Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Ann Thorac Surg. 2021 Aug;112(2):539-545. doi: 10.1016/j.athoracsur.2020.08.048. Epub 2020 Oct 28.
Clinical outcomes of redo surgical aortic valve replacement (redo-SAVR) compared with valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) are poorly understood. This study compared short- and midterm outcomes of patients undergoing isolated redo-SAVR vs VIV-TAVR after previous SAVR.
A single-institutional review of the initial use of VIV-TAVR from 2012 to 2019 identified 273 patients undergoing VIV-TAVR (n = 187) or redo-SAVR (n = 86) after prior SAVR. Outcomes analysis included a univariate analysis and Kaplan-Meier survival analysis.
The Society of Thoracic Surgeons predicted risk of mortality was higher for VIV-TAVR (6.3%; interquartile range [IQR], 3.6%-10.5%) vs redo-SAVR (4.2%; IQR, 2.4%-6.9%; P < .01). VIV-TAVR patients (76 years; IQR, 67.5-82.5 years) were older than redo-SAVR patients (64 years; IQR, 54-72; P < .01). Redo-SAVR and VIV-TAVR had similar early mortality (1.2% vs 1.6%, P = .92). Two redo-SAVR (2.3%) and 3 VIV-TAVR patients (1.6%) died 4.8 ± 0.5 years and 4.8 ± 1.5 months after discharge, respectively. Redo-SAVR had an increased stroke rate (7.0% vs 1.1%, P = .02). Postoperative mean valve gradients were similar between VIV-TAVR (14 mm Hg; IQR, 9-21 mm Hg) and redo-SAVR patients (12 mm Hg; IQR, 8-20 mm Hg; P = .08). Postprocedure transesophageal echocardiography showed at least mild aortic insufficiency for 24 VIV-TAVR patients (16%) and 2 redo-SAVR patients (2.9%) (P = .01). The cumulative incidence of aortic valve reintervention was 5.2% for the redo-SAVR patients and 28.5% for the VIV-TAVR patients (P = .07).
After previous SAVR, redo-SAVR and VIV-TAVR can both be performed with acceptable operative results. Despite treating a high-risk patient population, we found redo-SAVR and VIV-TAVR both carry similar operative outcomes. Improved valve hemodynamics were observed in redo-SAVR patients compared with VIV-TAVR patients.
与经导管主动脉瓣置换术（TAVR）相比，再次行主动脉瓣置换术（redo-SAVR）的临床结果了解甚少。本研究比较了既往行 SAVR 后行单纯 redo-SAVR 与经导管主动脉瓣置换术（TAVR）的患者的短期和中期结果。
对 2012 年至 2019 年首次使用经导管主动脉瓣置换术（TAVR）的单中心回顾性研究，确定了 273 例既往行 SAVR 后行 TAVR（n=187）或 redo-SAVR（n=86）的患者。结果分析包括单因素分析和 Kaplan-Meier 生存分析。
胸外科医师协会预测的死亡率 redo-SAVR（6.3%；四分位距 [IQR]，3.6%-10.5%）高于 TAVR（4.2%；IQR，2.4%-6.9%；P<.01）。TAVR 患者（76 岁；IQR，67.5-82.5 岁）比 redo-SAVR 患者（64 岁；IQR，54-72 岁；P<.01）年龄更大。 redo-SAVR 和 TAVR 的早期死亡率相似（1.2% vs 1.6%，P=.92）。2 例 redo-SAVR（2.3%）和 3 例 TAVR 患者（1.6%）分别在出院后 4.8±0.5 年和 4.8±1.5 个月死亡。 redo-SAVR 的卒中发生率更高（7.0% vs 1.1%，P=.02）。TAVR（14mmHg；IQR，9-21mmHg）和 redo-SAVR 患者（12mmHg；IQR，8-20mmHg；P=.08）的术后平均瓣叶梯度相似。术后经食管超声心动图显示 24 例 TAVR 患者（16%）和 2 例 redo-SAVR 患者（2.9%）存在至少轻度主动脉瓣关闭不全（P=.01）。 redo-SAVR 患者的主动脉瓣再介入累积发生率为 5.2%，TAVR 患者为 28.5%（P=.07）。
既往行 SAVR 后， redo-SAVR 和 TAVR 均可获得可接受的手术结果。尽管治疗的是高危患者人群，但我们发现 redo-SAVR 和 TAVR 的手术结果相似。与 TAVR 患者相比，redo-SAVR 患者的瓣膜血流动力学得到改善。
