Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland.
Department of Anesthesiology and Pain Medicine, Inselspital, University of Bern, Bern, Switzerland.
JAMA Netw Open. 2022 Jul 1;5(7):e2220689. doi: 10.1001/jamanetworkopen.2022.20689.
Noncardiac surgery after transcatheter aortic valve implantation (TAVI) is a clinical challenge with concerns about safety and optimal management.
To evaluate perioperative risk of adverse events associated with noncardiac surgery after TAVI by timing of surgery, type of surgery, and TAVI valve performance.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted using data from a prospective TAVI registry of patients at the tertiary care University Hospital in Bern, Switzerland. All patients undergoing noncardiac surgery after TAVI were identified. Data were analyzed from November through December 2021.
Timing, clinical urgency, and risk category of noncardiac surgery were assessed among patients who had undergone TAVI and subsequent noncardiac surgery.
A composite of death, stroke, myocardial infarction, and major or life-threatening bleeding within 30 days after noncardiac surgery.
Among 2238 patients undergoing TAVI between 2013 and 2020, 300 patients (mean [SD] age, 81.8 [6.6] years; 144 [48.0%] women) underwent elective (160 patients) or urgent (140 patients) noncardiac surgery after TAVI and were included in the analysis. Of these individuals, 63 patients (21.0%) had noncardiac surgery within 30 days of TAVI. Procedures were categorized into low-risk (21 patients), intermediate-risk (190 patients), and high-risk (89 patients) surgery. Composite end points occurred within 30 days of surgery among 58 patients (Kaplan-Meier estimate, 19.7%; 95% CI, 15.6%-24.7%). There were no significant differences in baseline demographics between patients with the 30-day composite end point and 242 patients without this end point, including mean (SD) age (81.3 [7.1] years vs 81.9 [6.5] years; P = .28) and sex (25 [43.1%] women vs 119 [49.2%] women; P = .37). Timing (ie, ≤30 days from TAVI to noncardiac surgery), urgency, and risk category of surgery were not associated with increased risk of the end point. Moderate or severe prosthesis-patient mismatch (adjusted hazard ratio [aHR], 2.33; 95% CI, 1.37-3.95; P = .002) and moderate or severe paravalvular regurgitation (aHR, 3.61; 95% CI 1.25-10.41; P = .02) were independently associated with increased risk of the end point.
These findings suggest that noncardiac surgery may be performed early after successful TAVI. Suboptimal device performance, such as prosthesis-patient mismatch and paravalvular regurgitation, was associated with increased risk of adverse outcomes after noncardiac surgery.
经导管主动脉瓣置换术（TAVI）后非心脏手术是一个临床挑战，涉及安全性和最佳管理问题。
通过手术时机、手术类型和 TAVI 瓣膜性能来评估 TAVI 后非心脏手术相关不良事件的围手术期风险。
设计、地点和参与者：这项队列研究使用了瑞士伯尔尼大学附属医院前瞻性 TAVI 注册中心的数据。确定了所有 TAVI 后接受非心脏手术的患者。数据于 2021 年 11 月至 12 月进行分析。
评估了 TAVI 后接受非心脏手术患者的手术时机、临床紧急程度和手术风险类别。
非心脏手术后 30 天内死亡、卒中和心肌梗死以及主要或危及生命的出血的复合终点。
在 2013 年至 2020 年间接受 TAVI 的 2238 例患者中，300 例（平均[SD]年龄 81.8[6.6]岁；144[48.0%]女性）接受了 TAVI 后择期（160 例）或紧急（140 例）非心脏手术，并纳入分析。在这些患者中，63 例（21.0%）在 TAVI 后 30 天内接受了非心脏手术。手术分为低风险（21 例）、中风险（190 例）和高风险（89 例）手术。58 例患者（30 天内手术的 Kaplan-Meier 估计值为 19.7%[95%CI，15.6%-24.7%]）在手术后 30 天内发生了复合终点事件。30 天复合终点和 242 例无此终点的患者之间在基线人口统计学特征上无显著差异，包括平均（SD）年龄（81.3[7.1]岁 vs 81.9[6.5]岁；P = .28）和性别（25[43.1%]女性 vs 119[49.2%]女性；P = .37）。手术时机（即 TAVI 至非心脏手术的时间≤30 天）、紧急程度和手术风险类别与终点风险增加无关。中度或重度假体-患者不匹配（调整后的危险比[aHR]，2.33；95%CI，1.37-3.95；P = .002）和中度或重度瓣周漏（aHR，3.61；95%CI，1.25-10.41；P = .02）与终点事件风险增加独立相关。
这些发现表明，TAVI 后可早期进行非心脏手术。设备性能不理想，如假体-患者不匹配和瓣周漏，与非心脏手术后不良结局的风险增加相关。
