经心尖主动脉瓣置换术与外科主动脉瓣置换术：针对高危人群的亚组分析。

Transapical aortic valve replacement versus surgical aortic valve replacement: A subgroup analyses for at-risk populations.

作者信息

Stachon Peter, Kaier Klaus, Oettinger Vera, Bothe Wolfgang, Zehender Manfred, Bode Christoph, von Zur Mühlen Constantin

机构信息

Faculty of Medicine, Department of Cardiology and Angiology I, Heart Center Freiburg, University of Freiburg, Freiburg, Germany.

Faculty of Medicine, Institute of Medical Biometry and Statistics, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany.

出版信息

J Thorac Cardiovasc Surg. 2021 Dec;162(6):1701-1709.e1. doi: 10.1016/j.jtcvs.2020.02.078. Epub 2020 Feb 29.

DOI:10.1016/j.jtcvs.2020.02.078

PMID:32222407

Abstract

BACKGROUND

If the transfemoral access is not feasible, a transapical access or surgical aortic valve replacement (SAVR) are alternatives for patients with aortic valve stenosis.

OBJECTIVES

To identify patient groups who benefit from SAVR or transapical transcatheter aortic valve replacement (TA-TAVR), we compared in-hospital outcomes of patients in a nationwide dataset.

METHODS

We identified 19,016 isolated SAVR and 6432 TA-TAVR performed in Germany from 2014 to 2016. We adjusted for risk factors using a covariate- and propensity-adjusted analysis.

RESULTS

Patients undergoing TA-TAVR were older, had more comorbidities, and accordingly greater estimated operative risk (logistic European System for Cardiac Operative Risk Evaluation 5.3 vs 17.0, P < .001). However, adjusted risk for in-hospital complications such as stroke, acute kidney injury, relevant bleeding, and prolonged mechanical ventilation >48 hours was lower in patients undergoing TA-TAVR (all P < .001). When we compared in-hospital mortality of all patients undergoing either TA-TAVR or SAVR, neither treatment strategy had a clear advantage (covariate-adjusted odds ratio [caOR], 1.13, P = .251; propensity-adjusted OR [paOR], 1.12, P = .309). Two patient subgroups seem to benefit more from SAVR than TA-TAVR: patients <75 years (caOR, 1.29, P = .237; paOR, 2.12, P = .001) and those with European System for Cardiac Operative Risk Evaluation 4-9 (caOR, 1.32, P = .114; paOR, 1.43, P = .041). Female patients had a tendency toward lower risk for in-hospital mortality when undergoing SAVR (caOR, 1.42, P = .030). In patients with chronic renal failure, TA-TAVR was superior (caOR, 0.56, P = .039, P = .040).

CONCLUSIONS

Patients <75 years and those at low operative risk who underwent SAVR had lower in-hospital mortality than those undergoing TA-TAVR. Patients with chronic renal failure who underwent TA-TAVR had lower in hospital mortality than those that underwent SAVR.

摘要

背景

如果经股动脉入路不可行，对于主动脉瓣狭窄患者，经心尖入路或外科主动脉瓣置换术（SAVR）是替代方案。

目的

为了确定从SAVR或经心尖经导管主动脉瓣置换术（TA-TAVR）中获益的患者群体，我们在一个全国性数据集中比较了患者的院内结局。

方法

我们确定了2014年至2016年在德国进行的19016例单纯SAVR和6432例TA-TAVR。我们使用协变量和倾向调整分析对风险因素进行了调整。

结果

接受TA-TAVR的患者年龄更大，合并症更多，因此估计手术风险更高（欧洲心脏手术风险评估系统logistic评分5.3对17.0，P <.001）。然而，接受TA-TAVR的患者发生院内并发症如中风、急性肾损伤、相关出血和机械通气延长>48小时的调整风险更低（所有P <.001）。当我们比较所有接受TA-TAVR或SAVR的患者的院内死亡率时，两种治疗策略均无明显优势（协变量调整比值比[caOR]，1.13，P =.251；倾向调整比值比[paOR]，1.12，P =.309）。两个患者亚组似乎从SAVR中获益比从TA-TAVR中更多：年龄<75岁的患者（caOR，1.29，P =.237；paOR，2.12，P =.001）和欧洲心脏手术风险评估系统评分为4-9的患者（caOR，1.32，P =.114；paOR，1.43，P =.041）。女性患者接受SAVR时院内死亡风险有降低趋势（caOR，1.42，P =.030）。在慢性肾衰竭患者中，TA-TAVR更具优势（caOR，0.56，P =.039，P =.040）。