Early Efficacy Of Transcatheter Aortic Valve Replacement For Severe Aortic Stenosis

Background.Transcatheter Aortic Valve Replacement(TAVR),as a new technology in the field of heart valves,has been widely developed abroad and is gradually maturing in China.Surgical Aortic Valve Replacement(SAVR)has been a routine treatment for patients with Aortic Stenosis(AS),but the risk is also considerable for patients at high-risk or extremely.high-risk in surgery.TAVR,as a minimally invasive interventional therapy,has less trauma and rapid recovery to patients.Not only is it equivalent to SAVR in reducing mortality and complications,but also can shorten the patient's hospital stay and improve postoperative quality of life,which is especially suitable for elderly patients with more comorbidities.And with the improvement of TAVR-related equipment and technology,the applicable population of TAVR is also changing,gradually from high-risk,very high-risk to intermediate-risk patients,and even studies have reported that TAVR is also safe and effective in low-risk patients.The high left ventricular load caused by severe AS can lead to left ventricular hypertrophy(LVH)in long-term.LVH can not only affect the long-term prognosis of AS patients,but also increase postoperative mortality.Both TAVR and SAVR can significantly reduce left ventricular obstruction,improve hemodynamics,and reverse ventricular remodeling to a certain extent.The more obvious the reverse ventricular remodeling is in the early postoperative period,the lower the risk of long-term death and the better the prognosis.At present,the majority of patients receiving TAVR treatment in the country are the aged and most of them have hypertension,diabetes,coronary heart disease and other diseases.The purpose of patients receiving treatment is not only to improve survival rate,but also to improve symptoms and quality of life,which are important reasons for clinical decisions made by patients.There are relatively few studies on the changes of early hemodynamics,reverse ventricular remodeling and quality of life in patients with severe AS after TAVR compared with standard SAVR.ObjectiveThe purpose of this study was to investigate the improvement of heart function,changes in hemodynamic indexes,characteristics of left ventricular reverse remodeling,and early changes of health-related quality of life of patients with severe AS in short-term after TAVR compared with standard SAVR.And observe the occurrence of early cardiovascular adverse events after TAVR.MethodsA total of 74 patients with severe AS who were treated at the First Affiliated Hospital of Zhengzhou University from April 2018 to October 2019 were included in the study.Of these,36 patients were treated with TAVR and 38 were treated with SAVR.Baseline clinical data of patients,cardiac ultrasound indicators before and 1 month after surgery were collected.Patients were surveyed and scored using the Short Form Health Survey-12 item(SF-12)and the Kansas City Cardiomyopathy Questionnaire-12 item(KCCQ-12)before and 1 month after surgery,respectively.The intra-group and inter-group comparisons were used to analyze the improvement of New York Heart Association(NYHA)?the occurrence of perivalvular leakage(PVL)and the changes of mean aortic valve mean pressure gradient(mPG),Peak aortic valve flow(Vmax),aortic valve area(AVA),left ventricular ejection fraction(LVEF),left ventricular end diastolic diameter(LVEDd),relative wall thickness(RWT)and left ventricular mass index(LVMI)in severe AS patients undergoing TAVR and SAVR at 1 month after operation;Compare and analyze the improvement of HRQoL at 1 month postoperatively between the two groups of patients.At the same time,the incidence of major adverse cardiovascular events(MACE)in all AS patients at 1 month after TAVR and SAVR was calculated.Results1.Baseline clinical data of two groups of patients:There was no statistical difference in gender,age,body mass index(BMI),body surface area(BSA),New York Heart Association(NYHA)),hypertension,diabetes,coronary