新英格兰北部快速部署瓣膜经验：2015 年至 2021 年的生存和程序结果。
The Northern New England Rapid Deployment Valve Experience: Survival and Procedural Outcomes From 2015 to 2021.
机构信息
Department of Cardiac Surgery, Maine Medical Center, Portland, ME, USA.
Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
出版信息
Innovations (Phila). 2024 Jan-Feb;19(1):54-63. doi: 10.1177/15569845231223504. Epub 2024 Feb 6.
OBJECTIVE
The optimal approach and choice of initial aortic valve replacement (AVR) is evolving in the growing era of transcatheter AVR. Further survival and hemodynamic data are needed to compare the emerging role of rapid deployment (rdAVR) versus stented (sAVR) valve options for AVR.
METHODS
The Northern New England Cardiovascular Database was queried for patients undergoing either isolated AVR or AVR + coronary artery bypass grafting (CABG) with rdAVR or sAVR aortic valves between 2015 and 2021. Exclusion criteria included endocarditis, mechanical valves, dissection, emergency case status, and prior sternotomy. This resulted in a cohort including 1,616 sAVR and 538 rdAVR cases. After propensity weighting, procedural characteristics, hemodynamic variables, and survival outcomes were examined.
RESULTS
The breakdown of the overall cohort (2,154) included 1,164 isolated AVR (222 rdAVR, 942 sAVR) and 990 AVR + CABG (316 rdAVR, 674 sAVR). After inverse propensity weighting, cohorts were well matched, notable only for more patients <50 years in the sAVR group (4.0% vs 1.9%, standardized mean difference [SMD] = -0.12). Cross-clamp (89 vs 64 min, SMD = -0.71) and cardiopulmonary bypass (121 vs 91 min, SMD = -0.68) times were considerably longer for sAVR versus rdAVR. Immediate postreplacement aortic gradient decreased with larger valve size but did not differ significantly between comparable sAVR and rdAVR valve sizes or overall (6.5 vs 6.7 mm Hg, SMD = 0.09). Implanted rdAVR tended to be larger with 51% either size L or XL versus 37.4% of sAVR ≥25 mm. Despite a temporal decrease in pacemaker rate within the rdAVR cohort, the overall pacemaker frequency was less in sAVR versus rdAVR (4.4% vs 7.4%, SMD = 0.12), and significantly higher rates were seen in size L (10.3% vs 3.7%, < 0.002) and XL (15% vs 5.6%, < 0.004) rdAVR versus sAVR. No significant difference in major adverse cardiac events (4.6% vs 4.6%, SMD = 0.01), 30-day survival (1.5% vs 2.6%, SMD = 0.08), or long-term survival out to 4 years were seen between sAVR and rdAVR.
CONCLUSIONS
Rapid deployment valves offer a safe alternative to sAVR with significantly decreased cross-clamp and cardiopulmonary bypass times. Despite larger implantation sizes, we did not appreciate a comparative difference in immediate postoperative gradients, and although pacemaker rates are improving, they remain higher in rdAVR compared with sAVR. Longer-term hemodynamic and survival follow-up are needed.
目的
在经导管主动脉瓣置换术（transcatheter AVR）日益发展的时代，主动脉瓣置换术（AVR）的最佳方法和选择正在不断演变。需要进一步的生存和血流动力学数据来比较快速部署（rdAVR）与带支架（sAVR）瓣膜在 AVR 中的新兴作用。
方法
在 2015 年至 2021 年间，对接受单纯 AVR 或 AVR+冠状动脉旁路移植术（CABG）的患者进行了北新英格兰心血管数据库查询，患者接受 rdAVR 或 sAVR 主动脉瓣置换术。排除标准包括心内膜炎、机械瓣膜、夹层、紧急病例状态和先前的正中切开术。这导致了包括 1616 例 sAVR 和 538 例 rdAVR 病例的队列。在进行倾向评分加权后，检查了手术特征、血流动力学变量和生存结果。
结果
总体队列（2154 例）包括 1164 例单纯 AVR（222 例 rdAVR，942 例 sAVR）和 990 例 AVR+CABG（316 例 rdAVR，674 例 sAVR）。在进行反向倾向评分加权后，队列匹配良好，sAVR 组的年龄<50 岁的患者比例更高（4.0%对 1.9%，标准化均数差值[SMD] = -0.12）。sAVR 与 rdAVR 相比，体外循环（CPB）时间（89 对 64 分钟，SMD = -0.71）和主动脉阻断时间（121 对 91 分钟，SMD = -0.68）都明显延长。主动脉瓣置换术后即刻的主动脉瓣跨瓣梯度随着瓣膜尺寸的增大而降低，但在可比的 sAVR 和 rdAVR 瓣膜尺寸或整体上没有显著差异（6.5 对 6.7 毫米汞柱，SMD = 0.09）。rdAVR 植入的瓣膜尺寸往往较大，51%的瓣膜尺寸为 L 或 XL，而 sAVR 中≥25 毫米的瓣膜尺寸为 37.4%。尽管 rdAVR 队列中的起搏器使用率呈下降趋势，但 sAVR 与 rdAVR 的总体起搏器使用率仍较低（4.4%对 7.4%，SMD = 0.12），并且在 L 尺寸（10.3%对 3.7%，<0.002）和 XL 尺寸（15%对 5.6%，<0.004）的 rdAVR 中明显更高。sAVR 与 rdAVR 之间在重大不良心脏事件（4.6%对 4.6%，SMD = 0.01）、30 天生存率（1.5%对 2.6%，SMD = 0.08）或 4 年的长期生存率方面没有显著差异。
结论
与 sAVR 相比，快速部署瓣膜提供了一种安全的替代方法，显著缩短了体外循环和主动脉阻断时间。尽管植入尺寸较大，但我们没有注意到术后即刻梯度的差异，尽管起搏器的使用率在提高，但与 sAVR 相比，rdAVR 的起搏器使用率仍然较高。需要进行更长时间的血流动力学和生存随访。
Zotero 插件