Evaluation of Changes in Functional Status in the Year After Aortic Valve Replacement
Evaluation of Changes in Functional Status in the Year After Aortic Valve Replacement
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DOI：
10.1001/jamainternmed.2018.6738
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发表时间：
2019-03-01
影响因子：
39
通讯作者：
Lipsitz, Lewis A.
中科院分区：
文献类型：
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作者：
Kim, Dae Hyun;Afilalo, Jonathan;Lipsitz, Lewis A.
重要性功能状态是一个以患者为中心的结果，对于主动脉瓣置换术后健康相关生活质量的有意义的增益是重要的。目的确定经导管主动脉瓣置换术（TAVR）和外科主动脉瓣置换术（SAVR）后一年的功能状态轨迹。设计，设置，在一家学术中心对246例接受TAVR或SAVR治疗重度主动脉瓣狭窄的患者进行了一项前瞻性队列研究，随访12个月。研究于2014年2月1日至2017年6月30日进行;数据分析于2017年12月27日至2018年5月7日进行。EXPOSURES术前进行综合老年评估，并进行缺陷累积虚弱指数（CGA-FI）（范围，0-1;主要结果和测量方法进行电话访谈，以评估自我在术后1、3、6、9和12个月，报告了进行22项活动和体力任务的能力。结果在纳入研究的246例患者中，143例接受了TAVR（74例[51.7%]女性;平均[SD]年龄，84.2 [5.9]岁），103例接受了SAVR（46例[44.7%]女性;年龄，78.1 [5.3]岁）。根据基线和随访期间的功能状态确定了5种轨迹：从基线时极好到随访时改善（极好基线-改善）、良好（高基线-完全恢复）、一般（中度基线-轻微下降）、差（低基线-中度下降）和非常差（低基线-大幅下降）。TAVR后，最常见的轨迹为一般（54 [37.8%]），其次为良好（33 [23.1%]）、差（21 [14.7%]）、极好（20 [14.0%]）和极差（12 [8.4%]）轨迹。SAVR后，最常见的轨迹为良好（39 [37.9%]），其次为极好（38 [36.9%]）、一般（20 [19.4%]）、差（3 [2.9%]）和非常差（1 [1.0%]）轨迹。术前虚弱程度与较低的功能改善概率和较高的功能下降概率相关。TAVR后，CGA-FI水平为0.20或更低的患者具有极好（3例[50.0%]）或良好（3例[50.0%]）轨迹，而CGA-FI水平为0.51或更高的大多数患者具有较差（10例[45.5%]）或非常差（5例[22.7%]）轨迹。SAVR后，CGA-FI水平为0.20或更低的大多数患者的轨迹为极好（24 [58.5%]）或良好（15 [36.6%]），而CGA-FI水平为0.41 - 0.50的患者轨迹为一般（5 [71.4%]）。术后谵妄和主要并发症与TAVR术后功能下降相关（存在谵妄vs无谵妄：14例[50.0%] vs 11例[13.4%];存在并发症vs无并发症：14例[51.9%] vs 19例[16.4%]）或SAVR后无改善（谵妄存在与不存在：27例[69.2%]与31例[81.6%];并发症存在与不存在：10 [62.5%] vs 69 [79.3%]）结论和相关性研究结果表明，功能下降或缺乏改善在接受TAVR的严重虚弱的老年人中很常见。或SAVR。虽然这项非随机研究不允许比较TAVR和SAVR之间的有效性，但预期的功能恢复可以为以患者为中心的决策和围手术期护理提供信息，以优化功能结局。
IMPORTANCE Functional status is a patient-centered outcome that is important for a meaningful gain in health-related quality of life after aortic valve replacement.OBJECTIVE To determine functional status trajectories in the year after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).DESIGN, SETTING, AND PARTICIPANTS A prospective cohort study with a 12-month follow-up was conducted at a single academic center in 246 patients undergoing TAVR or SAVR for severe aortic stenosis. The study was conducted between February 1, 2014, and June 30, 2017; data analysis was performed from December 27, 2017, to May 7, 2018.EXPOSURES Preoperative comprehensive geriatric assessment was performed and a deficit-accumulation frailty index (CGA-FI) (range, 0-1; higher values indicate greater frailty) was calculated.MAIN OUTCOMES AND MEASURES Telephone interviewswere conducted to assess self-reported ability to perform 22 activities and physical tasks at 1, 3, 6, 9, and 12 months after the procedure.RESULTS Of the 246 patients included in the study, 143 underwent TAVR (74 [51.7%] women; mean [SD] age, 84.2 [5.9] years), and 103 underwent SAVR (46 [44.7%] women; age, 78.1 [5.3] years). Five trajectories were identified based on functional status at baseline and during the follow-up: from excellent at baseline to improvement at follow-up (excellent baseline-improvement), good (high baseline-full recovery), fair (moderate baseline-minimal decline), poor (low baseline-moderate decline), and very poor (low baseline-large decline). After TAVR, the most common trajectory was fair (54 [37.8%]), followed by good (33 [23.1%]), poor (21 [14.7%]), excellent (20 [14.0%]), and very poor (12 [8.4%]) trajectories. After SAVR, the most common trajectory was good (39 [37.9%]), followed by excellent (38 [36.9%]), fair (20 [19.4%]), poor (3 [2.9%]), and very poor (1 [1.0%]) trajectories. Preoperative frailty level was associated with lower probability of functional improvement and greater probability of functional decline. After TAVR, patients with CGA-FI level of 0.20 or lower had excellent (3 [50.0%]) or good (3 [50.0%]) trajectories, whereas most patients with CGA-FI level of 0.51 or higher had poor (10 [45.5%]) or very poor (5 [22.7%]) trajectories. After SAVR, most patients with CGA-FI level of 0.20 or lower had excellent (24 [58.5%]) or good (15 [36.6%]) trajectories compared with a fair trajectory (5 [71.4%]) in those with CGA-FI levels of 0.41 to 0.50. Postoperative delirium and major complications were associated with functional decline after TAVR (delirium present vs absent: 14 [50.0%] vs 11 [13.4%]; complications present vs absent: 14 [51.9%] vs 19 [16.4%]) or lack of improvement after SAVR (delirium present vs absent: 27 [69.2%] vs 31 [81.6%]; complications present vs absent: 10 [62.5%] vs 69 [79.3%]).CONCLUSIONS AND RELEVANCE The findings suggest that functional decline or lack of improvement is common in older adults with severe frailty undergoing TAVR or SAVR. Although this nonrandomized study does not allow comparison of the effectiveness between TAVR and SAVR, anticipated functional trajectoriesmay inform patient-centered decision making and perioperative care to optimize functional outcomes.