Analysis of the short and medium term outcomes of transcatheter aortic valve replacement combined with percutaneous coronary intervention in the treatment of aortic stenosis and coronary heart disease
-
摘要: 目的 分析经导管主动脉瓣置换术(TAVR)同期行经皮冠状动脉介入(PCI)治疗严重主动脉瓣狭窄合并冠心病的近中期疗效。方法 回顾性纳入2018年1月—2023年7月于南京鼓楼医院、华中阜外医院接受TAVR同期或分期行PCI治疗的患者，分为同期组和分期组；比较两组的围术期资料和随访资料。结果 共纳入47例患者，同期组13例；分期组34例，其中29例PCI和TAVR在同一住院期间进行，5例于两次住院期间完成，间隔时间为2~87 d，中位间隔5(3，8) d。与分期组相比，同期组患者合并心绞痛显著较高，差异有统计学意义(P<0.01)。两组性别、年龄、体重指数、基础病史等基线资料比较差异均无统计学意义。围术期两组死亡、脑卒中和新发心肌梗死均差异无统计学意义。此外，两组围术期低心排量综合征、心房颤动、心室颤动、新发二、三度房室传导阻滞、永久起搏器置入、中重度瓣周漏、急性肾损伤、血管并发症等发生率，以及机械通气时间、ICU停留时间、术后住院时间、术中出血量、术后输血率等比较均差异无统计学意义。随访3~66个月，中位随访18.8(9.5，34.3)个月，两组中重度瓣周漏、死亡和再入院的发生率，以及术后3个月的左心室射血分数和左心室舒张末期内径比较均差异无统计学意义。结论 对于严重主动脉瓣狭窄合并冠心病的患者，TAVR同期行PCI治疗是安全可行的。
-
关键词:
- 主动脉瓣狭窄 /
- 冠心病 /
- 经导管主动脉瓣置换术 /
- 经皮冠状动脉介入
Abstract: Objective To evaluate the short-and medium-term outcomes of transcatheter aortic valve replacement(TAVR) combined with percutaneous coronary intervention(PCI) in patients with severe aortic stenosis and coronary artery disease.Methods This retrospective study included patients who underwent TAVR and either concurrent or staged PCI at Nanjing Drum Tower Hospital and Central China Fuwai Hospital between January 2018 and July 2023. Patients were classified into two groups: the concurrent group, in which TAVR and PCI were performed during the same hospitalization, and the staged group, where the procedures were performed during separate hospitalizations. Perioperative and follow-up data were compared between the two groups.Results A total of 47 patients were included, with 13 patients in the concurrent group and 34 patients in the staged group. Among the 47 patients, 29 underwent both PCI and TAVR in the same hospitalization, while 5 underwent the procedures during two separate hospitalizations. The interval between procedures in the staged group ranged from 2 to 87 days, with a median interval of 5(3, 8) days. The proportion of patients in the concurrent group presenting with angina symptoms was significantly higher than in the staged group(P<0.01). No significant differences were observed between the two groups regarding baseline characteristics, including gender, age, body mass index, and medical history(all P>0.05). Additionally, there were no significant differences in perioperative outcomes, including death, stroke, new myocardial infarction, and complications such as low cardiac output syndrome, atrial fibrillation, ventricular fibrillation, new-onset Ⅱ-Ⅲ degree atrioventricular block, permanent pacemaker implantation, moderate-to-severe paravalvular leak, acute kidney injury, vascular complications, mechanical ventilation time, ICU stay, postoperative hospital stay, intraoperative blood loss, and blood transfusion rates(all P>0.05). The median follow-up was 18.8 months(range 3-66 months). There were no significant differences in the incidence of moderate-to-severe paravalvular leak, mortality, readmissions, left ventricular ejection fraction, or left ventricular end-diastolic dimension 3 months post-surgery(all P>0.05).Conclusion TAVR combined with PCI is a safe and feasible treatment option for patients with severe aortic stenosis and coronary artery disease. -
-
表 1 两组基线资料比较
Table 1. Comparison of baseline data
