Kodra Arber, Cinelli Michael, Alexander Renita, Hamfreth Rahming, Wang Denny, Thampi Shankar, Basman Craig, Kliger Chad, Scheinerman Jacob, Pirelli Luigi
Department of Cardiothoracic Surgery, Lenox Hill Hospital, New York, NY 10075, USA.
Department of Cardiology, Staten Island University Hospital, Staten Island, NY 10305, USA.
J Clin Med. 2023 Mar 20;12(6):2390. doi: 10.3390/jcm12062390.
Treatment of congestive heart failure (CHF) with left ventricular (LV) systolic dysfunction and severe aortic stenosis (AS) is challenging, yet transcatheter aortic valve replacement (TAVR) has emerged as a suitable treatment option in such patients. We compared the periprocedural outcomes of TAVR in patients with an ejection fraction (EF) of ≤20% (VLEF group) to patients with an EF > 20% to ≤40% (LEF group). We included patients with severe AS and reduced LV ejection fraction (LVEF ≤ 40%) who underwent TAVR at four centers within Northwell Health between January 2016 and December 2020. Over 2000 consecutive patients were analyzed, of which 355 patients met the inclusion criteria. The primary composite endpoint was in-hospital mortality, moderate or greater paravalvular (PVL), stroke, conversion to open surgery, aortic valve re-intervention, and/or need for PPM. Secondary endpoints were length of stay, NYHA classification at 1 month and 1 year, mortality at 1 month and 1 year, mean valve gradient at 1 month, KCCQ score at 1 month, and ≥ moderate PVL at 1 month. There was no difference in the primary composite endpoint between the two groups (23.6% for VLEF vs. 25.3% for LEF, = 0.29). During TAVR placement, 40% of patients in the VLEF group required ≥1 vasopressors for hypotension lasting ≥30 min vs. only 21% of patients in the LEF group ( < 0.01). Intra-aortic balloon pump (IABP) use during procedure was greater in the VLEF group (9% vs. 1%, < 0.01)-all placed post TAVR. Emergency ECMO use was higher in the VLEF group as well (5% vs. 0%). Total length of stay was significantly different between the two groups as well (6 days vs. 3 days, < 0.01). Both groups had a change in LVEF of ~10%. One-year outcomes were similar between the groups. All-cause mortality at 1 year was not significantly different at 1 year (13% for VLEF vs. 11% for LEF), and KCC scores were also similar (77.54 vs. 74.97). Mean aortic valve gradients were also similar (12 mmHg vs. 11 mmHg, = 0.48). Our study suggests that patients with EF ≤ 20% can safely have TAVR with similar periprocedural outcomes compared to patients with EF > 20% to ≤40% despite higher rates of vasopressor and mechanical support.
对伴有左心室（LV）收缩功能障碍和严重主动脉瓣狭窄（AS）的充血性心力衰竭（CHF）患者进行治疗具有挑战性，但经导管主动脉瓣置换术（TAVR）已成为这类患者合适的治疗选择。我们比较了射血分数（EF）≤20%的患者（VLEF组）与EF>20%至≤40%的患者（LEF组）TAVR围手术期的结局。我们纳入了2016年1月至2020年12月在诺斯韦尔健康系统内四个中心接受TAVR的严重AS且左心室射血分数（LVEF）降低（LVEF≤40%）的患者。对连续2000多名患者进行了分析，其中355例患者符合纳入标准。主要复合终点为住院死亡率、中度或更严重的瓣周漏（PVL）、卒中、转为开胸手术、主动脉瓣再次干预和/或永久性起搏器植入需求。次要终点为住院时间、1个月和1年时的纽约心脏协会（NYHA）分级、1个月和1年时的死亡率、1个月时的平均瓣膜压差、1个月时的堪萨斯城心肌病问卷（KCCQ）评分以及1个月时≥中度PVL。两组之间的主要复合终点无差异（VLEF组为23.6%，LEF组为25.3%，P = 0.29）。在TAVR植入过程中，VLEF组40%的患者因低血压持续≥30分钟需要≥1种血管升压药，而LEF组仅21%的患者需要（P<0.01）。VLEF组术中主动脉内球囊反搏（IABP）的使用更多（9%对1%，P<0.01）——均在TAVR术后放置。VLEF组紧急体外膜肺氧合（ECMO）的使用也更高（5%对0%）。两组的总住院时间也有显著差异（6天对3天，P<0.01）。两组的LVEF均有~10%的变化。两组1年的结局相似。1年时全因死亡率无显著差异（VLEF组为13%，LEF组为11%），KCC评分也相似（77.54对74.97）。平均主动脉瓣压差也相似（12 mmHg对11 mmHg，P = 0.48）。我们的研究表明，尽管血管升压药和机械支持的使用率较高，但与EF>20%至≤40%的患者相比，EF≤20%的患者进行TAVR围手术期结局相似且安全。
