Ahmad Danial, Yousef Sarah, Kliner Dustin, Brown James A, Serna-Gallegos Derek, Toma Catalin, Makani Amber, West David, Wang Yisi, Thoma Floyd W, Sultan Ibrahim
Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
Am J Cardiol. 2024 Mar 15;215:1-7. doi: 10.1016/j.amjcard.2023.12.061. Epub 2024 Jan 15.
Structural valve degeneration is increasingly seen given the higher rates of bioprosthetic heart valve use for surgical and transcatheter aortic valve replacement (TAVR). Valve-in-valve TAVR (VIV-TAVR) is an attractive alternate for patients who are otherwise at high risk for reoperative surgery. We compared patients who underwent VIV-TAVR and native valve TAVR through a retrospective analysis of our institutional transcatheter valve therapy (TVT) database from 2013 to 2022. Patients who underwent either a native valve TAVR or VIV-TAVR were included. VIV-TAVR was defined as TAVR in patients who underwent a previous surgical aortic valve replacement. Kaplan-Meier survival analysis was used to obtain survival estimates. A Cox proportional hazards regression model was used for the multivariable analysis of mortality. A total of 3,532 patients underwent TAVR, of whom 198 (5.6%) underwent VIV-TAVR. Patients in the VIV-TAVR cohort were younger than patients who underwent native valve TAVR (79.5 vs 84 years, p <0.001), with comparable number of women and a higher Society of Thoracic Surgeons risk score (6.28 vs 4.46, p <0.001). The VIV-TAVR cohort had a higher incidence of major vascular complications (2.5% vs 0.8%, p = 0.008) but lower incidence of permanent pacemaker placement (2.5% vs 8.1%, p = 0.004). The incidence of stroke was comparable between the groups (VIV-TAVR 2.5% vs native TAVR 2.4%, p = 0.911). The 30-day readmission rates (VIV-TAVR 7.1% vs native TAVR 9%, p = 0.348), as well as in-hospital (VIV-TAVR 2% vs native TAVR 1.4%, p = 0.46), and overall (VIV-TAVR 26.3% vs native TAVR 30.8%, p = 0.18) mortality at a follow-up of 1.8 years (0.83 to 3.5) were comparable between the groups. The survival estimates were also comparable between the groups (log-rank p = 0.27). On multivariable Cox regression analysis, VIV-TAVR was associated with decreased hazards of death (hazard ratio 0.68 [0.5 to 0.9], p = 0.02). In conclusion, VIV-TAVR is a feasible and safe strategy for high-risk patients with bioprosthetic valve failure. There may be potentially higher short-term morbidity with VIV-TAVR, with no overt impact on survival.
鉴于生物人工心脏瓣膜在外科手术和经导管主动脉瓣置换术（TAVR）中的使用比例不断提高，结构瓣膜退变越来越常见。瓣中瓣TAVR（VIV-TAVR）对于再次手术风险较高的患者来说是一种有吸引力的替代方案。我们通过回顾性分析2013年至2022年我们机构的经导管瓣膜治疗（TVT）数据库，比较了接受VIV-TAVR和天然瓣膜TAVR的患者。纳入接受天然瓣膜TAVR或VIV-TAVR的患者。VIV-TAVR定义为在先前接受过外科主动脉瓣置换术的患者中进行的TAVR。采用Kaplan-Meier生存分析来获得生存估计值。使用Cox比例风险回归模型对死亡率进行多变量分析。共有3532例患者接受了TAVR，其中198例（5.6%）接受了VIV-TAVR。VIV-TAVR队列中的患者比接受天然瓣膜TAVR的患者年轻（79.5岁对84岁，p<0.001），女性数量相当，且胸外科医师协会风险评分更高（6.28对4.46，p<0.001）。VIV-TAVR队列中主要血管并发症的发生率较高（2.5%对0.8%，p=0.008），但永久性起搏器植入的发生率较低（2.5%对8.1%，p=0.004）。两组之间中风的发生率相当（VIV-TAVR为2.5%，天然TAVR为2.4%，p=0.911）。30天再入院率（VIV-TAVR为7.1%，天然TAVR为9%，p=0.348）以及1.8年（0.83至3.5）随访时的住院死亡率（VIV-TAVR为2%，天然TAVR为1.4%，p=0.46）和总体死亡率（VIV-TAVR为26.3%，天然TAVR为30.8%，p=0.18）在两组之间相当。两组之间的生存估计值也相当（对数秩检验p=0.27）。在多变量Cox回归分析中，VIV-TAVR与死亡风险降低相关（风险比0.68[0.5至0.9]，p=0.02）。总之，VIV-TAVR对于生物人工瓣膜功能衰竭的高危患者是一种可行且安全的策略。VIV-TAVR可能在短期内有更高的发病率，但对生存没有明显影响。
