Instituto Cardiovascular, Hospital Clínico San Carlos, Fundación para la Investigación Biomédica del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain.
Rev Esp Cardiol (Engl Ed). 2023 Aug;76(8):600-608. doi: 10.1016/j.rec.2022.12.011. Epub 2023 Jan 18.
Concomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD.
Using discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission.
Matching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P <.001) as was periprocedural stroke (0.9% vs 2.2%; P=.004), acute kidney injury (4.3% vs 16.0%, P <.001), blood transfusion (9.6% vs 21.1%, P <.001), and hospital-acquired pneumonia (0.1% vs 1.7%, P=.001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P <.001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P <.001) and SAVR/CABG (8.3 vs 6.8%, P <.001). Thirty-day cardiovascular readmission did not differ between groups.
In this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.
伴发冠状动脉疾病（CAD）在主动脉瓣狭窄患者中较为常见；然而，最佳治疗策略仍存在争议。我们研究了经导管主动脉瓣植入术（TAVI）联合经皮冠状动脉介入治疗（PCI）与外科主动脉瓣置换术（SAVR）联合冠状动脉旁路移植术（CABG）治疗伴发 CAD 的主动脉瓣狭窄患者的围手术期结局。
利用西班牙国家卫生系统的出院数据，我们于 2016 年至 2019 年期间识别出 6194 例患者（5217 例 SAVR/CABG 和 977 例 TAVI/PCI）。采用倾向评分匹配调整基线特征。主要结局为院内全因死亡率。次要结局为院内并发症和 30 天心血管再入院。
匹配后得到 774 对。SAVR/CABG 组院内全因死亡率更高（3.4% vs 9.4%，P<.001），围手术期卒中（0.9% vs 2.2%，P=.004）、急性肾损伤（4.3% vs 16.0%，P<.001）、输血（9.6% vs 21.1%，P<.001）和医院获得性肺炎（0.1% vs 1.7%，P=.001）发生率更高。TAVI/PCI 组永久性起搏器植入率更高（12.0% vs 5.7%，P<.001）。低容量中心（<130 例/年）两种手术的院内全因死亡率均较高：TAVI/PCI（3.6% vs 2.9%，P<.001）和 SAVR/CABG（8.3% vs 6.8%，P<.001）。两组 30 天心血管再入院率无差异。
在这项大型当代全国性研究中，TAVI/PCI 联合经皮治疗主动脉瓣狭窄和 CAD 的院内死亡率和发病率低于外科干预。高容量中心在两组中的院内死亡率均较低。专门的全国性大容量心脏中心值得进一步研究。
