Department of Internal Medicine, Michigan State University, East Lansing, Michigan.
Department of Internal Medicine, Michigan State University, East Lansing, Michigan.
Am J Cardiol. 2023 Sep 15;203:105-112. doi: 10.1016/j.amjcard.2023.06.120. Epub 2023 Jul 22.
Because of its anatomic and procedural complexities, bicuspid aortic valve (BAV) has been excluded from previous trials investigating transcatheter aortic valve replacement (TAVR). We aimed to compare the clinical outcomes of TAVR in BAV and tricuspid aortic valve patients. We searched the databases systematically from inception until March 2023 for studies that reported the outcomes of TAVR in BAV and tricuspid aortic valve patients. The primary focus was all-cause mortality at 1 year. Additional outcomes included outcomes at 30-day follow-up. Secondary and subgroup analyses were performed on propensity-matched patients, patients at low surgical risk, and based on the type of transcatheter valve type. We included 30 studies with a total of 193,274 patients who underwent TAVR, of which 14,353 patients had BAV stenosis. The rate of 1-year mortality was lower in the BAV group compared with the tricuspid group with the results reaching statistical significance (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.75 to 0.98, p = 0.02). The rate of 30-day stroke, however, was higher in patients with BAV who underwent TAVR (OR 1.24, 95% CI 1.08 to 1.43, p <0.05). Other 30-day clinical outcomes were similar between the 2 groups. Similar outcomes were observed in secondary analysis of matched populations with less mortality and higher rate of stroke in patients with BAV (OR 0.84, 95% CI 0.72 to 0.96, p = 0.01, and OR 1.38, 95% CI 1.09 to 1.75, p <0.05, respectively). Comparing the outcomes for self-expandable and balloon-expandable valves resulted in similar results. Subgroup analysis of low-surgical-risk patients similarly showed lower 1-year mortality in patients with BAV (OR 0.67, 95% CI 0.50 to 0.91, p = 0.01), without difference in 30-day stroke between the 2 groups (OR 1.24, 95% CI 0.83 to 1.88, p = 0.30). In conclusion, this report indicates that TAVR is safe and feasible in patients with BAV, including patients at low surgical risk. The higher rate of 30-day stroke, however, warrants caution when pursuing TAVR in this population. More studies, specifically randomized trials, are still warranted to further assess the safety and the long-term outcomes in this group.
由于解剖和程序上的复杂性，二叶式主动脉瓣（BAV）已被排除在前瞻性经导管主动脉瓣置换术（TAVR）研究之外。我们旨在比较 TAVR 在 BAV 和三叶式主动脉瓣患者中的临床结果。我们从成立之初到 2023 年 3 月系统地搜索了数据库，以寻找报告 TAVR 在 BAV 和三叶式主动脉瓣患者中结果的研究。主要重点是 1 年时的全因死亡率。其他结果包括 30 天随访时的结果。对倾向匹配患者、低手术风险患者以及基于经导管瓣膜类型进行了二次和亚组分析。我们纳入了 30 项研究，共有 193274 例患者接受了 TAVR，其中 14353 例患者有 BAV 狭窄。BAV 组的 1 年死亡率低于三叶式组，结果具有统计学意义（比值比 [OR] 0.86，95%置信区间 [CI] 0.75 至 0.98，p = 0.02）。然而，BAV 患者 TAVR 后 30 天的卒中发生率更高（OR 1.24，95%CI 1.08 至 1.43，p <0.05）。两组其他 30 天临床结果相似。在匹配人群的二次分析中也观察到了相似的结果，BAV 患者的死亡率较低，卒中发生率较高（OR 0.84，95%CI 0.72 至 0.96，p = 0.01，和 OR 1.38，95%CI 1.09 至 1.75，p <0.05，分别）。比较自膨式和球囊扩张式瓣膜的结果得出了相似的结果。低手术风险患者的亚组分析同样表明 BAV 患者 1 年死亡率较低（OR 0.67，95%CI 0.50 至 0.91，p = 0.01），两组 30 天卒中发生率无差异（OR 1.24，95%CI 0.83 至 1.88，p = 0.30）。总之，本报告表明 TAVR 在 BAV 患者中是安全可行的，包括低手术风险患者。然而，较高的 30 天卒中发生率在该人群中进行 TAVR 时需要谨慎。仍需要更多的研究，特别是随机试验，以进一步评估该组的安全性和长期结果。
