经导管主动脉瓣置换术后并发感染性心内膜炎的卒中。
Stroke Complicating Infective Endocarditis After Transcatheter Aortic Valve Replacement.
机构信息
Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada.
Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Heart Center, Segeberger Kliniken, Bad Segeberg, Germany.
出版信息
J Am Coll Cardiol. 2021 May 11;77(18):2276-2287. doi: 10.1016/j.jacc.2021.03.233.
BACKGROUND
Stroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR).
OBJECTIVES
The purpose of this study was to determine the incidence, risk factors, clinical characteristics, management, and outcomes of patients with definite IE after TAVR complicated by stroke during index IE hospitalization.
METHODS
Data from the Infectious Endocarditis after TAVR International Registry (including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries) was analyzed. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]).
RESULTS
A total of 57 (10%) patients had a stroke during IE hospitalization, with no differences in causative microorganism between groups. S-IE patients exhibited higher rates of acute renal failure, systemic embolization, and persistent bacteremia (p < 0.05 for all). Previous stroke before IE, residual aortic regurgitation ≥moderate after TAVR, balloon-expandable valves, IE within 30 days after TAVR, and vegetation size >8 mm were associated with a higher risk of stroke during the index IE hospitalization (p < 0.05 for all). Stroke rate in patients with no risk factors was 3.1% and increased up to 60% in the presence of >3 risk factors. S-IE patients had higher rates of in-hospital mortality (54.4% vs. 28.7%; p < 0.001) and overall mortality at 1 year (66.3% vs. 45.6%; p < 0.001). Surgical treatment was not associated with improved outcomes in S-IE patients (in-hospital mortality: 46.2% in surgical vs. 58.1% in no surgical treatment; p = 0.47).
CONCLUSIONS
Stroke occurred in 1 of 10 patients with IE post-TAVR. A history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation determined an increased risk. The occurrence of stroke was associated with increased in-hospital and 1-year mortality rates, and surgical treatment failed to improve clinical outcomes.
背景
中风是感染性心内膜炎（IE）最常见且潜在致残的并发症之一。然而，关于经导管主动脉瓣置换术（TAVR）后并发 IE 合并中风的相关数据却很少。
目的
本研究旨在确定经 TAVR 后确诊 IE 患者在 IE 住院期间并发中风的发生率、风险因素、临床特征、治疗和结局。
方法
对来自感染性心内膜炎后 TAVR 国际注册研究（纳入了来自 11 个国家 59 个中心的 569 例 TAVR 后确诊 IE 患者）的数据进行分析。根据 IE 住院期间是否发生中风（中风 [S-IE] 或无中风 [NS-IE]）将患者分为两组。
结果
共有 57 例（10%）患者在 IE 住院期间发生中风，两组之间的致病微生物无差异。S-IE 患者更易发生急性肾功能衰竭、全身栓塞和持续性菌血症（所有 p 值均<0.05）。IE 前有中风史、TAVR 后残余主动脉瓣反流≥中度、球囊扩张瓣膜、TAVR 后 30 天内发生 IE 和赘生物大小>8 mm 与 IE 住院期间中风风险增加相关（所有 p 值均<0.05）。无风险因素患者的中风发生率为 3.1%，存在>3 个风险因素时，中风发生率增至 60%。S-IE 患者的院内死亡率（54.4%比 28.7%；p<0.001）和 1 年总死亡率（66.3%比 45.6%；p<0.001）均较高。S-IE 患者的手术治疗与改善结局无关（院内死亡率：手术治疗为 46.2%，非手术治疗为 58.1%；p=0.47）。
结论
TAVR 后 IE 患者中有 1 例发生中风。中风史、TAVR 与 IE 之间的时间间隔短、赘生物大小、瓣膜假体类型和残余主动脉瓣反流决定了较高的风险。中风的发生与增加的院内和 1 年死亡率相关，且手术治疗未能改善临床结局。
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