Primerjava različnih metod vstavitve bioloških zaklopk pri bolnikih z aortno stenozo, starih osemdeset let ali več

Kolar, Tadeja (author), Bunc, Matjaž (mentor)

Uvod: Transkatetrska vstavitev aortne zaklopke (TAVI) se je v zadnjih letih uveljavila kot primerljiva metoda zdravljenja hude aortne stenoze pri starostnikih in bolnikih s pridruženimi obolenji. Namen naše študije je bil primerjati obolevnost in smrtnost pri bolnikih, starejših od 80 let, po TAVI in po kirurški menjavi aortne zaklopke (AVR) (z maloinvazivnim pristopom (MISAVR) ali s klasično menjavo aortne zaklopke (SAVR)). Pridobiti smo želeli podatke o zdravljenju bolnikov v UKC Ljubljana in s tem opredeliti primerljivost rezultatov zdravljenja s podatki, dostopnimi v literaturi. Poleg tega smo s tem tudi želeli ugotoviti, katera od tehnik je primernejša za posamezno skupino bolnikov glede na prisotne dejavnike tveganja pred posegom. Metode: Raziskavo smo zasnovali kot retrospektivno študijo, pri kateri smo zbirali podatke o bolnikih, obravnavanih v UKC Ljubljana zaradi izolirane hude aortne stenoze, pri katerih je bil napravljen TAVI ali AVR (v obdobju od januarja 2013 do maja 2019). Sledenje je bilo zaključeno maja 2022. Zbrali smo podatke o obolevnosti in smrtnosti. Bolnike smo nato razdelili tudi po predproceduralno opredeljeni stopnji tveganja za poseg (STS score). Pri statistični obdelavi smo uporabili tudi metodo usklajevanja glede na stopnjo nagnjenja (PSM - »propensity score matching«), da bi dobili čim bolj primerljive rezultate. Rezultati: V študijo je bilo vključenih 542 bolnikov, od tega je bil pri 273 napravljen TAVI, pri 206 MISAVR in pri 63 SAVR. Povprečna starost bolnikov je bila statistično pomembno višja v skupini TAVI (TAVI vs. MISAVR vs. SAVR: 85.8 ± 4.2 leta vs. 82.9 ± 2.9 leta vs. 82.5 ± 2.3 leta; P < 0.001). Tudi STS score (5.0 ± 4.0 vs. 2.8 ± 1.4, vs. 2.8 ± 1.1; P < 0.001) in EuroSCORE II (5.3 ± 4.1 vs. 2.4 ± 1.3 vs. 2.9 ± 1.6; P < 0.001) sta bila višja pri bolnikih v skupini TAVI. Pogostost pooperativne akutne poškodbe ledvic, novonastale atrijske fibrilacije in trajanje hospitalizacije je bila manjša oziroma krajša po TAVI. Pojavnost zmernega do hudega paravalvularnega puščanja pa je bila pogostejša po TAVI. Med skupinami ni bilo statistično pomembnih razlik v preživetju po 30 dneh (3.3% vs. 2.9% vs. 1.6%; P = 0.770), po enem letu (11.7% vs. 8.7% vs. 112.7%; P = 0.499) ali dveh letih (19.4% vs. 13.1% vs. 17.5%; P = 0.106) in pri vnaprej določenem sestavljenem opazovanem dogodku (3.3% vs. 5.3% vs. 4.8%; P = 0.534). Pojavila pa se je statistično pomembna razlika v preživetju po treh letih (P = 0.001). Pri primerjavi populacije z metodo PSM so bili kratkoročni rezultati boljši po TAVI, a srednjeročno preživetje je ostalo statistično pomembno boljše v kirurški skupini (3-letna smrtnost: TAVI vs. AVR: 42.4% vs. 28.2%; P = 0.047). Zaključek: Naša študija je pokazala primerljive postoperativne rezultate pri populaciji bolnikov, starih 80 let ali več, ne glede na vrsto opravljenega posega (TAVI, MISAVR ali SAVR). Ima pa manj invazivna kirurška metoda statistično pomembno boljše rezultate glede srednjeročnega preživetja.

• Language: Slovenian
• Keywords: TAVI, manj invazivna menjava aortne zaklopke, aortna stenoza, AVR
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2023
• PID: 20.500.12556/RUL-144454
• Publication date in RUL: 23.02.2023

Secondary language

• Language: English
• Title: Comparison of different methods of implantation of biological valve in octogenerians with aortic valve stenosis

Abstract

Background: In recent years transcatheter aortic valve implantation (TAVI) became an established method of treatment of severe aortic valve stenosis in the elderly patients and patients with comorbidities. With our study we sought to compare outcomes after TAVI, minimaly invasive aortic valve replavement (MISAVR) and standard full-sternotomy aortic valve replacement (SAVR) in octogenarians in our facility in the last decade. Methods: In this retrospective cohort study conducted at our teritary center, clinical data were gathered befor and after TAVI, MISAVR and SAVR procedures performed from January 2013 to May 2019; follow-up was completed in March 2021. We gathered data on pre-, peri- and postprocedural mortality and morbidity. Patients were also stratified according to Society of thoracic Surgeons (STS-PROM) score and procedure type. Propensity score-based matching was also performed. Results: Of 542 patients who matched the inclusion criteria, 273 underwent TAVI, 206 MISAVR and 63 SAVR. TAVI patients were older (TAVI vs. MISAVR vs. SAVR: 85.8±4.2 let vs. 82.9±2.9 let vs. 82.5±2.3 years; P<0.001) and had a higher STS score (5.0±4.0 vs. 2.8±1.4, vs. 2.8±1.1; P<0.001) and EuroSCORE II (5.3±4.1 vs. 2.4±1.3 vs. 2.9±1.6; P<0.001). The rates of postoperative acute kidney injury and atrial fibrillation were lower after TAVI. The lenght of hospital stay was also shorter after TAVI. The rate of moderate to severe paravalvular leak was higher after TAVI. There was no difference between treatment groups for 30-day mortality (TAVI vs. MISAVR vs. SAVR: 3.3% vs. 2.9% vs. 1.6%; P = 0.770), 1-year mortality (TAVI vs. MISAVR vs. SAVR: 11.7% vs. 8.7% vs. 112.7%; P = 0.499), 2-years mortality (TAVI vs. MISAVR vs. SAVR: 19.4% vs. 13.1% vs. 17.5%; P = 0.106) and MACE (TAVI vs. MISAVR vs. SAVR: 3.3% vs. 5.3% vs. 4.8%; P = 0.534). There was however a statisticaly significant difference for 3-years mortality. Propensity score analysis for our population showed similar clinica outcomes with the exception of 30-day mortality and rate of MACE, both in favour of TAVI group and 3-years mortality (TAVI vs. AVR: 42.4% vs. 28.2%; P = 0.047) in favour of AVR. Conclusion: Our analysis of octogenarian »real-life« population undergoing TAVI, MISAVR or SAVR showed similar outcomes with the exception of statisticaly significant difference in 3-year mortality in favour of MISAVR.

• Keywords: TAVI, aortic stenosis, minimally invasive aortic valve replacement, AVR