Department of Cardiac Surgery, Cedars-Sinai, Los Angeles, California, USA.
Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
J Am Coll Cardiol. 2021 Jul 6;78(1):1-9. doi: 10.1016/j.jacc.2021.04.062. Epub 2021 May 1.
Transcatheter edge-to-edge (TEER) mitral repair may be complicated by residual or recurrent mitral regurgitation. An increasing need for surgical reintervention has been reported, but operative outcomes are ill defined.
This study evaluated national outcomes of mitral surgery after TEER.
The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was used to identify 524 adults who underwent mitral surgery after TEER between July 2014 and June 2020. Emergencies (5.0%; n = 26), previous mitral surgery (5.3%; n = 28), or open implantation of transcatheter prostheses (1.5%; n = 8) were excluded. The primary outcome was 30-day or in-hospital mortality.
In the study cohort of 463 patients, the median age was 76 years (interquartile range [IQR]: 67 to 81 years), median left ventricular ejection fraction was 57% (IQR: 48% to 62%), and 177 (38.2%) patients had degenerative disease. Major concomitant cardiac surgery was performed in 137 (29.4%) patients: in patients undergoing isolated mitral surgery, the median STS-predicted mortality was 6.5% (IQR: 3.9% to 10.5%), the observed mortality was 10.2% (n = 23 of 225), and the ratio of observed to expected mortality was 1.2 (95% confidence interval [CI]: 0.8 to 1.9). Predictors of mortality included urgent surgery (odds ratio [OR]: 2.4; 95% CI: 1.3 to 4.6), nondegenerative/unknown etiology (OR: 2.2; 95% CI: 1.1 to 4.5), creatinine of >2.0 mg/dl (OR: 3.8; 95% CI: 1.9 to 7.9) and age of >80 years (OR: 2.1; 95% CI: 1.1 to 4.4). In a volume outcomes analysis in an expanded cohort of 591 patients at 227 hospitals, operative mortality was 2.6% (n = 2 of 76) in 4 centers that performed >10 cases versus 12.4% (n = 64 of 515) in centers performing fewer (p = 0.01). The surgical repair rate after failed TEER was 4.8% (n = 22) and was 6.8% (n = 12) in degenerative disease.
This study indicates that mitral repair is infrequently achieved after failed TEER, which may have implications for treatment choice in lower-risk and younger patients with degenerative disease. These findings should inform patient consent for TEER, clinical trial design, and clinical performance measures.
经导管缘对缘（TEER）二尖瓣修复术可能会出现残余或复发的二尖瓣反流。据报道，需要进行越来越多的手术干预，但手术结果尚未明确。
本研究评估了 TEER 后二尖瓣手术的全国性结果。
使用胸外科医师学会（STS）成人心脏手术数据库，确定了 2014 年 7 月至 2020 年 6 月间 524 名接受 TEER 后二尖瓣手术的成年人。排除急诊（5.0%；n=26）、先前的二尖瓣手术（5.3%；n=28）或经导管假体的开放性植入（1.5%；n=8）。主要结局为 30 天或住院死亡率。
在研究队列的 463 名患者中，中位年龄为 76 岁（四分位距[IQR]：67 至 81 岁），中位左心室射血分数为 57%（IQR：48%至 62%），177 名（38.2%）患者为退行性疾病。137 名（29.4%）患者同时进行了主要的心脏手术：在接受单纯二尖瓣手术的患者中，STS 预测死亡率为 6.5%（IQR：3.9%至 10.5%），实际死亡率为 10.2%（n=23 例/225 例），观察死亡率与预测死亡率的比值为 1.2（95%置信区间[CI]：0.8 至 1.9）。死亡的预测因素包括急诊手术（比值比[OR]：2.4；95%CI：1.3 至 4.6）、非退行性/未知病因（OR：2.2；95%CI：1.1 至 4.5）、肌酐>2.0mg/dl（OR：3.8；95%CI：1.9 至 7.9）和年龄>80 岁（OR：2.1；95%CI：1.1 至 4.4）。在一个由 591 名患者和 227 家医院组成的扩展队列中进行的手术量结果分析中，在进行了>10 例手术的 4 家中心，手术死亡率为 2.6%（n=76 例中的 2 例），而在进行了较少手术（n=515 例中的 64 例）的中心，手术死亡率为 12.4%（p=0.01）。TEER 失败后的二尖瓣修复率为 4.8%（n=22 例），退行性疾病的修复率为 6.8%（n=12 例）。
本研究表明，TEER 失败后很少能进行二尖瓣修复，这可能对低风险和年轻的退行性疾病患者的治疗选择产生影响。这些发现应该为 TEER 的患者知情同意、临床试验设计和临床绩效评估提供信息。
