主动脉瓣狭窄(AS)和心脏淀粉样变(CA)是老年人的典型疾病。多达16%的严重AS老年人经导管主动脉瓣置换术(TAVR)伴有CA的诊断。与AS患者相比,CA-AS人群的功能能力降低,预后较差。由于TAVR对CA-AS患者的预后影响历来受到质疑,并且根据最近发表的证据,我们旨在提供TAVR在CA-AS患者中的疗效和安全性的综合.
我们对以下研究进行了系统评价和荟萃分析:(i)评估与药物治疗相比,在CA-AS患者中使用TAVR的死亡率,以及(ii)报告与单独使用AS患者相比,在CA-AS患者中使用TAVR的并发症和临床结果。总共确定了7项观察性研究:4项报告的TAVR死亡率,与单独的AS患者相比,CA-AS患者在TAVR后的4例报告的并发症和临床结局。在CA-AS患者中,与药物治疗(n=36)相比,TAVR(n=44)的死亡风险较低[比值比(OR)0.23,95%置信区间(CI)0.07-0.73,I2=0%,P=0.001,需要治疗的数量=3]。与单纯AS患者(n=536)相比,CA-AS患者(n=75)的TAVR的安全性似乎相似。中风的风险相当,血管并发症,危及生命的出血,急性肾损伤,和30天的死亡率,尽管CA-AS与永久性起搏器植入风险增加的趋势相关(OR1.76,95%CI0.91-4.09,I2=0%,P=0.085)。与单纯AS患者相比,CA-AS患者在TAVR后的长期死亡率和再住院率在数值上较高。
TAVR是CA-AS患者的一种有效且安全的手术,与药物治疗相比,有很大的生存益处,除了永久性起搏器植入风险较高的趋势外,安全性与单纯AS患者相当。
Aortic stenosis (AS) and cardiac amyloidosis (CA) are typical diseases of the elderly. Up to 16% of older adults with severe AS referred to transcatheter aortic valve replacement (TAVR) have a concomitant diagnosis of CA. CA-AS population suffers from reduced functional capacity and worse prognosis than AS patients. As the prognostic impact of TAVR in patients with CA-AS has been historically questioned and in light of recently published evidence, we aim to provide a comprehensive synthesis of the efficacy and safety of TAVR in CA-AS patients.
We performed a systematic
review and meta-analysis of studies: (i) evaluating mortality with TAVR as compared with medical therapy in CA-AS patients and (ii) reporting complications and clinical outcomes of TAVR in CA-AS patients as compared with patients with AS alone. A total of seven observational studies were identified: four reported mortality with TAVR, and four reported complications and clinical outcomes after TAVR of patients with CA-AS compared with AS alone patients. In patients with CA-AS, the risk of mortality was lower with TAVR (n = 44) as compared with medical therapy (n = 36) [odds ratio (OR) 0.23, 95% confidence interval (CI) 0.07-0.73, I2 = 0%, P = 0.001, number needed to treat = 3]. The safety profile of TAVR seems to be similar in patients with CA-AS (n = 75) as compared with those with AS alone (n = 536), with comparable risks of stroke, vascular complications, life-threatening bleeding, acute kidney injury, and 30 day mortality, although CA-AS was associated with a trend towards an increased risk of permanent pacemaker implantation (OR 1.76, 95% CI 0.91-4.09, I2 = 0%, P = 0.085). CA is associated with a numerically higher rate of long-term mortality and rehospitalizations following TAVR in patients with CA-AS as compared with those with AS alone.
TAVR is an effective and safe procedure in CA-AS patients, with a substantial survival benefit as compared with medical therapy, and a safety profile comparable with patients with AS alone except for a trend towards higher risk of permanent pacemaker implantation.