{"title":"经导管主动脉瓣置换术中瓣膜有意过大:越大越好吗?大型单中心经验","authors":"Khawaja Afzal Ammar MD , Alexandria Graeber BS , Abdur Rahman Ahmad MD , Jodi Zilinski MD , Daniel P. O’Hair MD , Renuka Jain MD , Suhail Q. Allaqaband MD , Tanvir Bajwa MD","doi":"10.1016/j.shj.2023.100278","DOIUrl":null,"url":null,"abstract":"<div><h3>Background</h3><p>The current clinical practice standard is 10% to 20% oversizing of self-expanding valves in transcatheter aortic valve replacement. We aimed to determine whether >20% oversizing of self-expanding valves (Medtronic Evolut) would lead to better valve performance with similar or better outcomes.</p></div><div><h3>Methods</h3><p>From October 2011 to December 2016, we approached all transcatheter aortic valve replacement patients with a conscious attempt at large oversizing (>20%). The most common valve used, excluding those used in valve-in-valve patients, was the 29-mm Evolut R (29%). We used a retrospective chart review to compare moderate oversizing (group 1; 10% to 20%) with large oversizing (group 2; >20%).</p></div><div><h3>Results</h3><p>Of 556 patients, 45% were male; the overall mean Society of Thoracic Surgeons risk score was 5.8 ± 3.8. Eighty-five (15%) patients needed a pacemaker, and 21 (3.8%) developed significant paravalvular leak. Mean oversizing was 20.3% ± 6.0%, with 41.4% of patients included in group 1 and 54.5% in group 2. Incidences of complications in group 2 vs. group 1 were as follows: a) paravalvular leak (2.0 vs. 6.1%; odds ratio = 0.31, <em>p</em> = 0.01), b) pacemaker (15 vs. 14%), c) gastrointestinal bleed (n = 4 vs. 0; 1.3 vs. 0.0%; <em>p</em> = 0.03), d) annular dissection (n = 1 vs. 0; 0.3 vs. 0%; <em>p</em> = 0.29), e) mortality (n = 5 vs. 4; 1.6 vs. 1.7%). Incidence of paravalvular leak was higher in those who died than survivors (13 vs. 1.3%; <em>p</em> ≤ 0.0001).</p></div><div><h3>Conclusions</h3><p>These data suggest that, in current self-expanding valves, >20% oversizing delivers a significantly lower prevalence of paravalvular leak without an increase in other complications. Since paravalvular leak is associated with increased mortality, >20% oversizing may represent a superior prosthesis choice.</p></div>","PeriodicalId":36053,"journal":{"name":"Structural Heart","volume":null,"pages":null},"PeriodicalIF":1.4000,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2474870623002294/pdfft?md5=618648d083cfd5a7c1c483c5ce1b3ec9&pid=1-s2.0-S2474870623002294-main.pdf","citationCount":"0","resultStr":"{\"title\":\"Intentional Oversizing of Valve in Transcatheter Aortic Valve Replacement: Is Bigger Better? A Large, Single-Center Experience\",\"authors\":\"Khawaja Afzal Ammar MD , Alexandria Graeber BS , Abdur Rahman Ahmad MD , Jodi Zilinski MD , Daniel P. O’Hair MD , Renuka Jain MD , Suhail Q. Allaqaband MD , Tanvir Bajwa MD\",\"doi\":\"10.1016/j.shj.2023.100278\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<div><h3>Background</h3><p>The current clinical practice standard is 10% to 20% oversizing of self-expanding valves in transcatheter aortic valve replacement. We aimed to determine whether >20% oversizing of self-expanding valves (Medtronic Evolut) would lead to better valve performance with similar or better outcomes.</p></div><div><h3>Methods</h3><p>From October 2011 to December 2016, we approached all transcatheter aortic valve replacement patients with a conscious attempt at large oversizing (>20%). The most common valve used, excluding those used in valve-in-valve patients, was the 29-mm Evolut R (29%). We used a retrospective chart review to compare moderate oversizing (group 1; 10% to 20%) with large oversizing (group 2; >20%).</p></div><div><h3>Results</h3><p>Of 556 patients, 45% were male; the overall mean Society of Thoracic Surgeons risk score was 5.8 ± 3.8. Eighty-five (15%) patients needed a pacemaker, and 21 (3.8%) developed significant paravalvular leak. Mean oversizing was 20.3% ± 6.0%, with 41.4% of patients included in group 1 and 54.5% in group 2. Incidences of complications in group 2 vs. group 1 were as follows: a) paravalvular leak (2.0 vs. 6.1%; odds ratio = 0.31, <em>p</em> = 0.01), b) pacemaker (15 vs. 14%), c) gastrointestinal bleed (n = 4 vs. 0; 1.3 vs. 0.0%; <em>p</em> = 0.03), d) annular dissection (n = 1 vs. 0; 0.3 vs. 0%; <em>p</em> = 0.29), e) mortality (n = 5 vs. 4; 1.6 vs. 1.7%). Incidence of paravalvular leak was higher in those who died than survivors (13 vs. 1.3%; <em>p</em> ≤ 0.0001).