复杂冠状动脉疾病患者经导管与外科主动脉瓣置换术的比较
Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Complex Coronary Artery Disease.
作者信息
Alperi Alberto, Mohammadi Siamak, Campelo-Parada Francisco, Munoz-Garcia Erika, Nombela-Franco Luis, Faroux Laurent, Veiga Gabriela, Serra Vicenç, Fischer Quentin, Pascual Isaac, Asmarats Luis, Gutiérrez Enrique, Regueiro Ander, Vilalta Victoria, Ribeiro Henrique B, Matta Anthony, Munoz-Garcia Antonio, Armijo German, Metz Damien, De la Torre Hernandez Jose M, Rodenas-Alesina Eduard, Urena Marina, Moris Cesar, Arzamendi Dabit, Perez-Fuentes Pedro, Fernandez-Nofrerias Eduard, Campanha-Borges Diego Carter, Mesnier Jules, Voisine Pierre, Dumont Eric, Kalavrouziotis Dimitri, Rodés-Cabau Josep
机构信息
Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
Rangueil University Hospital, Toulouse, France.
出版信息
JACC Cardiovasc Interv. 2021 Nov 22;14(22):2490-2499. doi: 10.1016/j.jcin.2021.08.073.
OBJECTIVES
The aim of this study was to compare, in a cohort of patients with complex coronary artery disease (CAD) and severe aortic stenosis (AS), the clinical outcomes associated with transfemoral transcatheter aortic valve replacement (TAVR) (plus percutaneous coronary intervention [PCI]) versus surgical aortic valve replacement (SAVR) (plus coronary artery bypass grafting [CABG]).
BACKGROUND
Patients with complex CAD were excluded from the main randomized trials comparing TAVR with SAVR, and no data exist comparing TAVR + PCI vs SAVR + CABG in such patients.
METHODS
A multicenter study was conducted including consecutive patients with severe AS and complex CAD (SYNTAX [Synergy Between PCI with Taxus and Cardiac Surgery] score >22 or unprotected left main disease). A 1:1 propensity-matched analysis was performed to account for unbalanced covariates. The rates of major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, nonprocedural myocardial infarction, need for new coronary revascularization, and stroke, were evaluated.
RESULTS
A total of 800 patients (598 undergoing SAVR + CABG and 202 undergoing transfemoral TAVR + PCI) were included, and after propensity matching, a total of 156 pairs of patients were generated. After a median follow-up period of 3 years (interquartile range: 1-6 years), there were no significant differences between groups for MACCE (HR for transfemoral TAVR vs SAVR: 1.33; 95% CI: 0.89-1.98), all-cause mortality (HR: 1.25; 95% CI: 0.81-1.94), myocardial infarction (HR: 1.16; 95% CI: 0.41-3.27), and stroke (HR: 0.42; 95% CI: 0.13-1.32), but there was a higher rate of new coronary revascularization in the TAVR + PCI group (HR: 5.38; 95% CI: 1.73-16.7).
CONCLUSIONS
In patients with severe AS and complex CAD, TAVR + PCI and SAVR + CABG were associated with similar rates of MACCE after a median follow-up period of 3 years, but TAVR + PCI recipients exhibited a higher risk for repeat coronary revascularization. Future trials are warranted.
目的
本研究旨在比较一组患有复杂冠状动脉疾病（CAD）和严重主动脉瓣狭窄（AS）的患者中，经股动脉经导管主动脉瓣置换术（TAVR）（加经皮冠状动脉介入治疗[PCI]）与外科主动脉瓣置换术（SAVR）（加冠状动脉旁路移植术[CABG]）的临床结局。
背景
复杂CAD患者被排除在比较TAVR与SAVR的主要随机试验之外，且尚无关于此类患者中TAVR + PCI与SAVR + CABG比较的数据。
方法
进行了一项多中心研究，纳入连续的严重AS和复杂CAD患者（SYNTAX[紫杉醇洗脱支架与心脏外科手术协同作用]评分>22或无保护左主干病变）。进行1:1倾向匹配分析以处理不平衡的协变量。评估主要不良心脑血管事件（MACCE）发生率，包括全因死亡率、非手术相关心肌梗死、新的冠状动脉血运重建需求和卒中。
结果
共纳入800例患者（598例行SAVR + CABG，202例行经股动脉TAVR + PCI），倾向匹配后共产生156对患者。中位随访期3年（四分位间距：1 - 6年）后，两组MACCE（经股动脉TAVR与SAVR的HR：1.33；95%CI：0.89 - 1.98）、全因死亡率（HR：1.25；95%CI：0.81 - 1.94）、心肌梗死（HR：1.16；95%CI：0.41 - 3.27）和卒中（HR：0.42；95%CI：0.13 - 1.32）无显著差异，但TAVR + PCI组新的冠状动脉血运重建率更高（HR：5.38；95%CI：1.73 - 16.7）。
结论
在严重AS和复杂CAD患者中，中位随访3年后，TAVR + PCI和SAVR + CABG的MACCE发生率相似，但接受TAVR + PCI的患者再次冠状动脉血运重建风险更高。未来有必要进行试验。
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