■经导管主动脉瓣置换术(TAVR)后假体-患者不匹配(PPM)的临床后果目前是临床研究的重点。具有小主动脉瓣环的患者显示PPM的风险较高。在小主动脉瓣环中使用球囊扩张(BEV)或自扩张(SEV)经导管心脏瓣膜进行TAVR后PPM的发生率和临床后果的数据很少。
■主动脉瓣环较小(周长<72mm或主动脉瓣环面积<400mm2)的患者接受了BEV或SEV的现代经导管心脏瓣膜类型。倾向评分匹配应用于BEV或SEV患者之间不平衡的基线特征。根据VARC-3建议,超声心动图和临床随访超过3年。主要终点是出院前PPM的发生率及其与3年死亡率的关系。
■共有507例小主动脉瓣环患者,确定了192对匹配的SEV或BEV患者。平均年龄为81±7(SEV)81±6(BEV)年(p=0.5),主动脉瓣环周长为69±3vs.69±3mm,(p=0.8),环面积为357±27vs.357±27mm2(p=0.8),EuroScoreII为5.8±6.6vs.7±7.2(p=0.9)。SEV导致不太温和(20%与31%,p<0.001)和严重的出院前PPM(9%vs.18%,p<0.001)与BEV相比。放电时(7±4vs.12±9mmHg,p=0.003)和1年随访(7±5vs.13±3mmHg,p<0.001),与BEV相比,SEV显示更低的平均梯度。SEV后1年的估计生存率为85%(95%置信区间(CI):80%-90%),2年时80%(95%CI:75%-86%),和71%(95%CI:65%-78%)在3年;BEV后估计生存率为87%(95%CI:82%-92%)在1年,81%(95%CI:75%-86%)在2年,3年时为72%(95%CI:66%-79%),两组之间没有显着差异(p=0.9)体表面积(OR:1.35,p<0.001),植入BEV(比值比(OR):3.32,p<0.001),没有扩张后(OR:2.16,p<0.001)是任何PPM的独立危险因素。三年后,与≥中度PPM患者相比,无PPM患者的3年生存率更高(77%vs.67%,p=0.03)。
■BEV在小环患者中的植入与出院前严重PPM的发生率比SEV植入高两倍相关。TAVR后3年的生存率与BEV和SEV相似。然而,与≥中度PPM患者相比,无出院前PPM患者的3年生存率更高.
UNASSIGNED: Clinical consequences of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) is currently in the focus of clinical research. Patients with small aortic annulus are at higher risk to display PPM. Data on incidence and clinical consequences of PPM after TAVR with either balloon-expandable (
BEV) or self-expanding (SEV) transcatheter heart valves in small aortic annulus are sparse.
UNASSIGNED: Patients with small aortic annulus (perimeter < 72 mm or aortic annulus area < 400 mm2) who underwent
BEV or SEV with contemporary transcatheter heart valve types were identified from the institutional TAVR database. Propensity score matching was applied for imbalanced baseline characteristics between patients undergoing BEV or SEV. Echocardiography and clinical follow-up beyond 3 years was reported following VARC-3 recommendations. Primary endpoint was the incidence of pre-discharge PPM and its association with 3-year mortality.
UNASSIGNED: From a total of 507 patients with small aortic annulus, 192 matched patient pairs with SEV or
BEV were identified. Mean age was 81 ± 7 (SEV) vs. 81 ± 6 (
BEV) years (p = 0.5), aortic annulus perimeter was 69 ± 3 vs.69 ± 3 mm, (p = 0.8), annulus area was 357 ± 27 vs.357 ± 27 mm2 (p = 0.8), and EuroScore II was 5.8 ± 6.6 vs.5.7 ± 7.2 (p = 0.9). SEV resulted in less moderate (20% vs. 31%, p < 0.001) and severe pre-discharge PPM (9% vs.18%, p < 0.001) compared to BEV. At discharge (7 ± 4 vs. 12 ± 9 mmHg, p = 0.003) and at 1-year follow-up (7 ± 5 vs.13 ± 3 mmHg, p < 0.001), SEV displayed lower mean gradients compared to BEV. Estimated survival after SEV was 85% (95% confidence interval (CI): 80%-90%) at 1 year, 80% (95% CI: 75%-86%) at 2 years, and 71% (95% CI: 65%-78%) at 3 years; estimated survival after BEV was 87% (95% CI: 82%-92%) at 1 year, 81% (95% CI: 75%-86%) at 2 years, and 72% (95% CI: 66%-79%) at 3 years, with no significant difference among the groups (p = 0.9) Body surface area (OR: 1.35, p < 0.001), implantation of BEV (odds ratio (OR): 3.32, p < 0.001), and the absence of postdilatation (OR: 2.16, p < 0.001) were independent risk factors for any PPM. At 3 years, patients without PPM had a higher 3-year survival compared with patients with ≥moderate PPM (77% vs. 67%, p = 0.03).
UNASSIGNED: BEV implantation in patients with small annulus was associated with a twofold higher incidence of pre-discharge severe PPM compared to SEV implantation. Survival at 3 years after TAVR was similar after
BEV and SEV. However, patients with the absence of pre-discharge PPM had a higher 3-year survival compared to patients with ≥moderate PPM.