Peeraphatdit Thoetchai Bee, Nkomo Vuyisile T, Naksuk Niyada, Simonetto Douglas A, Thakral Nimish, Spears Grant M, Harmsen William S, Shah Vijay H, Greason Kevin L, Kamath Patrick S
Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN.
Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
Hepatology. 2020 Nov;72(5):1735-1746. doi: 10.1002/hep.31193. Epub 2020 Oct 15.
Hepatologists often determine whether transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) is preferred for patients with cirrhosis and severe aortic stenosis. The goal of this cohort study is to compare outcomes following TAVR and SAVR in patients with cirrhosis to inform the preferred intervention.
Prospectively collected data on 105 consecutive patients with cirrhosis and aortic stenosis who underwent TAVR (n = 55) or SAVR (n = 50) between 2008 and 2016 were reviewed retrospectively. Two control groups were included: 2,680 patients without cirrhosis undergoing TAVR and SAVR and 17 patients with cirrhosis who received medical therapy alone. Among the 105 patients with cirrhosis, the median Society of Thoracic Surgeons score was 3.8% (1.5, 6.9), and the median Model for End-Stage Liver Disease (MELD) score was 11.6 (9.4, 14.0). The TAVR group had similar in-hospital (1.8% vs. 2.0%) and 30-day mortality (3.6% vs. 4.2%) as the SAVR group. During the median follow-up of 3.8 years (95% confidence interval, 3.0-6.9), there were 63 (60%) deaths. MELD score (adjusted hazard ratio, 1.13; 95% confidence interval, 1.05-1.21; P = 0.002) was an independent predictor of long-term survival. In the subgroup of patients with MELD score <12, the TAVR group had reduced survival compared with the SAVR group (median survival of 2.8 vs. 4.4 years; P = 0.047). However, in those with MELD score ≥12, survival after TAVR, SAVR, and medical therapy was similar (1.3 vs. 2.1 vs. 1.6 years, respectively; P = 0.53).
In select patients with cirrhosis, both TAVR and SAVR have acceptable and comparable short-term outcomes. MELD score, but not Society of Thoracic Surgeons score, independently predicts long-term survival after TAVR and SAVR. For patients with MELD score <12, SAVR is a preferred procedure; however, neither procedure appears superior to medical therapy in patients with MELD score ≥12.
肝病专家常常需要确定，对于肝硬化合并严重主动脉瓣狭窄的患者，经导管主动脉瓣置换术（TAVR）还是外科主动脉瓣置换术（SAVR）更为合适。这项队列研究的目的是比较肝硬化患者接受TAVR和SAVR后的结局，为首选干预措施提供依据。
回顾性分析了2008年至2016年间连续接受TAVR（n = 55）或SAVR（n = 50）的105例肝硬化合并主动脉瓣狭窄患者的前瞻性收集数据。纳入了两个对照组：2680例未患肝硬化接受TAVR和SAVR的患者，以及17例仅接受药物治疗的肝硬化患者。在这105例肝硬化患者中，胸外科医师协会评分中位数为3.8%（1.5，6.9），终末期肝病模型（MELD）评分中位数为11.6（9.4，14.0）。TAVR组与SAVR组的院内死亡率（1.8%对2.0%）和30天死亡率（3.6%对4.2%）相似。在中位随访3.8年（95%置信区间，3.0 - 6.9）期间，有63例（60%）死亡。MELD评分（校正风险比，1.13；95%置信区间，1.05 - 1.21；P = 0.002）是长期生存的独立预测因素。在MELD评分<12的患者亚组中，TAVR组的生存率低于SAVR组（中位生存期2.8年对4.4年；P = 0.047）。然而，在MELD评分≥12的患者中，TAVR、SAVR和药物治疗后的生存率相似（分别为1.3年、2.1年和1.6年；P = 0.53）。
在特定的肝硬化患者中，TAVR和SAVR均具有可接受的且相当的短期结局。MELD评分而非胸外科医师协会评分可独立预测TAVR和SAVR后的长期生存。对于MELD评分<12的患者，SAVR是首选术式；然而，对于MELD评分≥12的患者，两种术式均未显示出优于药物治疗。
