Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address: https://twitter.com/Hirji1987.
Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
J Am Coll Cardiol. 2020 Oct 20;76(16):1848-1859. doi: 10.1016/j.jacc.2020.08.048.
Currently, there is a paucity of information on surgical explantation after transcatheter aortic valve replacement (TAVR).
The purpose of this study was to examine the incidence, patient characteristics, predictors, and outcomes of surgical explantation after TAVR using a population-based, nationally representative database.
We analyzed the Medicare Provider profile to include all U.S. patients undergoing TAVR from 2012 to 2017. Time to surgical explant was calculated from the index TAVR discharge to surgical explantation. Post-operative survival was assessed using time-dependent Cox proportional hazard regression analysis and landmark analysis.
The incidence of surgical explantation was 0.2% (227 of 132,633 patients), and was 0.28% and 0.14% in the early and newer TAVR era, respectively. The median time to surgical explant was 212 days, whereas 8.8% and 70.9% underwent surgical explantation within 30 days and 1 year, respectively. The primary indication for reintervention was bioprosthetic failure (79.3%). Compared with the no-explant cohort, the explant cohort was significantly younger (mean age 73.7 years vs. 81.7 years), with a lower prevalence of heart failure (55.9% vs. 65.8%) but more likely a lower-risk profile cohort (15% vs. 2.4%; all p < 0.05). The 30-day and 1-year mortality rates were 13.2% and 22.9%, respectively, and did not vary by either time to surgical explant or TAVR era, or between patients with versus without endocarditis (all p > 0.05). The time-dependent Cox regression analysis demonstrated a higher mortality in those with surgical explantation (hazard ratio: 4.03 vs. no-explant group; 95% confidence interval: 1.81 to 8.98). Indication, time-to-surgical-explant, and year of surgical explantation were not associated with worse post-explantation survival (all p > 0.05).
The present study provides updated evidence on the incidence, timing, and outcomes of surgical explantation of a TAVR prosthesis. Although the overall incidence was low, short-term mortality was high. These findings stress the importance of future mechanistic studies on TAVR explantation and may have implications on lifetime management of aortic stenosis, particularly in younger patients.
目前，关于经导管主动脉瓣置换术（TAVR）后的外科瓣膜取出术，信息匮乏。
本研究旨在使用基于人群的全国代表性数据库，研究 TAVR 后外科瓣膜取出术的发生率、患者特征、预测因素和结局。
我们分析了 Medicare Provider 档案，纳入了 2012 年至 2017 年期间在美国接受 TAVR 的所有患者。从 TAVR 索引出院到外科瓣膜取出术的时间计算为手术取出时间。使用时间依赖性 Cox 比例风险回归分析和 landmark 分析评估术后生存情况。
外科瓣膜取出术的发生率为 0.2%（132633 例患者中有 227 例），在早期和较新的 TAVR 时代，分别为 0.28%和 0.14%。外科瓣膜取出术的中位时间为 212 天，30 天内和 1 年内分别有 8.8%和 70.9%的患者进行了外科瓣膜取出术。再次干预的主要指征是生物瓣失效（79.3%）。与无取出组相比，取出组明显更年轻（平均年龄 73.7 岁 vs. 81.7 岁），心力衰竭的发生率较低（55.9% vs. 65.8%），但更可能是低风险评分组（15% vs. 2.4%；均 P < 0.05）。30 天和 1 年的死亡率分别为 13.2%和 22.9%，与手术取出时间或 TAVR 时代或有或无心内膜炎的患者之间均无差异（均 P > 0.05）。时间依赖性 Cox 回归分析显示，进行外科瓣膜取出术的患者死亡率更高（风险比：4.03 vs. 无取出组；95%置信区间：1.81 至 8.98）。手术指征、手术至取出时间和取出术年份与术后生存无相关性（均 P > 0.05）。
本研究提供了关于 TAVR 假体外科瓣膜取出术的发生率、时机和结局的最新证据。尽管总体发生率较低，但短期死亡率较高。这些发现强调了未来关于 TAVR 瓣膜取出术的机制研究的重要性，特别是对年轻患者，可能对主动脉瓣狭窄的终身管理有影响。
