Hawkins Robert B, Deeb G Michael, Sukul Devraj, Patel Himanshu J, Gualano Sarah K, Chetcuti Stanley J, Grossman P Michael, Ailawadi Gorav, Fukuhara Shinichi
Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.
Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.
JACC Cardiovasc Interv. 2023 Apr 24;16(8):942-953. doi: 10.1016/j.jcin.2023.03.015.
Aortic stenosis treatment should consider risks and benefits for lifetime management. Although the feasibility of redo transcatheter aortic valve replacement (TAVR) remains unclear, concerns are emerging regarding reoperation after TAVR.
The authors sought to define comparative risk of surgical aortic valve replacement (SAVR) after prior TAVR or SAVR.
Data on patients undergoing bioprosthetic SAVR after TAVR and/or SAVR were extracted from the Society of Thoracic Surgeons Database (2011-2021). Overall and isolated SAVR cohorts were analyzed. The primary outcome was operative mortality. Risk adjustment using hierarchical logistic regression as well as propensity score matching for isolated SAVR cases were performed.
Of 31,106 SAVR patients, 1,126 had prior TAVR (TAVR-SAVR), 674 had prior SAVR and TAVR (SAVR-TAVR-SAVR), and 29,306 had prior SAVR (SAVR-SAVR). Yearly rates of TAVR-SAVR and SAVR-TAVR-SAVR increased over time, whereas SAVR-SAVR was stable. The TAVR-SAVR patients were older, with higher acuity, and with greater comorbidities than other cohorts. The unadjusted operative mortality was highest in the TAVR-SAVR group (17% vs 12% vs 9%, respectively; P < 0.001). Compared with SAVR-SAVR, risk-adjusted operative mortality was significantly higher for TAVR-SAVR (OR: 1.53; P = 0.004), but not SAVR-TAVR-SAVR (OR: 1.02; P = 0.927). After propensity score matching, operative mortality of isolated SAVR was 1.74 times higher for TAVR-SAVR than SAVR-SAVR patients (P = 0.020).
The number of post-TAVR reoperations is increasing and represent a high-risk population. Yet even in isolated SAVR cases, SAVR after TAVR is independently associated with increased risk of mortality. Patients with life expectancy beyond a TAVR valve and unsuitable anatomy for redo-TAVR should consider a SAVR-first approach.
主动脉瓣狭窄的治疗应考虑终身管理的风险和益处。尽管再次经导管主动脉瓣置换术（TAVR）的可行性仍不明确，但TAVR术后再次手术的问题日益受到关注。
作者试图确定先前接受TAVR或外科主动脉瓣置换术（SAVR）后行SAVR的相对风险。
从胸外科医师协会数据库（2011 - 2021年）中提取TAVR和/或SAVR术后接受生物瓣SAVR患者的数据。对总体和单纯SAVR队列进行分析。主要结局为手术死亡率。采用分层逻辑回归进行风险调整，并对单纯SAVR病例进行倾向评分匹配。
在31106例SAVR患者中，1126例曾接受TAVR（TAVR - SAVR），674例曾接受SAVR和TAVR（SAVR - TAVR - SAVR），29306例曾接受SAVR（SAVR - SAVR）。TAVR - SAVR和SAVR - TAVR - SAVR的年发生率随时间增加，而SAVR - SAVR保持稳定。TAVR - SAVR患者比其他队列年龄更大，病情更严重，合并症更多。TAVR - SAVR组未调整的手术死亡率最高（分别为17%、12%和9%；P < 0.001）。与SAVR - SAVR相比，TAVR - SAVR风险调整后的手术死亡率显著更高（OR：1.53；P = 0.004），但SAVR - TAVR - SAVR并非如此（OR：1.02；P = 0.927）。倾向评分匹配后，TAVR - SAVR单纯SAVR的手术死亡率比SAVR - SAVR患者高1.74倍（P = 0.020）。
TAVR术后再次手术的数量在增加，且代表了高危人群。然而，即使在单纯SAVR病例中，TAVR后行SAVR也独立与死亡风险增加相关。预期寿命超过TAVR瓣膜且再次TAVR解剖结构不合适的患者应考虑优先选择SAVR。