</p></div><div><h3>Conclusions</h3><p>These data suggest that, in current self-expanding valves, >20% oversizing delivers a significantly lower prevalence of paravalvular leak without an increase in other complications. Since paravalvular leak is associated with increased mortality, >20% oversizing may represent a superior prosthesis choice.</p></div>\",\"PeriodicalId\":36053,\"journal\":{\"name\":\"Structural Heart\",\"volume\":null,\"pages\":null},\"PeriodicalIF\":1.4000,\"publicationDate\":\"2024-05-01\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"https://www.sciencedirect.com/science/article/pii/S2474870623002294/pdfft?md5=618648d083cfd5a7c1c483c5ce1b3ec9&pid=1-s2.0-S2474870623002294-main.pdf\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Structural Heart\",\"FirstCategoryId\":\"1085\",\"ListUrlMain\":\"https://www.sciencedirect.com/science/article/pii/S2474870623002294\",\"RegionNum\":0,\"RegionCategory\":null,\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q3\",\"JCRName\":\"CARDIAC & CARDIOVASCULAR SYSTEMS\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Structural Heart","FirstCategoryId":"1085","ListUrlMain":"https://www.sciencedirect.com/science/article/pii/S2474870623002294","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"CARDIAC & CARDIOVASCULAR SYSTEMS","Score":null,"Total":0}
引用次数: 0
摘要
背景目前的临床实践标准是在经导管主动脉瓣置换术中将自扩张瓣膜过大10%至20%。我们旨在确定>20%的自扩张瓣膜(美敦力 Evolut)过大是否会带来更好的瓣膜性能,以及相似或更好的预后。方法从 2011 年 10 月到 2016 年 12 月,我们接触了所有经导管主动脉瓣置换术患者,有意识地尝试大尺寸过大(>20%)。除瓣中瓣患者外,最常用的瓣膜是 29 毫米 Evolut R(29%)。我们使用回顾性病历审查对中度过大(第 1 组;10% 至 20%)和大度过大(第 2 组;>20%)进行了比较。结果 在 556 名患者中,45% 为男性;胸外科医师协会风险评分的总体平均值为 5.8 ± 3.8。85名患者(15%)需要安装起搏器,21名患者(3.8%)出现了严重的瓣膜旁漏。平均过大比例为 20.3% ± 6.0%,其中 41.4% 的患者属于第一组,54.5% 的患者属于第二组。 第二组与第一组的并发症发生率如下:a) 腔旁漏(2.0 vs. 6.1%;几率比 = 0.31, p = 0.01),b) 起搏器(15 vs. 14%),c) 胃肠道出血(n = 4 vs. 0; 1.3 vs. 0.0%; p = 0.03),d) 瓣环剥离(n = 1 vs. 0; 0.3 vs. 0%; p = 0.29),e) 死亡率(n = 5 vs. 4; 1.6 vs. 1.7%)。结论这些数据表明,在目前的自扩张瓣膜中,>20%的过大可显著降低瓣膜旁漏的发生率,而不会增加其他并发症。由于瓣膜旁漏与死亡率增加有关,>20%过大可能是一种更好的假体选择。
Intentional Oversizing of Valve in Transcatheter Aortic Valve Replacement: Is Bigger Better? A Large, Single-Center Experience
Background
The current clinical practice standard is 10% to 20% oversizing of self-expanding valves in transcatheter aortic valve replacement. We aimed to determine whether >20% oversizing of self-expanding valves (Medtronic Evolut) would lead to better valve performance with similar or better outcomes.
Methods
From October 2011 to December 2016, we approached all transcatheter aortic valve replacement patients with a conscious attempt at large oversizing (>20%). The most common valve used, excluding those used in valve-in-valve patients, was the 29-mm Evolut R (29%). We used a retrospective chart review to compare moderate oversizing (group 1; 10% to 20%) with large oversizing (group 2; >20%).
Results
Of 556 patients, 45% were male; the overall mean Society of Thoracic Surgeons risk score was 5.8 ± 3.8. Eighty-five (15%) patients needed a pacemaker, and 21 (3.8%) developed significant paravalvular leak. Mean oversizing was 20.3% ± 6.0%, with 41.4% of patients included in group 1 and 54.5% in group 2. Incidences of complications in group 2 vs. group 1 were as follows: a) paravalvular leak (2.0 vs. 6.1%; odds ratio = 0.31, p = 0.01), b) pacemaker (15 vs. 14%), c) gastrointestinal bleed (n = 4 vs. 0; 1.3 vs. 0.0%; p = 0.03), d) annular dissection (n = 1 vs. 0; 0.3 vs. 0%; p = 0.29), e) mortality (n = 5 vs. 4; 1.6 vs. 1.7%). Incidence of paravalvular leak was higher in those who died than survivors (13 vs. 1.3%; p ≤ 0.0001).
Conclusions
These data suggest that, in current self-expanding valves, >20% oversizing delivers a significantly lower prevalence of paravalvular leak without an increase in other complications. Since paravalvular leak is associated with increased mortality, >20% oversizing may represent a superior prosthesis choice.