Incidence, Characteristics, Predictors, and Outcomes of Surgical Explantation After Transcatheter Aortic Valve Replacement

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

卷:76

Article

Hirji, Sameer A.¹  Percy, Edward D.¹  McGurk, Siobhan¹  Malarczyk, Alexandra¹  Harloff, Morgan T.¹  Yazdchi, Farhang¹  Sabe, Ashraf A.¹  Bapat, Vinayak N.²  Tang, Gilbert H. L.³  Bhatt, Deepak L.⁴  Thourani, Vinod H.⁵  Leon, Martin B.^6,7  O'Gara, Patrick⁴  Shah, Pinak B.⁴  Kaneko, Tsuyoshi¹ 

[1] Harvard Med Sch, Brigham & Womens Hosp, Dept Surg, Div Cardiac Surg, Boston, MA 02115 USA

[2] Columbia Univ, Med Ctr, Dept Cardiac Surg, New York, NY USA

[3] Mt Sinai Med Ctr, Dept Cardiovasc Surg, New York, NY 10029 USA

[4] Harvard Med Sch, Brigham & Womens Hosp, Dept Med, Div Cardiol, Boston, MA 02115 USA

[5] Marcus Valve Ctr, Piedmont Heart Inst, Dept Cardiovasc Surg, Atlanta, GA USA

[6] Columbia Univ, Med Ctr, New York Presbyterian Hosp, New York, NY USA

[7] Cardiovasc Res Fdn, New York, NY USA

关键词: surgical aortic valve replacement;    TAVR explantation;    transcatheter aortic valve replacement;   

DOI  :  10.1016/j.jacc.2020.08.048

来源: Elsevier

【 摘 要 】

BACKGROUND Currently, there is a paucity of information on surgical explantation after transcatheter aortic valve replacement (TAVR). OBJECTIVES The purpose of this study was to examine the incidence, patient characteristics, predictors, and outcomes of surgical explantation after TAVR using a population-based, nationally representative database. METHODS We analyzed the Medicare Provider profile to include all U.S. patients undergoing TAVR from 2012 to 2017. Time to surgical explant was calculated from the index TAVR discharge to surgical explantation. Post-operative survival was assessed using time-dependent Cox proportional hazard regression analysis and landmark analysis. RESULTS The incidence of surgical explantation was 0.2% (227 of 132,633 patients), and was 0.28% and 0.14% in the early and newer TAVR era, respectively. The median time to surgical explant was 212 days, whereas 8.8% and 70.9% underwent surgical explantation within 30 days and 1 year, respectively. The primary indication for reintervention was bioprosthetic failure (79.3%). Compared with the no-explant cohort, the explant cohort was significantly younger (mean age 73.7 years vs. 81.7 years), with a lower prevalence of heart failure (55.9% vs. 65.8%) but more likely a lower-risk profile cohort (15% vs. 2.4%; all p < 0.05). The 30-day and 1-year mortality rates were 13.2% and 22.9%, respectively, and did not vary by either time to surgical explant or TAVR era, or between patients with versus without endocarditis (all p > 0.05). The time-dependent Cox regression analysis demonstrated a higher mortality in those with surgical explantation (hazard ratio: 4.03 vs. no-explant group; 95% confidence interval: 1.81 to 8.98). Indication, time-to-surgical-explant, and year of surgical explantation were not associated with worse post-explantation survival (all p > 0.05). CONCLUSIONS The present study provides updated evidence on the incidence, timing, and outcomes of surgical explantation of a TAVR prosthesis. Although the overall incidence was low, short-term mortality was high. These findings stress the importance of future mechanistic studies on TAVR explantation and may have implications on lifetime management of aortic stenosis, particularly in younger patients. (C) 2020 by the American College of Cardiology Foundation.

【 授权许可】

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