Hermiller James B, Gunnarsson Candace L, Ryan Michael P, Moore Kimberly A, Clancy Seth J, Irish William
Deptartment of Cardiology, Ascension St. Vincent's Heart Center of Indiana, Indianapolis, Indiana, USA.
Gunnarsson Consulting, Jupiter, Florida, USA.
Catheter Cardiovasc Interv. 2021 Nov 1;98(5):950-956. doi: 10.1002/ccd.29841. Epub 2021 Jul 6.
The aim of the study was to estimate the percentage of Medicare patients needing coronary access for percutaneous coronary intervention (PCI) or coronary angiography following aortic valve replacement (AVR). Indications for TAVR have expanded to include younger and low-risk patients, raising the question of coronary access for future procedures. Medicare patients <80 years old with an AVR between 2011 and 2018 were included. Time-to-event analyses were conducted using Cox hazard models to estimate risk of coronary access up to 7 years after AVR. Model adjustments included age, sex, race, region, comorbidity, concomitant CABG, and smoking. A total of 13,469 Medicare patients (mean age 70.6) met inclusion criteria. Models estimated that 2.5% of patients at 1-year post-index and 17% at over 7 years would need coronary access. For patients who had SAVR (with or without CABG), estimates for coronary access were similar and over 15% after 6.5 years. For TAVR patients, with a previous PCI, 28% at 4.5 years required coronary access, which was higher than TAVR patients without a previous PCI. SAVR patients with and without CAD at baseline were similar; however, TAVR patients with CAD had a 22% rate of coronary access versus 7% for those without at 3 years. Approximately half of patients who needed coronary access returned to the same hospital as their initial AVR. Coronary access is required in a substantial portion of AVR patients especially those with PCI or a history of CAD undergoing TAVR. The need for coronary access may increase as transcatheter AVR becomes accessible to younger patients with a longer life expectancy.
本研究的目的是估计在主动脉瓣置换术（AVR）后需要进行冠状动脉介入治疗（PCI）或冠状动脉造影的医疗保险患者的比例。经导管主动脉瓣置换术（TAVR）的适应症已扩大到包括年轻和低风险患者，这引发了未来手术中冠状动脉通路的问题。纳入了2011年至2018年间年龄小于80岁且接受AVR的医疗保险患者。使用Cox风险模型进行事件发生时间分析，以估计AVR后长达7年的冠状动脉通路风险。模型调整包括年龄、性别、种族、地区、合并症、同期冠状动脉旁路移植术（CABG）和吸烟情况。共有13469名医疗保险患者（平均年龄70.6岁）符合纳入标准。模型估计，索引后1年有2.5%的患者以及7年以上有17%的患者需要冠状动脉通路。对于接受外科主动脉瓣置换术（SAVR，无论是否同期CABG）的患者，冠状动脉通路的估计情况相似，6.5年后超过15%。对于既往有PCI的TAVR患者，4.5年时有28%需要冠状动脉通路，这高于既往无PCI的TAVR患者。基线时有CAD和无CAD的SAVR患者情况相似；然而，有CAD的TAVR患者在3年时冠状动脉通路发生率为22%，而无CAD的患者为7%。大约一半需要冠状动脉通路的患者回到了他们最初接受AVR的同一家医院。很大一部分AVR患者需要冠状动脉通路，尤其是那些接受PCI或有CAD病史且接受TAVR的患者。随着预期寿命较长的年轻患者能够接受经导管主动脉瓣置换术，冠状动脉通路的需求可能会增加。