例(%), X±S 项目 同期组(13例) 分期组(34例) χ2/t P 男性 9(69.2) 20(58.8) 0.431 0.511 年龄/岁 71.6±5.8 71.8±6.0 -0.092 0.927 BMI/(kg/m2) 23.6±1.8 24.8±4.7 -0.929 0.359 高血压 9(69.2) 24(70.6) 0.008 1.000 糖尿病 4(30.8) 8(23.5) 0.713 高脂血症 6(46.2) 11(32.4) 0.776 0.378 吸烟史 7(50.0) 15(44.1) 0.367 0.550 COPD 2(15.4) 5(14.7) 1.000 PCI史 3(23.1) 7(20.9) 1.000 心绞痛 8(61.5) 15(44.1) 47.000 <0.001 心肌梗死 5(38.5) 8(23.5) 1.048 0.306 心房颤动 2(15.4) 5(14.7) 1.000 脑血管疾病 3(23.1) 7(20.6) 1.000 肾功能不全 4(30.8) 6(17.6) 0.441 NYHA心功能 Ⅲ级 10(76.9) 29(85.3) 0.666 Ⅳ级 2(15.4) 5(14.7) 1.000 病变血管数 0.056 0.972 1支 5(38.4) 12(35.3) 2支 6(46.2) 16(47.1) 3支 2(15.4) 6(17.6) 病变血管部位 左主干 1(7.7) 3(8.8) 1.000 前降支 10(76.9) 27(79.4) 1.000 回旋支 7(53.8) 20(58.8) 0.095 0.758 右冠脉 7(53.8) 14(41.2) 0.611 0.435 超声心动图 LVEF/% 54.8±9.3 54.7±9.7 0.012 0.990 LVEDD/mm 53.5±6.0 52.5±8.3 0.461 0.647 注：COPD：慢性阻塞性肺疾病；NYHA：美国纽约心脏病学会；LVEF：左心室射血分数；LVEDD：左心室舒张末期内径。 
下载: 导出CSV
表 2 两组围术期资料比较
Table 2. Comparison of perioperative data
例(%), M(P25, P75) 围术期资料 同期组(13例) 分期组(34例) Z/χ2 P 死亡 1(7.7) 1(2.9) 0.481 新发心肌梗死 0 1(2.9) 1.000 脑卒中 1(7.7) 3(8.8) 1.000 低心排血量综合征 1(7.7) 1(2.9) 0.481 ECMO辅助 0 1(2.9) 1.000 心房颤动 2(15.4) 4(11.8) 1.000 心室颤动 2(15.4) 2(5.9) 0.304 新发房室传导阻滞 3(23.1) 6(17.6) 0.692 永久起搏器置入 1(7.7) 1(2.9) 0.481 中重度瓣周漏 0 1(2.9) 1.000 急性肾损伤 1(7.7) 1(2.9) 0.481 血管并发症 0 1(2.9) 1.000 消化道出血 0 1(2.9) 1.000 机械通气时间/h 11(6，18) 8(5，26) -1.239 0.215 ICU停留时间/h 24(21，45) 20(18，46) -1.621 0.105 术后住院时间/d* 6(5，8) 5(4，7) -1.633 0.102 术中出血量/mL 20(15，40) 20(10，30) -0.220 0.826 术后输血 2(15.4) 5(14.7) 1.000 完全血运重建 8(61.5) 22(64.7) 0.041 0.840 *指TAVR术后住院时间。
下载: 导出CSV
表 3 两组随访资料比较
Table 3. Comparison of follow-up data
例(%), X±S, M(P25, P75) 随访资料 同期组(12例) 分期组(33例) Z/t/χ2 P 随访时间/月 17.9(8.9，35.2) 21.8(11.1，34.4) -0.499 0.617 随访超声心动图 中重度瓣周漏 1(8.3) 1(3.0) 1.000 术后3个月LVEF/% 59.1±6.2 59.5±6.6 -0.171 0.865 术后3个月LVEDD/mm 48.0±6.3 48.4±8.0 -0.148 0.833 死亡 1(8.3) 2(6.1) 0.787 心脏骤停 1(8.3) 0 0.267 脑梗死 0 1(3.0) 1.000 胃癌转移 0 1(3.0) 1.000 再入院 2(16.7) 4(12.1) 0.644 心律失常 1(8.3) 0 0.267 胃部不适 0 1(3.0) 1.000 胸闷、中度瓣周漏 1(8.3) 0 0.267 完全性左束支传导阻滞 0 2(6.1) 0.600 新冠肺炎 0 1(3.0) 1.000
下载: 导出CSV
表 4 TAVR患者不同PCI治疗时机策略的优缺点
Table 4. Advantages and disadvantages of different strategies
策略 TAVR前分期PCI 同期PCI和TAVR TAVR后分期PCI 优点 ①不受限制的冠脉通路；②减少TAVR前的缺血性负荷；③降低围术期急性冠脉综合征的风险；④单次较少的造影剂使用量 ①减少TAVR前入院，可能会降低相关费用；②TAVR术后血流动力学即刻改善；③避免额外的血管通路管理 ①减少左心室压力负荷，PCI期间血流动力学稳定；②提高冠脉生理评估的准确性；③对复杂PCI的耐受性更高 缺点 ①双联抗血小板治疗会增加出血的风险；②在主动脉瓣跨瓣压差较大的情况下，PCI期间存在血流动力学不稳定的风险；③额外的血管穿刺和增加入路并发症的风险 ①手术时间较长，对术者的手术经验要求较高；②单次较多的造影剂使用量 ①TAVR后PCI的难度显著增加，尤其对于自膨胀式瓣膜；②CAD增加TAVR期间血流动力学不稳定的风险；③额外的血管穿刺和增加入路并发症的风险
下载: 导出CSV
-
[1] Androshchuk V, Patterson T, Redwood SR. Management of coronary artery disease in patients with aortic stenosis[J]. Heart, 2023, 109(4): 322-329. doi: 10.1136/heartjnl-2022-321605
[2] del Portillo JH, Pasos JIF, Galhardo A, et al. Aortic stenosis combined with coronary artery disease: SAVR or TAVR-when and how?[J]. Can J Cardiol, 2023, 282(23): 1738. http://dx.doi.org/10.1016/j.cjca.2023.09.023
[3] Massussi M, Adamo M, Rosati F, et al. Coronary artery disease and TAVI: current evidence on a recurrent issue[J]. Catheter Cardiovasc Interv, 2023, 101(6): 1154-1160. doi: 10.1002/ccd.30653
[4] Guo Y, Zhang W, Wu H. Percutaneous versus surgical approach to aortic valve replacement with coronary revascularization: a systematic review andmeta-analysis[J]. Perfusion, 2024, 39(6): 1152-1160. doi: 10.1177/02676591231178894
[5] Lérault A, Villecourt A, Decottignies-Dienne T, et al. Catheter versus surgical approach for the management of concomitant aortic stenosis and coronary artery disease: an inverse probability treatment weighting analysis[J]. Arch Cardiovasc Dis, 2023, 116(3): 117-125. doi: 10.1016/j.acvd.2022.12.004
