Naser Jwan A, Luis Sushil Allen, Pislaru Sorin V, Michelena Hector I, Kennedy Austin M, Eleid Mackram F, Crestanello Juan A, Chebib Fouad T, Pellikka Patricia A, Nkomo Vuyisile T
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota.
Am J Cardiol. 2024 Jan 1;210:163-171. doi: 10.1016/j.amjcard.2023.10.014. Epub 2023 Oct 19.
Transcatheter aortic valve replacement (TAVR) is now widely approved for the treatment of aortic stenosis, regardless of the patients' surgical risk. However, the outcomes of TAVR and their determinants in patients with chronic kidney disease (CKD) beyond 1 year of follow-up are unknown. We aimed to assess the medium-term outcomes of TAVR in CKD, develop a risk score to estimate the 2-year mortality in patients with CKD, and evaluate the changes in kidney function at discharge after TAVR. Adults who underwent TAVR were retrospectively identified. The CKD stage was determined using the Chronic Kidney Disease Epidemiology 2021 creatinine formula. Improved kidney function was defined as post-TAVR creatinine ≤50% of pre-TAVR creatinine or decrease in creatinine of ≥0.3 mg/100 ml compared with pre-TAVR creatinine. Overall, 1,523 patients (median age 82 years; 59% men; 735 with CKD stage II or less, 661 with CKD III, 83 with CKD IV, and 44 with CKD V [of whom 40 were on dialysis]) were included. The all-cause mortality was higher in CKD stages IV and V on the multivariable analysis (p <0.001) at median follow-up of 2.9 (interquartile range 2.0 to 4.2) years. Moderate or severe tricuspid regurgitation, anemia, right ventricular systolic pressure >40 mm Hg and CKD stages IV and V were independent predictors of 2-year mortality and were used to develop a risk score. At hospital discharge, persisting acute kidney injury after TAVR occurred in 88 of 1,466 patients (6%), whereas improved kidney function occurred in 170 of 1,466 patients (12%). In conclusion, CKD stage was an independent determinant of mortality beyond 2 years after TAVR. Kidney function was more likely to improve than worsen at the time of hospital discharge after TAVR.
经导管主动脉瓣置换术（TAVR）目前已被广泛批准用于治疗主动脉瓣狭窄，无论患者的手术风险如何。然而，对于慢性肾脏病（CKD）患者，TAVR术后1年以上的结局及其决定因素尚不清楚。我们旨在评估CKD患者TAVR的中期结局，制定一个风险评分以估计CKD患者的2年死亡率，并评估TAVR术后出院时肾功能的变化。对接受TAVR的成年人进行了回顾性识别。使用2021年慢性肾脏病流行病学肌酐公式确定CKD分期。肾功能改善定义为TAVR术后肌酐≤TAVR术前肌酐的50%，或与TAVR术前肌酐相比肌酐下降≥0.3mg/100ml。总体而言，纳入了1523例患者（中位年龄82岁；59%为男性；735例CKD II期或以下，661例CKD III期，83例CKD IV期，44例CKD V期[其中40例接受透析]）。在中位随访2.9年（四分位间距2.0至4.2年）时，多变量分析显示CKD IV期和V期的全因死亡率更高（p<0.001）。中度或重度三尖瓣反流、贫血、右心室收缩压>40mmHg以及CKD IV期和V期是2年死亡率的独立预测因素，并用于制定风险评分。在出院时，1466例患者中有88例（6%）在TAVR后持续存在急性肾损伤，而1466例患者中有170例（12%）肾功能得到改善。总之，CKD分期是TAVR术后2年以上死亡率的独立决定因素。TAVR术后出院时肾功能改善的可能性大于恶化。
