低流量、低梯度主动脉瓣狭窄患者外科手术与经导管主动脉瓣置换术的疗效比较
Outcomes of surgical versus transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis.
作者信息
Brown James A, Ashwat Eishan, Warraich Nav, Iyanna Nidhi, Serna-Gallegos Derek, Kliner Dustin, Toma Catalin, West David, Makani Amber, Hasan Irsa, Ogami Takuya, Ahmad Danial, Thoma Floyd, Wang Yisi, Sultan Ibrahim
机构信息
Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa; Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pa.
Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa; Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pa.
出版信息
J Thorac Cardiovasc Surg. 2025 May 4. doi: 10.1016/j.jtcvs.2025.04.034.
OBJECTIVE
This study sought to determine the impact of surgical versus transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis.
METHODS
This was an observational study of consecutive aortic valve replacements for severe aortic stenosis from 2010 to 2023. Patients with low-flow, low-gradient aortic stenosis (aortic valve mean gradient <40 mm Hg and a stroke volume index <35 mL/m) were included. Both classical (ejection fraction <50%) and paradoxical (ejection fraction ≥50%) subtypes were included. Concomitant procedures and history of aortic valve replacement were excluded. Patients were dichotomized by intervention.
RESULTS
A total of 575 patients underwent isolated, first-time aortic valve replacement for low-flow, low-gradient aortic stenosis, of whom 248 (43%) were low operative risk (Society of Thoracic Surgeons Predicted Risk of Mortality <4%). A total of 131 patients (52.8%) underwent surgical aortic valve replacement, and 117 patients (47.2%) underwent transcatheter aortic valve replacement. Those undergoing transcatheter aortic valve replacement were older than those undergoing surgical aortic valve replacement: 79.0 [76.0-84.0] years versus 66.0 [59.0-73.0] years (P < .001). The incidence of 30-day mortality, stroke, and pacemaker was not different across each group, but the incidence of paravalvular leak was higher in the transcatheter aortic valve replacement group. At 1-year follow-up, aortic valve mean gradient (9.0 [7.0-12.0] mm Hg) and ejection fraction (55.0% [40.0-60.0]) were no different across each group. On multivariable analysis, transcatheter aortic valve replacement was not associated with an increased hazard of death compared with surgical aortic valve replacement (hazard ratio, 1.38, 95% CI, 0.72-2.66, P = .34) or an increased hazard of heart failure readmission (hazard ratio, 1.70, 95% CI, 0.88-3.30, P = .11) compared with surgical aortic valve replacement.
CONCLUSIONS
For patients with low-flow, low-gradient aortic stenosis, surgical and transcatheter approaches to aortic valve replacement may be equally as advantageous with respect to long-term outcomes.
目的
本研究旨在确定手术主动脉瓣置换术与经导管主动脉瓣置换术对低流量、低梯度主动脉瓣狭窄患者的影响。
方法
这是一项对2010年至2023年连续进行的严重主动脉瓣狭窄主动脉瓣置换术的观察性研究。纳入低流量、低梯度主动脉瓣狭窄患者（主动脉瓣平均梯度<40 mmHg且每平方米体表面积的每搏量指数<35 mL）。纳入经典型（射血分数<50%）和矛盾型（射血分数≥50%）两种亚型。排除同期手术及主动脉瓣置换史。根据干预措施将患者分为两组。
结果
共有575例患者因低流量、低梯度主动脉瓣狭窄接受了单纯首次主动脉瓣置换术，其中248例（43%）手术风险较低（胸外科医师协会预测死亡率<4%）。共有131例患者（52.8%）接受了外科主动脉瓣置换术，117例患者（47.2%）接受了经导管主动脉瓣置换术。接受经导管主动脉瓣置换术的患者比接受外科主动脉瓣置换术的患者年龄更大：分别为79.0 [76.0 - 84.0]岁和66.0 [59.0 - 73.0]岁（P <.001）。两组30天死亡率、卒中及起搏器植入发生率无差异，但经导管主动脉瓣置换术组瓣周漏发生率更高。在1年随访时，两组主动脉瓣平均梯度（9.0 [7.0 - 12.0] mmHg）和射血分数（55.0% [40.0 - 60.0]）无差异。多变量分析显示，与外科主动脉瓣置换术相比，经导管主动脉瓣置换术与死亡风险增加无关（风险比，1.38，95%CI，0.72 - 2.66，P =.34），与外科主动脉瓣置换术相比，经导管主动脉瓣置换术与心力衰竭再入院风险增加无关（风险比，1.70，95%CI，0.88 - 3.30，P =.11）。
结论
对于低流量、低梯度主动脉瓣狭窄患者，手术和经导管主动脉瓣置换术在长期预后方面可能同样具有优势。
Zotero 插件