严重主动脉瓣狭窄患者的急诊与择期经导管主动脉瓣置换术
Urgent vs Elective Transcatheter Aortic Valve Replacement in Patients With Severe Aortic Stenosis.
作者信息
Zhou Jennifer Y, Nanayakkara Shane, Johnston Rozanne, Gardner Ellen, Gartner Elisha, Fernando Romaniya, Htun Nay Min, Palmer Sonny, Noaman Samer, McGaw David, Kaye David M, Walton Antony S, Stub Dion
机构信息
Department of Cardiology, Heart Centre, Alfred Health, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
Department of Cardiology, Heart Centre, Alfred Health, Melbourne, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Australia; Department of Cardiology, Cabrini Hospital, Malvern, Australia.
出版信息
JACC Adv. 2025 Jul 28;4(8):102039. doi: 10.1016/j.jacadv.2025.102039.
BACKGROUND
Urgent transcatheter aortic valve replacement (TAVR) is increasingly performed for acutely decompensated aortic stenosis, but outcome data remain limited, particularly in contemporary lower-risk populations.
OBJECTIVES
This study aimed to compare characteristics, procedural success, and outcomes among patients undergoing urgent vs elective TAVR.
METHODS
Consecutive patients who underwent TAVR at 2 high-volume centers between 2017 and 2023 were included. The primary outcome was 30-day mortality. Secondary outcomes included procedural success, in-hospital complications, and postdischarge outcomes at 30 days and 12 months.
RESULTS
Of 1,414 patients undergoing TAVR, 127 (9.0%) underwent urgent procedures (median Society of Thoracic Surgeons Predicted Risk of Mortality score 3.3 [Q1-Q3: 2.0-5.0]). Compared to elective cases, urgent TAVR patients were younger, more likely to reside in regional or socioeconomically disadvantaged areas, and exhibited more severe valve stenosis with greater cardiac remodeling. Procedural success and post-TAVR valve function were similar between groups. However, urgent TAVR was associated with higher rates of acute kidney injury (9.2% vs 3.4%, P = 0.002), 30-day mortality (2.9% vs 0.8%, P = 0.04), and 12-month mortality (14.3% vs 5.3%, P = 0.02). After multivariable adjustment, 30-day mortality differences were no longer significant, but urgent TAVR remained independently associated with increased acute kidney injury (adjusted OR: 2.43; 95% CI: 1.17-5.05; P = 0.017) and 12-month mortality (adjusted HR: 3.18; 95% CI: 1.06-9.54; P = 0.04).
CONCLUSIONS
In this low-intermediate risk cohort, urgent TAVR offered comparable procedural success and adjusted 30-day mortality to elective TAVR but was associated with higher 12-month mortality. These findings support urgent TAVR as a feasible short-term intervention while highlighting the need for targeted strategies to optimize long-term outcomes in high-risk populations.
背景
对于急性失代偿性主动脉瓣狭窄，紧急经导管主动脉瓣置换术（TAVR）的应用越来越多，但相关结局数据仍然有限，尤其是在当代低风险人群中。
目的
本研究旨在比较接受紧急TAVR与择期TAVR患者的特征、手术成功率和结局。
方法
纳入2017年至2023年间在2个高容量中心接受TAVR的连续患者。主要结局为30天死亡率。次要结局包括手术成功率、住院并发症以及30天和12个月的出院后结局。
结果
在1414例接受TAVR的患者中，127例（9.0%）接受了紧急手术（胸外科医师协会预测死亡率评分中位数为3.3[四分位间距：2.0 - 5.0]）。与择期手术相比，紧急TAVR患者更年轻，更有可能居住在地区或社会经济条件不利地区，并且瓣膜狭窄更严重，心脏重塑更明显。两组之间的手术成功率和TAVR术后瓣膜功能相似。然而，紧急TAVR与急性肾损伤发生率较高（9.2%对3.4%，P = 0.002）、30天死亡率较高（2.9%对0.8%，P = 0.04）以及12个月死亡率较高（14.3%对5.3%，P = 0.02）相关。多变量调整后，30天死亡率差异不再显著，但紧急TAVR仍与急性肾损伤增加（调整后比值比：2.43；95%置信区间：1.17 - 5.05；P = 0.017）和12个月死亡率增加（调整后风险比：3.18；95%置信区间：1.06 - 9.54；P = 0.04）独立相关。
结论
在这个中低风险队列中，紧急TAVR与择期TAVR的手术成功率相当，30天死亡率经调整后相近，但与12个月死亡率较高相关。这些发现支持紧急TAVR作为一种可行的短期干预措施，同时强调需要采取针对性策略来优化高风险人群的长期结局。
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