Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Ann Thorac Surg. 2022 Jan;113(1):138-145. doi: 10.1016/j.athoracsur.2021.01.041. Epub 2021 Feb 3.
Despite the rapid adoption of transcatheter aortic replacement (TAVR), surgical TAVR valve explantation (TAVR-explant) and the clinical impact of explanted TAVR device type are not well described.
TAVR-explant from 2016 to 2019 was queried using the Society of Thoracic Surgeons (STS) National Database. A total of 483 patients with documented explanted valve type, consisting of 330 (68%) patients with balloon-expandable and 153 (32%) patients with self-expandable devices, were identified. The primary outcome was 30-day mortality. The secondary outcome was the need for any simultaneous procedures with TAVR-explant.
The mean age was 72.8 years, 38% of the patients were female, and 51% demonstrated New York Heart Association functional class III to IV symptoms. During TAVR-explant, 63% of patients required other simultaneous procedures, including aortic repair (27%), mitral procedures (22%), coronary artery bypass grafting (15%), and tricuspid procedures (7%). Patients with a self-expandable device underwent more frequent ascending aortic replacement (22% vs 9%; P < .001) than those with a balloon-expandable device, whereas the aortic root replacement rate was similar (19% vs 24%; P = .22). The overall 30-day mortality was 18% without differences in the mortality or other major complications between the groups. Of the 157 patients with isolated surgical aortic valve replacement and available STS predicted risk of mortality score, the observed-to-expected (O/E) mortality ratio was 2.2.
The TAVR-explant outcomes were comparable between patients with balloon-expandable devices and patients with self-expandable devices, whereas ascending aortic replacement was observed more frequently in patients with self-expandable devices. Younger patients undergoing TAVR should be informed of the future TAVR-explant risk that may accompany a higher O/E ratio and frequent morbid concurrent procedures.
尽管经导管主动脉瓣置换术（TAVR）的应用迅速普及，但外科 TAVR 瓣膜取出术（TAVR-explant）以及已取出的 TAVR 装置类型的临床影响尚不清楚。
使用胸外科医师学会（STS）国家数据库查询 2016 年至 2019 年期间的 TAVR-explant。共确定了 483 例有记录的瓣膜取出类型患者，其中 330 例（68%）为球囊扩张型，153 例（32%）为自膨式装置。主要结局为 30 天死亡率。次要结局是 TAVR-explant 时是否需要同时进行任何其他程序。
平均年龄为 72.8 岁，38%的患者为女性，51%的患者表现出纽约心脏协会功能分级 III 至 IV 级症状。在 TAVR-explant 期间，63%的患者需要同时进行其他程序，包括主动脉修复（27%）、二尖瓣手术（22%）、冠状动脉旁路移植术（15%）和三尖瓣手术（7%）。与球囊扩张型装置相比，自膨式装置患者更频繁地进行升主动脉置换（22%比 9%；P<0.001），而主动脉根部置换率相似（19%比 24%；P=0.22）。两组之间的 30 天死亡率无差异，死亡率或其他主要并发症无差异。在 157 例仅行外科主动脉瓣置换术且有 STS 预测死亡率评分的患者中，观察到的与预期的死亡率比值为 2.2。
球囊扩张型装置和自膨式装置患者的 TAVR-explant 结果相当，然而，自膨式装置患者更频繁地进行升主动脉置换。接受 TAVR 的年轻患者应被告知未来 TAVR-explant 的风险，这可能伴随着更高的 O/E 比值和频繁的并发疾病。
