Comparison of Postdischarge Outcomes Between Valve-in-Valve Transcatheter Mitral Valve Replacement and Reoperative Surgical Mitral Valve Replacement.
Comparison of Postdischarge Outcomes Between Valve-in-Valve Transcatheter Mitral Valve Replacement and Reoperative Surgical Mitral Valve Replacement.
复制标题
瓣中瓣经导管二尖瓣置换术与再次手术二尖瓣置换术的出院后结果比较。
DOI：
10.1016/j.amjcard.2023.01.039
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发表时间：
2023
期刊：
影响因子：
--
通讯作者：
Kaneko,Tsuyoshi
中科院分区：
文献类型：
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作者：
Zogg,CherylK;Hirji,SameerA;Percy,EdwardD;Newell,PaigeC;Shah,PinakB;Kaneko,Tsuyoshi
在全国范围内，孤立瓣中瓣经导管二尖瓣置换术（VIV-TMVR）与外科再手术二尖瓣置换术（re-SMVR）出院后围手术期结果的比较数据有限。本研究的目的是利用一个大型的国家多中心纵向数据库，对孤立的VIV-TMVR和re-SMVR的当代出院后预后进行有力的正面评估。在2015年至2019年全国再入院数据库中确定了年龄≥18岁、接受分离VIV-TMVR或re-SMVR的生物假体二尖瓣失败/退化的成年患者。使用倾向性评分加权和重叠权重来模拟随机对照试验的结果，比较30天、90天和180天预后的风险调整差异。并比较了经鼻中隔和经根尖VIV-TMVR入路的差异。共纳入687例VIV-TMVR患者和2047例re-SMVR患者。在重叠加权以达到治疗组之间的平衡后，在30天（优势比[95%可信区间（CI）] 0.0.31[0.22 ~ 0.46]）、90天（0.34[0.23 ~ 0.50]）和180天（0.35[0.24 ~ 0.51]）内，VIV-TMVR与较低的主要发病率相关。主要发病率的差异主要是由较少的大出血（0.20[0.14至0.30]）、新发完全性心脏传导阻滞（0.48[0.28至0.84]）和需要放置永久性起搏器（0.26[0.12至0.55]）驱动的。在肾功能衰竭和中风方面差异不显著。VIV-TMVR还与较短的指数住院时间（中位差[95% CI] - 7.0[4.9至9.1]天）和患者出院回家的能力增加相关（优势比[95% CI] 3.35[2.37至4.72]）。两组住院总费用差异无统计学意义；住院或30天、90天和180天死亡率；或重新接纳。当使用经鼻中隔和经根尖入路分层VIV-TMVR通路时，结果仍然相似。随着时间的推移，结果的变化表明，从2015年到2019年，VIV-TMVR患者的结果明显改善，而re-SMVR患者的结果停滞不前。在这个具有全国代表性的大型二尖瓣生物假体失效/退化患者队列中，VIV-TMVR在发病率、出院和住院时间方面似乎比re-SMVR具有短期优势。死亡率和再入院率相等。需要更长期的研究来评估超过180天的进一步随访。
Limited data are available comparing the postdischarge perioperative outcomes of isolated valve-in-valve transcatheter mitral valve replacement (VIV-TMVR) versus surgical reoperative mitral valve replacement (re-SMVR) on a nationwide scale. The objective of this study was to perform a robust head-to-head assessment of contemporary postdischarge outcomes between isolated VIV-TMVR and re-SMVR using a large national multicenter longitudinal database. Adult patients aged ≥18 years with failed/degenerated bioprosthetic mitral valves who underwent either isolated VIV-TMVR or re-SMVR were identified in the 2015 to 2019 Nationwide Readmissions Database. The risk-adjusted differences in 30-, 90-, and 180-day outcomes were compared using propensity score weighting with overlap weights to mimic the results of a randomized controlled trial. The differences between a transeptal and transapical VIV-TMVR approach were also compared. A total of 687 patients with VIV-TMVR and 2,047 patients with re-SMVR were included. After the overlap weighting to attain balance between treatment groups, VIV-TMVR was associated with significantly lower major morbidity within 30 (odds ratio [95% confidence interval (CI)] 0.0.31 [0.22 to 0.46]), 90 (0.34 [0.23 to 0.50]), and 180 (0.35 [0.24 to 0.51]) days. The differences in major morbidity were primarily driven by less major bleeding (0.20 [0.14 to 0.30]), new onset complete heart block (0.48 [0.28 to 0.84]) and need for permanent pacemaker placement (0.26 [0.12 to 0.55]). The differences in renal failure and stroke were not significant. VIV-TMVR was also associated with shorter index hospital stays (median difference [95% CI] −7.0 [4.9 to 9.1] days) and an increased ability for patients to be discharged home (odds ratio [95% CI] 3.35 [2.37 to 4.72]). There were no significant differences in total hospital costs; in-hospital or 30-, 90-, and 180-day mortality; or readmission. The findings remained similar when stratifying the VIV-TMVR access using a transeptal versus a transapical approach. The changes in outcomes over time suggest marked improvements for patients with VIV-TMVR relative to stagnant results for patients with re-SMVR from 2015 to 2019. In this large nationally representative cohort of patients with failed/degenerated bioprosthetic mitral valves, VIV-TMVR appears to confer a short-term advantage over re-SMVR in terms of morbidity, discharge home, and length of stay. It yielded equivalent outcomes for mortality and readmission. Longer-term studies are needed to assess further follow-up beyond 180 days.