting chronically implanted valves with the potential need for aortic repair is not negligible. These data should be used to more appropriately select TAVR candidates as TAVR practices expand into younger and lower risk patients.
尽管经导管主动脉瓣置换术（TAVR）的应用迅速普及，且全球对其植入也很感兴趣，但 TAVR 瓣膜的取出术尚未得到很好的描述。
我们回顾性分析了 2011 年至 2019 年间连续 1442 例接受 TAVR 手术的患者，其中 15 例（1.0%）进行了 TAVR 瓣膜取出术。此外，还有 2 例来自外院的患者在我院进行了 TAVR 瓣膜取出术。我们回顾了这 17 例患者的临床资料。
TAVR 瓣膜取出术的频率随着时间的推移而增加，从 2011 年至 2015 年期间的 0 例增加到 2019 年的 6 例。患者的平均年龄为 73.0±9.3 岁。大多数患者（88.2%）处于纽约心脏协会心功能Ⅳ级心力衰竭状态。与最初的 TAVR 相比，在瓣膜取出时，胸外科医生协会预测死亡率评分明显更高（3.5%比 9.9%；P<0.001）。瓣膜取出的指征包括结构性瓣膜退化（23.5%）、严重瓣周漏（41.2%）、TAVR 手术相关并发症（23.5%）、心内膜炎（5.9%）和桥接至确定性手术（5.9%）。所有 TAVR 瓣膜年龄大于 1 年的 5 例中均有 TAVR 瓣膜新内膜内皮化至主动脉壁，需要进行强烈的主动脉内膜切除术，其中 2 例（40%）需要进行计划性主动脉根部修复。有 2 例（11.8%）院内死亡。
外科 TAVR 瓣膜取出术的应用正在增加，且在不久的将来可能会变得普遍。取出慢性植入瓣膜并可能需要进行主动脉修复的临床效果不容忽视。随着 TAVR 实践向年轻和低危患者扩展，这些数据应被用于更恰当地选择 TAVR 患者。