heart disease,chronic obstructive pulmonary disease(COPD),old cerebral infarction,atrial fibrillation,peripheral vascular disease,previous history of coronary artery bypass grafting(CABG),previous history of percutaneous coronary intervention(PCI)(P>0.05).The age of patients in the TAVR group[(72.28 ± 7.39)years vs(66.71±3.78)years]was higher than that in the SAVR group(P<0.05).The the average score of the Society of Thoracic Surgeons(STS)[(9.91 ± 4.24)vs(7.50 ± 2.46)]were higher than those in the SAVR group,and the difference was statistically significant(P<0.05).The total length of hospital stay[(15.52 ± 4.25)d vs(21.02 ± 4.51)d]and intensive care time[(2.28±0.91)d vs(3.47±1.12)d]in the TAVR group were shorter than that in the SAVR group,the difference was statistically significant(P<0.05).2.The NYHA grades of the TAVR group and SAVR group were improved after 1 month after operation(P<0.05),and there was no statistical difference in the total effective rate of postoperative NYHA grade improvement[85.3%vs 89.2%]of the two groups in AS patients(P>0.05).3.In the TAVR group,11 cases of PVL occurred at 1 month after operation,including 6 cases of mild PVL and 5 cases of trace PVL,and there was no moderate or severe PVL.In the SAVR group,1 case of mild PVL and 1 case of trace PVL occurred at 1 month after operation.The difference of the incidence of PVL between TAVR and SAVR was statistically significant(P<0.05).4.TAVR group at 1 month after operation:the aortic valve mPG[(63.89 ±13.17)mmHg vs(12.65±7.43)mmHg]?Vmax[(4.91±0.57)m/s vs(2.09±0.50)m/s]?RWT[(0.58±0.12)vs(0.49±0.08)]?LVMI[(148.60±33.21)g/m2 vs(125.84±31.55)g/m2]were all lower than that before surgery,both AVA[(0.62±0.13)cm2 vs(1.95±0.42)cm2]?LVEF[(53.75±9.04)%vs(58.76±5.83)%]were improved compared with that before surgery,and the differences were statistically significant(P<0.05),and there no differences in LVEDd[(47.78±4.92)mm vs(49.44±5.76)mm].SAVR group at 1 month after operation:the aortic valve mPG[(54.73 ± 13.34)mmHg vs(10.64±3.07)mmHg]?Vmax[(4.70±0.61)m/s vs(2.27±0.34)m/s]?LVEDd[(49.63±7.15)mm vs(43.97±5.20)mm]?LVMI[(157.72±41.70)g/m2 vs(116.66±29.55)g/m2]were all lower than that before surgery,both AVA[(0.64 ± 0.14)cm2 vs(1.54 ± 0.45)cm2]and LVEF[(53.42±8.01)%vs(59.92±4.02)%]were improved compared with those before surgery,and the differences were statistically significant(P<0.05),and there was no statistically significant change in RWT[(0.50 ± 0.09)vs(0.51 ± 0.08)](P>0.05).The change of mPG,Vmax,AVA,and RWT in TAVR group is more obvious(P>0.05),and the decreased of LVEDd and LVMI were more significantly in SAVR group(P<0.05);LVEF between the two groups had the same degree of increase(P>0.05).5.The preoperative HRQoL scores of the TAVR group and SAVR group were lower in all dimensions,while the preoperative HRQoL scores of the SF-PCS?KCCQ-OS?KCCQ-PL?KCCQ-SF and KCCQ-QoL dimensions of the TAVR group were lower than those of the SAVR group(P<0.05).At 1 month,HRQoL increased in all dimensions compared with pre-operation,the difference was statistically significant(P<0.05),and the improvement of the two groups of patients in each dimension was equivalent,the difference was not statistically significant(P>0.05).6.At 1 month after operation,the incidence of MACE[(16.67%)vs(13.16%)]in the TAVR group and the SAVR group was comparable,and the difference was not statistically significant(P<0.05).Conclusions.1.TAVR can shorten the patient's total hospitalization time and intensive care time,and the cardiac function and health-related quality of life at the first month after surgery are improved compared with that before surgery;2.The hemodynamic improvement of the TAVR group was better than that of the SAVR group at 1 month after surgery,but the rate of ventricular remodeling in the TAVR group was slower than that of the SAVR group;the incidence of PVL in the TAVR group was higher than that of the SAVR group.3.There was no statistical difference in the incidence of MACE between TAVR group and SAVR group 1 month after surgery.