Anticoagulation After Surgical or Transcatheter Bioprosthetic Aortic Valve Replacement
Anticoagulation After Surgical or Transcatheter Bioprosthetic Aortic Valve Replacement
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DOI：
10.1016/j.jacc.2019.06.058
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发表时间：
2019-09-03
影响因子：
24
通讯作者：
Makkar, Raj R.
中科院分区：
文献类型：
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作者：
Chakravarty, Tarun;Patel, Akshar;Makkar, Raj R.
背景：关于生物主动脉瓣置换术（AVR）后抗凝治疗（AC）对瓣膜血流动力学和临床结局的影响，缺乏证据。在AVR后30天和1年进行超声心动图检查。分别采用线性回归模型和倾向评分校正考克斯比例模型评估AC对瓣膜血流动力学和临床结局的影响。（经导管主动脉瓣置换术[TAVR]，n = 3，889和外科AVR [SAVR]，研究了PARTNER 2（经导管主动脉瓣膜置入术）随机试验和非随机登记研究汇总队列中的患者（n = 943）。在评估血流动力学时调整瓣膜尺寸、瓣环直径、房颤和射血分数后，对于TAVR或SAVR队列，接受AC出院的患者与未接受AC出院的患者之间的主动脉瓣平均压差或主动脉瓣面积无显著差异。从30天到1年，未接受AC出院的患者中平均压差增加>10 mm Hg的比例显著高于接受AC出院的患者（2.3% vs. 1.1%，p = 0.03）。TAVR术后AC与不良结局之间无独立相关性（死亡，p = 0.15;再住院，p = 0.16），而SAVR后AC与卒中显著减少相关（风险比[HR]：0.17; 95%置信区间[CI]：0.05-0.60;结论：生物瓣膜主动脉瓣置换术后早期人工主动脉瓣关闭不导致不良临床事件，对主动脉瓣血流动力学无明显影响（主动脉瓣压差或面积），并与SAVR后卒中发生率降低相关（但与TAVR后无关）。生物瓣膜主动脉瓣置换术后早期AC是否对长期结局有影响仍有待确定。（AoRTic TraNscathetER瓣膜的放置[PARTNERII A]; NCT 01314313）（C）2019由Elsevier代表美国心脏病学会基金会发表。
BACKGROUND There is paucity of evidence on the impact of anticoagulation (AC) after bioprosthetic aortic valve replacement (AVR) on valve hemodynamics and clinical outcomes.OBJECTIVES The study aimed to assess the impact of AC after bioprosthetic AVR on valve hemodynamics and clinical outcomes.METHODS Data on antiplatelet and antithrombotic therapy were collected. Echocardiograms were performed at 30 days and 1 year post-AVR. Linear regression model and propensity-score adjusted cox proportional model were used to assess the impact of AC on valve hemodynamics and clinical outcomes, respectively.RESULTS A total of 4,832 patients undergoing bioprosthetic AVR (transcatheter aortic valve replacement [TAVR], n = 3,889 and surgical AVR [SAVR], n = 943) in the pooled cohort of PARTNER2 (Placement of Aortic Transcatheter Valves) randomized trials and nonrandomized registries were studied. Following adjustment for valve size, annular diameter, atrial fibrillation, and ejection fraction at the time of assessment of hemodynamics, there was no significant difference in aortic valve mean gradients or aortic valve areas between patients discharged on AC vs. those not discharged on AC, for either TAVR or SAVR cohorts. A significantly greater proportion of patients not discharged on AC had an increase in mean gradient >10 mm Hg from 30 days to 1 year, compared with those discharged on AC (2.3% vs. 1.1%, p = 0.03). There was no independent association between AC after TAVR and adverse outcomes (death, p = 0.15; rehospitalization, p = 0.16), whereas AC after SAVR was associated with significantly fewer strokes (hazard ratio [HR]: 0.17; 95% confidence interval [CI]: 0.05-0.60; p = 0.006).CONCLUSIONS In the short term, early AC after bioprosthetic AVR did not result in adverse clinical events, did not significantly affect aortic valve hemodynamics (aortic valve gradients or area), and was associated with decreased rates of stroke after SAVR (but not after TAVR). Whether early AC after bioprosthetic AVR has impact on long-term outcomes remains to be determined. (Placement of AoRTic TraNscathetER Valves [PARTNERII A]; NCT01314313) (C) 2019 Published by Elsevier on behalf of the American College of Cardiology Foundation.