[6] 王世杰, 刘鹏, 温姝钰, 等. 主动脉瓣疾病手术治疗现状与进展[J]. 临床心血管病杂志, 2023, 39(6): 417-424. doi: 10.13201/j.issn.1001-1439.2023.06.003
[7] Patlolla SH, Schaff HV, Dearani JA, et al. Aortic stenosis and coronary artery disease: cost of transcatheter vs surgical management[J]. Ann Thorac Surg, 2022, 114(3): 659-666. doi: 10.1016/j.athoracsur.2021.08.028
[8] 郭颖, 张瑞生. 中国成人心脏瓣膜病超声心动图规范化检查专家共识[J]. 中国循环杂志, 2021, 36(2): 109-125. doi: 10.3969/j.issn.1000-3614.2021.02.002
[9] Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction(2018)[J]. J Am Coll Cardiol, 2018, 72(18): 2231-2264. doi: 10.1016/j.jacc.2018.08.1038
[10] Rao V, Ivanov J, Weisel RD, et al. Predictors of low cardiac output syndrome after coronary artery bypass[J]. J Thorac Cardiovasc Surg, 1996, 112(1): 38-51. doi: 10.1016/S0022-5223(96)70176-9
[11] Khwaja A. KDIGO clinical practice guidelines for acute kidney injury[J]. Nephron Clin Pract, 2012, 120(4): c179-c184. doi: 10.1159/000339789
[12] Hermiller JB Jr, Gunnarsson CL, Ryan MP, et al. The need for future coronary access following surgical or transcatheter aortic valve replacement[J]. Catheter Cardiovasc Interv, 2021, 98(5): 950-956. doi: 10.1002/ccd.29841
[13] Yang Y, Huang FY, Huang BT, et al. The safety of concomitant transcatheter aortic valve replacement and percutaneous coronary intervention: a systematic review and meta-analysis[J]. Medicine, 2017, 96(48): e8919. doi: 10.1097/MD.0000000000008919
[14] Søndergaard L, Popma JJ, Reardon MJ, et al. Comparison of a complete percutaneous versus surgical approach to aortic valve replacement and revascularization in patients at intermediate surgical risk: results from the randomized SURTAVI trial[J]. Circulation, 2019, 140(16): 1296-1305. doi: 10.1161/CIRCULATIONAHA.118.039564
[15] Patterson T, Clayton T, Dodd M, et al. ACTIVATION(PercutAneous coronary inTervention prIor to transcatheter aortic VAlve implantaTION): a randomized clinical trial[J]. JACC Cardiovasc Interv, 2021, 14(18): 1965-1974. doi: 10.1016/j.jcin.2021.06.041
[16] Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American college of cardiology/American heart association joint committee on clinical practice guidelines[J]. Circulation, 2021, 143(5): e35-e71.
[17] Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease[J]. Eur Heart J, 2022, 43(7): 561-632. doi: 10.1093/eurheartj/ehab395
[18] Kumar A, Sammour Y, Reginauld S, et al. Adverse clinical outcomes in patients undergoing both PCI and TAVR: analysis from a pooled multi-center registry [J]. Catheter Cardiovasc Interv, 2021, 97(3): 529-539. doi: 10.1002/ccd.29233
[19] Ochiai T, Yoon SH, Flint N, et al. Timing and outcomes of percutaneous coronary intervention in patients who underwent transcatheter aortic valve implantation [J]. Am J Cardiol, 2020, 125(9): 1361-1368. doi: 10.1016/j.amjcard.2020.01.043
[20] Rheude T, Costa G, Ribichini FL, et al. Comparison of different percutaneous revascularisation timing strategies in patients undergoing transcatheter aortic valve implantation[J]. EuroIntervention, 2023, 19(7): 589-599. doi: 10.4244/EIJ-D-23-00186
[21] Tran Z, Hadaya J, Downey P, et al. Staged versus concomitant transcatheter aortic valve replacement and percutaneous coronary intervention: a national analysis[J]. JTCVS Open, 2022, 10: 148-161. doi: 10.1016/j.xjon.2022.02.019
-
计量
- 文章访问数: 717
- 施引文献: 0