Incidence and Sequelae of Prosthesis-Patient Mismatch in Transcatheter Versus Surgical Valve Replacement in High-Risk Patients With Severe Aortic Stenosis A PARTNER Trial Cohort-A Analysis

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

卷:64

Article

Pibarot, Philippe¹  Weissman, Neil J.²  Stewart, William J.³  Hahn, Rebecca T.^4,5  Lindman, Brian R.⁶  McAndrew, Thomas⁵  Kodali, Susheel K.^4,5  Mack, Michael J.⁷  Thourani, Vinod H.⁸  Miller, Craig⁹  Svensson, Lars G.¹⁰  Herrmann, Howard C.¹¹  Smith, Craig R.^4,5  Rodes-Cabau, Josep¹  Webb, John^12,13  Lim, Scott¹⁴  Xu, Ke⁵  Hueter, Irene⁴  Douglas, Pamela S.^15,16  Leon, Martin B.^4,5 

[1] Univ Laval, Quebec Heart & Lung Inst, Inst Univ Cardiol & Pneumol Quebec, Quebec City, PQ, Canada

[2] Medstar Hlth Res Inst, Washington, DC USA

[3] Cleveland Clin, Dept Cardiovasc Med, Cleveland, OH 44106 USA

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

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

[6] Washington Univ, Sch Med, St Louis, MO USA

[7] Baylor Healthcare Syst, Dallas, TX USA

[8] Emory Univ, Sch Med, Atlanta, GA USA

[9] Stanford Univ, Sch Med, Stanford, CA 94305 USA

[10] Cleveland Clin, Dept Thorac & Cardiovasc Surg, Cleveland, OH 44106 USA

[11] Hosp Univ Penn, Philadelphia, PA 19104 USA

[12] Univ British Columbia, Vancouver, BC V5Z 1M9, Canada

[13] St Pauls Hosp, Vancouver, BC V6Z 1Y6, Canada

[14] Univ Virginia, Med Ctr, Charlottesville, VA USA

[15] Duke Univ, Med Ctr, Durham, NC USA

[16] Duke Clin Res Inst, Durham, NC USA

关键词: aortic regurgitation;    Doppler echocardiography;    left ventricular mass regression;    mortality;   

DOI  :  10.1016/j.jacc.2014.06.1195

来源: Elsevier

【 摘 要 】

BACKGROUND Little is known about the incidence of prosthesis-patient mismatch (PPM) and its impact on outcomes after transcatheter aortic valve replacement (TAVR). OBJECTIVES The objectives of this study were: 1) to compare the incidence of PPM in the TAVR and surgical aortic valve replacement (SAVR) randomized control trial (RCT) arms of the PARTNER (Placement of AoRTic TraNscathetER Valves) I Trial cohort A; and 2) to assess the impact of PPM on regression of left ventricular (LV) hypertrophy and mortality in these 2 arms and in the TAVR nonrandomized continued access (NRCA) registry cohort. METHODS The PARTNER Trial cohort A randomized patients 1: 1 to TAVR or bioprosthetic SAVR. Postoperative PPM was defined as absent if the indexed effective orifice area (EOA) was >0.85 cm(2)/m(2), moderate if the indexed EOA was >= 0.65 but <= 0.85 cm(2)/m(2), or severe if the indexed EOA was <0.65 cm(2)/m(2). LV mass regression and mortality were analyzed using the SAVR-RCT (n = 270), TAVR-RCT (n = 304), and TAVR-NRCA (n = 1,637) cohorts. RESULTS The incidence of PPM was 60.0% (severe: 28.1%) in the SAVR-RCT cohort versus 46.4% (severe: 19.7%) in the TAVR-RCT cohort (p < 0.001) and 43.8% (severe: 13.6%) in the TAVR-NRCA cohort. In patients with an aortic annulus diameter <20 mm, severe PPM developed in 33.7% undergoing SAVR compared with 19.0% undergoing TAVR (p = 0.002). PPM was an independent predictor of less LV mass regression at 1 year in the SAVR-RCT (p = 0.017) and TAVR-NRCA (p = 0.012) cohorts but not in the TAVR-RCT cohort (p = 0.35). Severe PPM was an independent predictor of 2-year mortality in the SAVR-RCT cohort (hazard ratio [HR]: 1.78; p = 0.041) but not in the TAVR-RCT cohort (HR: 0.58; p = 0.11). In the TAVR-NRCA cohort, severe PPM was not a predictor of 1-year mortality in all patients (HR: 1.05; p = 0.60) but did independently predict mortality in the subset of patients with no post-procedural aortic regurgitation (HR: 1.88; p = 0.02). CONCLUSIONS In patients with severe aortic stenosis and high surgical risk, PPM is more frequent and more often severe after SAVR than TAVR. Patients with PPM after SAVR have worse survival and less LV mass regression than those without PPM. Severe PPM also has a significant impact on survival after TAVR in the subset of patients with no post-procedural aortic regurgitation. TAVR may be preferable to SAVR in patients with a small aortic annulus who are susceptible to PPM to avoid its adverse impact on LV mass regression and survival. (C) 2014 by the American College of Cardiology Foundation.

【 授权许可】

Free