经导管主动脉瓣置换术和外科主动脉瓣置换术后血流对人工瓣膜-患者不匹配的影响。
Impact of Flow on Prosthesis-Patient Mismatch Following Transcatheter and Surgical Aortic Valve Replacement.
机构信息
Department of Internal Medicine. Oakland University William Beaumont School of Medicine, Auburn Hills, MI (A.E.A.).
Department of Cardiovascular Medicine. Beaumont Hospital Royal Oak, MI (A.E.A.).
出版信息
Circ Cardiovasc Imaging. 2021 Aug;14(8):e012364. doi: 10.1161/CIRCIMAGING.120.012364. Epub 2021 Aug 13.
BACKGROUND
Severe prosthesis-patient mismatch (PPM) is diagnosed by an indexed effective orifice area <0.65 cm/m, which is derived from stroke volume index. We examined the impact of flow, determined by stroke volume index, on severe PPM following transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).
METHODS
We included SAVR patients from the PARTNER 2A trial (Placement of Aortic Transcatheter Valve 2A) and TAVR patients from the PARTNER 2 S3i (Placement of Aortic Transcatheter Valve 2 S3i) registry. The primary end point was the separate analysis of all-cause death, cardiac death, and rehospitalization at 5 years. Following TAVR and SAVR, we compared the primary end points between severe versus no-severe PPM in all patients, in low flow (LF), and in normal flow. Multivariable analysis was performed to determine variables associated with the end points.
RESULTS
Nine hundred fifty-four TAVR and 726 SAVR patients with PPM and flow data were included. Severe PPM following TAVR was significantly lower compared with SAVR in all patients (9% versus 28%, <0.0001), in normal flow (5% versus 8%, =0.04), and in LF (20% versus 42%, <0.0001). Severe PPM was associated with rehospitalization following TAVR (odds ratio, 1.52 [95% CI, 1.01-2.29], =0.0456) and SAVR (odds ratio, 1.51 [95% CI, 1.06-2.16], =0.0237). Severe PPM in LF was independently associated with cardiac death following TAVR (odds ratio, 1.85 [95% CI, 1.06-3.23], =0.0308). Following SAVR, severe PPM in LF and low ejection fraction was associated with increased cardiac death (35.26% versus 12.51%, =0.01) and rehospitalization (37.59% versus 15.46%, =0.006) compared with severe PPM in LF and preserved ejection fraction, respectively. Severe PPM in normal flow was not associated with clinical outcomes despite higher gradients and smaller valves compared with severe PPM in LF.
CONCLUSIONS
Severe PPM is more common following SAVR compared with TAVR. Regardless of the implanted valve size or gradient, severe PPM impacts mortality only in patients with LF following TAVR and LF and low ejection fraction following SAVR. Severe PPM in normal flow is not associated with poor outcomes. Registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01314313 and NCT02687035.
背景
严重的假体-患者不匹配（PPM）通过有效开口面积<0.65 cm/m 指数来诊断，该指数来源于心排量指数。我们研究了心排量指数决定的流量对经导管主动脉瓣置换术（TAVR）和外科主动脉瓣置换术（SAVR）后严重 PPM 的影响。
方法
我们纳入了 PARTNER 2A 试验（经导管主动脉瓣置换术 2A 期）中的 SAVR 患者和 PARTNER 2 S3i 注册研究中的 TAVR 患者。主要终点是所有原因死亡、心脏死亡和 5 年再住院的单独分析。TAVR 和 SAVR 后，我们比较了所有患者、低流量（LF）和正常流量中严重 PPM 与非严重 PPM 的主要终点。进行多变量分析以确定与终点相关的变量。
结果
共纳入了 954 例 TAVR 和 726 例 PPM 和流量数据的 SAVR 患者。TAVR 后的严重 PPM 明显低于 SAVR 中的严重 PPM（所有患者中为 9%对 28%，<0.0001）、正常流量中为 5%对 8%（=0.04）和 LF 中为 20%对 42%（<0.0001）。严重 PPM 与 TAVR 后再住院（比值比，1.52[95%可信区间，1.01-2.29]，=0.0456）和 SAVR 后再住院（比值比，1.51[95%可信区间，1.06-2.16]，=0.0237）相关。LF 中的严重 PPM 与 TAVR 后的心脏死亡独立相关（比值比，1.85[95%可信区间，1.06-3.23]，=0.0308）。在 SAVR 后，LF 和低射血分数中的严重 PPM 与心脏死亡（35.26%对 12.51%，=0.01）和再住院（37.59%对 15.46%，=0.006）增加相关，而 LF 和保留射血分数中的严重 PPM 则没有相关性。尽管 LF 中的严重 PPM 与较高的梯度和较小的瓣膜相关，但与正常流量中的严重 PPM 相比，正常流量中的严重 PPM 并不与临床结果相关。
结论
与 SAVR 相比，严重 PPM 在 SAVR 后更为常见。无论植入瓣膜的大小或梯度如何，严重 PPM 仅影响 LF 中的 TAVR 和 LF 及低射血分数中的 SAVR 患者的死亡率。正常流量中的严重 PPM 与不良预后无关。注册：网址：https://www.clinicaltrials.gov；独特标识符：NCT01314313 和 NCT02687035。
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