Alabbadi Sundos, Bowdish Michael E, Sallam Aminah, Tam Derrick Y, Hasan Irsa, Kumaresan Abirami, Alzahrani Anas H, Iribarne Alexander, Egorova Natalia, Chikwe Joanna
Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif.
J Thorac Cardiovasc Surg. 2025 Jan 9. doi: 10.1016/j.jtcvs.2024.12.025.
The study objective was to characterize the trends and outcomes of aortic valve replacement in patients aged less than 65 years with aortic stenosis between 2013 and 2021.
This retrospective analysis included 9557 patients who underwent biological aortic valve replacement in California, New York, and New Jersey from 2013 to 2021. Patients were stratified by approach: transcatheter aortic valve replacement versus surgical aortic valve replacement. Our primary outcomes were 30-day and 6-year mortality and morbidity (stroke, heart failure rehospitalization, reintervention, and new pacemaker implantation). After propensity score matching, Cox proportional hazard and Fine-Gray models were used to compare outcomes after transcatheter aortic valve replacement and surgical aortic valve replacement.
The proportion of patients aged less than 65 years with aortic stenosis undergoing transcatheter aortic valve replacement versus surgical aortic valve replacement increased from 7.1% in 2013 to 54.7% in 2021. After propensity score matching, 30-day mortality was similar between both groups (1.0% vs 1.5%, P = .33). Transcatheter aortic valve replacement had a higher 6-year mortality (23.3% vs 10.5%, hazard ratio, 2.27; 95% CI, 1.82-2.83; P < .001). The 30-day rate of new pacemaker implantation was higher after transcatheter aortic valve replacement (10.7% vs 6.2%, P < .001). There was no difference in the 6-year cumulative incidence of stroke, heart failure hospitalizations, or reoperations. Multiple sensitivity analyses confirmed these findings.
Despite clinical guidelines, the use of transcatheter aortic valve replacement has increased in patients aged less than 65 years. Transcatheter aortic valve replacement in this population is associated with a higher 6-year mortality and a higher rate of new permanent pacemaker implantation when compared with a matched cohort treated with biologic surgical aortic valve replacement. These findings support the need for a randomized controlled trial comparing long-term outcomes of transcatheter aortic valve replacement versus surgical aortic valve replacement in patients aged less than 65 years.
本研究旨在描述2013年至2021年间年龄小于65岁的主动脉瓣狭窄患者进行主动脉瓣置换术的趋势和结果。
这项回顾性分析纳入了2013年至2021年在加利福尼亚州、纽约州和新泽西州接受生物主动脉瓣置换术的9557例患者。患者按手术方式分层：经导管主动脉瓣置换术与外科主动脉瓣置换术。我们的主要结局指标为30天和6年死亡率及并发症（中风、心力衰竭再住院、再次干预和新起搏器植入）。在倾向评分匹配后，使用Cox比例风险模型和Fine-Gray模型比较经导管主动脉瓣置换术和外科主动脉瓣置换术后的结局。
年龄小于65岁的主动脉瓣狭窄患者中，接受经导管主动脉瓣置换术与外科主动脉瓣置换术的比例从2013年的7.1%增至2021年的54.7%。倾向评分匹配后，两组30天死亡率相似（1.0%对1.5%，P = 0.33）。经导管主动脉瓣置换术的6年死亡率更高（23.3%对10.5%，风险比2.27；95%CI，1.82 - 2.83；P < 0.001）。经导管主动脉瓣置换术后新起搏器植入的30天发生率更高（10.7%对6.2%，P < 0.001）。中风、心力衰竭住院或再次手术的6年累积发生率无差异。多项敏感性分析证实了这些结果。
尽管有临床指南，但年龄小于65岁的患者中经导管主动脉瓣置换术的使用仍有所增加。与接受生物外科主动脉瓣置换术的匹配队列相比，该人群中经导管主动脉瓣置换术与更高的6年死亡率和更高的新永久性起搏器植入率相关。这些发现支持开展一项随机对照试验，比较年龄小于65岁的患者经导管主动脉瓣置换术与外科主动脉瓣置换术的长期结局。
