Alperi Alberto, Muntané-Carol Guillem, Freitas-Ferraz Afonso B, Junquera Lucia, Del Val David, Faroux Laurent, Philippon François, Rodés-Cabau Josep
Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada.
Ann Cardiothorac Surg. 2020 Nov;9(6):429-441. doi: 10.21037/acs-2020-av-40.
Transcatheter aortic valve replacement (TAVR) has been shown to be a good alternative to surgery for treating severe symptomatic aortic stenosis (AS) across the whole range of surgical risk patients. Whereas most periprocedural TAVR complications have significantly decreased over time, conduction disturbances remain high. Approaches to decrease this shortcoming are under continuous investigation.
We conducted a systematic review focusing on modifiable factors impacting post-TAVR conduction disturbances, such as balloon aortic valvuloplasty (BAV), type of new-generation transcatheter valve and implantation depth (ID). Search strategies were based on the best available evidence from each study. Primary endpoints were post-TAVR need of permanent pacemaker implantation (PPI) and new onset left bundle branch block (NOLBBB).
Data from 35 studies with a total of 29,982 patients were analyzed. BAV did not negatively impact PPI rates after TAVR. In propensity-matched and randomized trials, the Evolut R valve was associated with higher rates of PPI compared to the Sapien 3 valve (25% 19.2% in propensity-matched studies; 22.9% 19% in a randomized trial). The Acurate Neo valve was associated with the lowest PPI rate in observational studies (10.4%), but a PPI rate similar to Sapien 3 was reported in a randomized trial (10% 9%). The Portico valve system was associated with a higher PPI risk (PPI rate of 21.9% and 27.7% in propensity-matched and randomized studies, respectively). ID and its relation with the membranous septum (MS) length predicted post-TAVR conduction disturbances, particularly with Evolut R and Sapien 3 valves.
Pre-TAVR BAV did not increase the risk of conduction disturbances post-TAVR. Among the new-generation transcatheter valve systems, Sapien 3 and Acurate Neo valves were associated with the lowest PPI rates followed by the Evolut and Portico valves. A deeper valve implantation and a shorter MS length determined an increased risk of conduction disturbances post-TAVR.
经导管主动脉瓣置换术（TAVR）已被证明是治疗全范围手术风险患者严重症状性主动脉瓣狭窄（AS）的一种良好的手术替代方案。尽管随着时间的推移，大多数围手术期TAVR并发症已显著减少，但传导障碍的发生率仍然很高。降低这一缺点的方法正在持续研究中。
我们进行了一项系统评价，重点关注影响TAVR术后传导障碍的可改变因素，如球囊主动脉瓣成形术（BAV）、新一代经导管瓣膜类型和植入深度（ID）。检索策略基于每项研究中可得的最佳证据。主要终点是TAVR术后永久性起搏器植入（PPI）的需求和新发左束支传导阻滞（NOLBBB）。
分析了35项研究的数据，共纳入29982例患者。BAV对TAVR术后的PPI发生率没有负面影响。在倾向匹配和随机试验中，与Sapien 3瓣膜相比，Evolut R瓣膜的PPI发生率更高（倾向匹配研究中为25%对19.2%；随机试验中为22.9%对19%）。在观察性研究中，Acurate Neo瓣膜的PPI发生率最低（10.4%），但在一项随机试验中报告的PPI发生率与Sapien 3瓣膜相似（10%对9%）。Portico瓣膜系统的PPI风险更高（倾向匹配和随机研究中的PPI发生率分别为21.9%和27.7%）。ID及其与膜性间隔（MS）长度的关系可预测TAVR术后的传导障碍，特别是对于Evolut R和Sapien 3瓣膜。
TAVR术前BAV不会增加TAVR术后传导障碍的风险。在新一代经导管瓣膜系统中，Sapien 3和Acurate Neo瓣膜的PPI发生率最低，其次是Evolut和Portico瓣膜。瓣膜植入更深和MS长度更短会增加TAVR术后传导障碍的风险。
