From the Department of Anesthesia, Critical Care & Pain Medicine.
Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Anesth Analg. 2023 Sep 1;137(3):618-628. doi: 10.1213/ANE.0000000000006377. Epub 2023 Jan 24.
The recommendation for transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) in patients 65 to 80 years of age is equivocal, leaving patients with a difficult decision. We evaluated whether TAVR compared to SAVR is associated with reduced odds for loss of independent living in patients ≤65, 66 to 79, and ≥80 years of age. Further, we explored mechanisms of the association of TAVR and adverse discharge.
Adult patients undergoing TAVR or SAVR within a large academic medical system who lived independently before the procedure were included. A multivariable logistic regression model, adjusting for a priori defined confounders including patient demographics, preoperative comorbidities, and a risk score for adverse discharge after cardiac surgery, was used to assess the primary association. We tested the interaction of patient age with the association between aortic valve replacement (AVR) procedure and loss of independent living. We further assessed whether the primary association was mediated (ie, percentage of the association that can be attributed to the mediator) by the procedural duration as prespecified mediator.
A total of 1751 patients (age median [quartiles; min-max], 76 [67, 84; 23-100]; sex, 56% female) were included. A total of 27% (222/812) of these patients undergoing SAVR and 20% (188/939) undergoing TAVR lost the ability to live independently. In our cohort, TAVR was associated with reduced odds for loss of independent living compared to SAVR (adjusted odds ratio [OR adj ] 0.19 [95% confidence interval {CI}, 0.14-0.26]; P < .001). This association was attenuated in patients ≤65 years of age (OR adj 0.63 [0.26-1.56]; P = .32) and between 66 and 79 years of age (OR adj 0.23 [0.15-0.35]; P < .001), and magnified in patients ≥80 years of age (OR adj 0.16 [0.10-0.25]; P < .001; P -for-interaction = .004). Among those >65 years of age, a shorter procedural duration mediated 50% (95% CI, 28-76; P < .001) of the beneficial association of TAVR and independent living.
Patients >65 years of age undergoing TAVR compared to SAVR had reduced odds for loss of independent living. This association was partly mediated by shorter procedural duration. No association between AVR approach and the primary end point was found in patients ≤65 years of age.
对于 65 至 80 岁的患者，经导管主动脉瓣置换术（TAVR）或外科主动脉瓣置换术（SAVR）的推荐意见存在分歧，这使得患者面临艰难的抉择。我们评估了 TAVR 是否与 SAVR 相比，与≤65 岁、66 至 79 岁和≥80 岁患者丧失独立生活能力的几率降低有关。此外，我们探讨了 TAVR 和不良出院结局之间关联的机制。
纳入在大型学术医疗系统中接受 TAVR 或 SAVR 的成年患者，这些患者在手术前独立生活。使用多变量逻辑回归模型，根据预先确定的混杂因素（包括患者人口统计学、术前合并症和心脏手术后不良出院风险评分）进行调整，以评估主要关联。我们测试了患者年龄与主动脉瓣置换术（AVR）程序和丧失独立生活能力之间关联的交互作用。我们进一步评估了该主要关联是否被预设的中介（即，可归因于中介的关联百分比）所中介。
共纳入 1751 例患者（年龄中位数[四分位数；最小-最大；23-100]：76 [67，84]；性别：56%女性）。其中，27%（222/812）接受 SAVR 的患者和 20%（188/939）接受 TAVR 的患者丧失了独立生活能力。在我们的队列中，与 SAVR 相比，TAVR 降低了丧失独立生活能力的几率（校正比值比[OR adj]：0.19 [95%置信区间{CI}：0.14-0.26]；P<0.001）。这种关联在≤65 岁的患者中减弱（OR adj：0.63 [0.26-1.56]；P=0.32）和 66 至 79 岁的患者中减弱（OR adj：0.23 [0.15-0.35]；P<0.001），而在≥80 岁的患者中增强（OR adj：0.16 [0.10-0.25]；P<0.001；P-交互=0.004）。在>65 岁的患者中，较短的手术持续时间部分解释了 TAVR 和独立生活之间有益关联的 50%（95%CI：28-76；P<0.001）。
与 SAVR 相比，>65 岁的患者接受 TAVR 丧失独立生活能力的几率降低。这种关联部分是由手术持续时间较短引起的。在≤65 岁的患者中，AVR 方法与主要终点之间没有关联。
