Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
STS Research and Analytic Center, The Society of Thoracic Surgeons, Chicago, Illinois.
Ann Thorac Surg. 2024 Jul;118(1):155-162. doi: 10.1016/j.athoracsur.2024.03.024. Epub 2024 Apr 3.
Reports of cardiac operations after transcatheter aortic valve replacement (TAVR) and early TAVR explantation are increasing. The purpose of this report is to document trends and outcomes of cardiac surgery after initial TAVR.
The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for all adult patients undergoing cardiac surgery after a previously placed TAVR between January 2012 and March 2023. This identified an overall cohort and 2 subcohorts: nonaortic valve operations and surgical aortic valve replacement (SAVR) after previous TAVR. Cohorts were examined with descriptive statistics, trend analyses, and 30-day outcomes.
Of 5457 patients who were identified, 2485 (45.5%) underwent non-SAVR cardiac surgery, and 2972 (54.5%) underwent SAVR. The frequency of cardiac surgery after TAVR increased 4235.3% overall and 144.6% per year throughout the study period. The incidence of operative mortality and stroke were 15.5% and 4.5%, respectively. Existing The Society of Thoracic Surgeons risk models performed poorly, because observed-to-expected mortality ratios were significantly >1.0. Among those undergoing SAVR after TAVR, increasing preoperative surgical urgency, age, dialysis, need for SAVR, and concomitant procedures were associated with increased mortality, whereas type of TAVR explant was not.
The need for cardiac surgery, including redo SAVR after TAVR, is increasing rapidly. Risks are higher, and outcomes are worse than predicted. These data should closely inform heart team decisions if TAVR is considered at lowering age and risk profiles in the absence of longitudinal evidence.
经导管主动脉瓣置换术（TAVR）后和早期 TAVR 取出后的心脏手术报告正在增加。本报告的目的是记录初始 TAVR 后心脏手术的趋势和结果。
通过 2012 年 1 月至 2023 年 3 月期间在 Society of Thoracic Surgeons 成人心脏手术数据库中查询所有先前接受 TAVR 后接受心脏手术的成年患者，确定了一个总体队列和两个亚队列：非主动脉瓣手术和先前 TAVR 后行外科主动脉瓣置换术（SAVR）。使用描述性统计、趋势分析和 30 天结果对队列进行检查。
在确定的 5457 名患者中，2485 名（45.5%）患者接受了非 SAVR 心脏手术，2972 名（54.5%）患者接受了 SAVR。TAVR 后心脏手术的频率总体增加了 4235.3%，每年增加 144.6%。手术死亡率和中风的发生率分别为 15.5%和 4.5%。现有的 Society of Thoracic Surgeons 风险模型表现不佳，因为观察到的与预期死亡率比值明显大于 1.0。在 TAVR 后接受 SAVR 的患者中，术前手术紧急程度、年龄、透析、需要 SAVR 和伴随手术的增加与死亡率的增加相关，而 TAVR 瓣膜的类型则无关。
需要进行心脏手术，包括 TAVR 后再次行 SAVR，这一需求正在迅速增加。风险更高，结果比预测的更差。如果没有纵向证据，考虑在年龄和风险状况较低的情况下进行 TAVR，这些数据应密切告知心脏团队决策。
