Department of Internal Medicine, Division of Cardiology, University of Vermont Medical Center, Burlington, Vermont.
Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Am J Cardiol. 2022 Jun 15;173:94-99. doi: 10.1016/j.amjcard.2022.02.042. Epub 2022 Mar 30.
The 2020 American Health Association/American College of Cardiology valve guidelines recommend surgical aortic valve replacement (SAVR) for symptomatic patients with aortic stenosis (AS) age <65 years and transcatheter aortic valve implantation (TAVI) for patients with AS age >80 years. We analyzed TAVI versus SAVR practice patterns using age-based recommendations. We compared 2016-to-2019 TAVI and isolated SAVR in northern New England at 5 centers according to guideline-recommended age groups. Multivariable logistic regression was performed to identify independent predictors of TAVI for the intermediate age group. The study was approved by each site's institutional review board in accordance with ongoing participation and quality improvement efforts in the Northern New England Cardiovascular Study Group. Among 4,161 patients with isolated severe AS, TAVI increased from 2016 to 2019: 55.8% versus 76.1%, p <0.01 for trend. SAVR for patients with AS age >80 years was uncommon and decreased over time: 13.1% versus 1.6%, p <0.01. TAVI utilization nearly doubled over time in young patients with AS age <65 years (14.3% vs 26.2%, p <0.01). Preference for SAVR decreased by 50% over time (p <0.01) in the intermediate age group (65 to 80 years). Independent predictors of TAVI among patients aged 65 to 80 years included older age, chronic obstructive pulmonary disease, previous stroke, and coronary artery bypass grafting, whereas vascular disease and clinical urgency favored SAVR. In conclusion, consistent with current American Health Association/American College of Cardiology guidelines, TAVI was the treatment of choice in >97% of severe patients with AS age >80 years by 2019. TAVI utilization in patients <65 years has doubled over time and thus may not reflect current guideline recommendations. TAVI is the preferred choice in those aged 65 to 80 years, especially among patients with previous stroke or coronary artery bypass grafting.
2020 年美国心脏协会/美国心脏病学会瓣膜指南建议，对于年龄<65 岁有症状的主动脉瓣狭窄（AS）患者，推荐进行外科主动脉瓣置换术（SAVR）；对于年龄>80 岁的 AS 患者，推荐行经导管主动脉瓣植入术（TAVI）。我们根据年龄建议，分析了 TAVI 与 SAVR 的实践模式。我们根据指南推荐的年龄组，比较了 2016 年至 2019 年在新英格兰北部 5 个中心的 TAVI 和孤立性 SAVR。采用多变量逻辑回归分析了中间年龄组 TAVI 的独立预测因素。该研究得到了每个中心机构审查委员会的批准，符合新英格兰北部心血管研究组正在进行的参与和质量改进工作。在 4161 例孤立性严重 AS 患者中，TAVI 的比例从 2016 年到 2019 年增加：55.8%比 76.1%，趋势有统计学意义（p<0.01）。对于年龄>80 岁的 AS 患者，SAVR 少见且随时间减少：13.1%比 1.6%，趋势有统计学意义（p<0.01）。年龄<65 岁的年轻 AS 患者 TAVI 的使用率随时间几乎翻了一番（14.3%比 26.2%，p<0.01）。中间年龄组（65 至 80 岁）SAVR 的偏好程度随时间降低了 50%（p<0.01）。65 至 80 岁患者 TAVI 的独立预测因素包括年龄较大、慢性阻塞性肺疾病、既往卒中史和冠状动脉旁路移植术，而血管疾病和临床紧急情况则有利于 SAVR。总之，与当前的美国心脏协会/美国心脏病学会指南一致，到 2019 年，超过 97%的年龄>80 岁严重 AS 患者选择 TAVI 作为治疗方法。年龄<65 岁的患者 TAVI 的使用率随时间翻了一番，因此可能无法反映当前的指南建议。TAVI 是 65 至 80 岁患者的首选治疗方法，尤其是在有既往卒中或冠状动脉旁路移植术的患者中。
