Zaid Syed, Hirji Sameer A, Bapat Vinayak N, Denti Paolo, Modine Thomas, Nguyen Tom C, Mack Michael J, Reardon Michael J, Kaneko Tsuyoshi, Tang Gilbert H L
Division of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, Massachusetts.
Ann Thorac Surg. 2023 Nov;116(5):933-942. doi: 10.1016/j.athoracsur.2023.05.036. Epub 2023 Jun 22.
Recent reports have demonstrated worse than expected outcomes of surgical explantation after transcatheter aortic valve replacement (TAVR). However in-depth analysis of the short- and mid-term risk of concomitant cardiac surgery at the time of TAVR explant is lacking.
Data from the multicenter EXPLANT-TAVR registry of patients undergoing TAVR-explant between November 2009 and September 2020 were retrospectively analyzed. Patients undergoing concomitant procedures were included, but explants performed during the same admission as the initial TAVR or concomitant procedures performed on the aortic root, ascending aorta, or arch were excluded. Outcomes were evaluated between the isolated surgical aortic valve replacement (SAVR) and concomitant SAVR groups. Median follow-up was 6.6 months.
Among 199 patients, concomitant SAVR was performed in 94 patients (47.2%), primarily with mitral valve surgery (n = 45) followed by coronary artery bypass grafting (n = 23). Despite similar mean ages between groups (72.8 vs 73.4 years), concomitant SAVR had a higher median Society of Thoracic Surgeons Predicted Risk of Mortality score at the index TAVR (5.9% vs 3.7%, P = .001). There were no differences in median time-to-explant between groups (12.9 vs 8.7 months, P = .78). However concomitant SAVR had longer mean cardiopulmonary bypass (166 vs 114 minutes, P = .001) and cross-clamp times (123 vs 81 minutes, P = .001). Both 30-day (16.7% vs 9.9%) and 1-year mortality (36.1% vs 22.1%) were higher with concomitant SAVR but did not reach statistical significance (both P > .05). On Kaplan-Meier analysis, actuarial estimates of cumulative survival were significantly lower with concomitant SAVR at 3 years (56.8% vs 81.1%, P = .020).
For surgical explantation after TAVR failure, concomitant SAVR is associated with increased mortality. Further studies with longer follow-up are warranted to examine the benefit from earlier intervention before concomitant disease develops.
近期报告显示，经导管主动脉瓣置换术（TAVR）后外科取出瓣膜的结果比预期更差。然而，缺乏对TAVR取出瓣膜时同期心脏手术短期和中期风险的深入分析。
对2009年11月至2020年9月期间接受TAVR取出瓣膜的患者的多中心EXPLANT-TAVR注册数据进行回顾性分析。纳入接受同期手术的患者，但排除在初次TAVR同一住院期间进行的取出瓣膜手术或在主动脉根部、升主动脉或主动脉弓进行的同期手术。对单纯外科主动脉瓣置换术（SAVR）组和同期SAVR组的结果进行评估。中位随访时间为6.6个月。
199例患者中，94例（47.2%）进行了同期SAVR，主要是二尖瓣手术（n = 45），其次是冠状动脉旁路移植术（n = 23）。尽管两组平均年龄相似（72.8岁对73.4岁），但同期SAVR在初次TAVR时胸外科医师协会预测死亡风险评分中位数更高（5.9%对3.7%，P = .001）。两组间取出瓣膜的中位时间无差异（12.9个月对8.7个月，P = .78）。然而，同期SAVR的平均体外循环时间更长（166分钟对114分钟，P = .001）和主动脉阻断时间更长（123分钟对81分钟，P = .001）。同期SAVR的30天死亡率（16.7%对9.9%）和1年死亡率（36.1%对22.1%）均更高，但未达到统计学意义（P均>.05）。在Kaplan-Meier分析中，同期SAVR的3年累积生存率精算估计值显著更低（56.8%对81.1%，P = .020）。
对于TAVR失败后的外科取出瓣膜，同期SAVR与死亡率增加相关。有必要进行更长随访时间的进一步研究，以探讨在合并疾病发展之前早期干预的益处。
