Beth Israel Deaconess Medical Center, Boston, Massachusetts (E.E.R., H.L.).
Lahey Hospital & Medical Center, Burlington, Massachusetts (S.J.B.).
Ann Intern Med. 2021 Apr;174(4):521-528. doi: 10.7326/M21-0724. Epub 2021 Apr 13.
Aortic stenosis (AS) is common, especially among the elderly. Left untreated, severe symptomatic AS is typically fatal. Surgical aortic valve replacement (SAVR) was the standard of care until transcatheter aortic valve replacement (TAVR) was shown to have lower mortality rates in patients at the highest surgical risk and was recommended for this group in the 2014 American Heart Association/American College of Cardiology (AHA/ACC) guidelines. In the 2017 AHA/ACC focused update, evidence of benefit and noninferiority extended the use of TAVR to intermediate-risk patients. More recent studies suggest potential benefit to low-risk patients, although no published guidelines yet recommend the use of TAVR for this population. An advantage of SAVR is a 30-year experience with valve durability, but SAVR may have higher rates of perioperative death and a slower return of quality of life. Although TAVR has less than 10-year experience with valve durability, it has lower or noninferior primary end points, such as mortality and stroke, and fewer periprocedural complications among anatomically permissive patients. Here, a cardiologist and a cardiothoracic surgeon debate the risks and benefits of TAVR versus SAVR for a patient with severe symptomatic AS who is at low risk for surgical death.
主动脉瓣狭窄（AS）很常见，尤其是在老年人中。未经治疗，严重症状性 AS 通常是致命的。外科主动脉瓣置换术（SAVR）是标准的治疗方法，直到经导管主动脉瓣置换术（TAVR）在手术风险最高的患者中显示出较低的死亡率，并在 2014 年美国心脏协会/美国心脏病学会（AHA/ACC）指南中推荐用于该组患者。在 2017 年 AHA/ACC 重点更新中，获益和非劣效性的证据将 TAVR 的使用扩展到了中危风险患者。最近的研究表明，低危患者可能有潜在获益，尽管尚未有任何发布的指南推荐将 TAVR 用于这一人群。SAVR 的一个优势是具有 30 年的瓣膜耐久性经验，但 SAVR 可能有更高的围手术期死亡率和更慢的生活质量恢复。尽管 TAVR 在瓣膜耐久性方面的经验不足 10 年，但在解剖学上允许的患者中，其主要终点（如死亡率和中风）的风险较低或非劣效，围手术期并发症也较少。在这里，一位心脏病专家和一位心胸外科医生就 TAVR 与 SAVR 治疗低手术死亡风险的严重症状性 AS 患者的风险和益处进行了辩论。
