RESUMEN
BACKGROUND: The American College of Cardiology/American Heart Association guidelines recommend the assessment and grading of severity of aortic stenosis (AS) as mild, moderate, or severe, per echocardiogram, and recommend aortic valve replacement (AVR) when the AS is severe. OBJECTIVES: The authors sought to describe mortality rates across the entire spectrum of untreated AS from a contemporary, large, real-world database. METHODS: We analyzed a deidentified real-world data set including 1,669,536 echocardiographic reports (1,085,850 patients) from 24 U.S. hospitals (egnite Database, egnite). Patients >18 years of age were classified by diagnosed AS severity. Untreated mortality and treatment rates were examined with Kaplan-Meier (KM) estimates, with results compared using the log-rank test. Multivariate hazards analysis was performed to assess associations with all-cause mortality. RESULTS: Among 595,120 patients with available AS severity assessment, the KM-estimated 4-year unadjusted, untreated, all-cause mortality associated with AS diagnosis of none, mild, mild-to-moderate, moderate, moderate-to-severe, or severe was 13.5% (95% CI: 13.3%-13.7%), 25.0% (95% CI: 23.8%-26.1%), 29.7% (95% CI: 26.8%-32.5%), 33.5% (95% CI: 31.0%-35.8%), 45.7% (95% CI: 37.4%-52.8%), and 44.9% (95% CI: 39.9%-49.6%), respectively. Results were similar when adjusted for informative censoring caused by treatment. KM-estimated 4-year observed treatment rates were 0.2% (95% CI: 0.2%-0.2%), 1.0% (95% CI: 0.7%-1.3%), 4.2% (95% CI: 2.0%-6.3%), 11.4% (95% CI: 9.5%-13.3%), 36.7% (95% CI: 31.8%-41.2%), and 60.7% (95% CI: 58.0%-63.3%), respectively. After adjustment, all degrees of AS severity were associated with increased mortality. CONCLUSIONS: Patients with AS have high mortality risk across all levels of untreated AS severity. Aortic valve replacement rates remain low for patients with severe AS, suggesting that more research is needed to understand barriers to diagnosis and appropriate approach and timing for aortic valve replacement.
Asunto(s)
Estenosis de la Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Resultado del Tratamiento , Implantación de Prótesis de Válvulas Cardíacas/métodos , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Ecocardiografía , Índice de Severidad de la Enfermedad , Factores de RiesgoAsunto(s)
Coristoma/cirugía , Paro Circulatorio Inducido por Hipotermia Profunda , Atrios Cardíacos/cirugía , Cardiopatías/cirugía , Hígado , Coristoma/diagnóstico por imagen , Coristoma/patología , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/patología , Cardiopatías/diagnóstico por imagen , Cardiopatías/patología , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
OBJECTIVE: To better understand morbidity and mortality in patients with a low left ventricular ejection fraction (LVEF) undergoing aortic root replacement. METHODS: All patients who underwent aortic root replacement at our institution between 2005 and 2013 (n = 595) were retrospectively reviewed and included in the study. The primary outcome was mortality. Secondary outcomes were in-hospital mortality and perioperative morbidity. Restricted cubic spline analysis showed a relatively linear inverse relationship between LVEF and the hazard ratio for mortality in patients with an LVEF <50% with no unique cutoff. Therefore, LVEF was treated as a continuous variable. Patients were divided into 3 groups (LVEF <40%, LVEF 40%-49%, and LVEF ≥50%) in order to illustrate the impact of LVEF on mortality. RESULTS: LVEF <40% patients had greater in-hospital mortality (14.0% vs 5.0% vs 1.0%, P < .001) and longer median hospital and intensive care unit stays (10.5 vs 8 vs 6 days, P < .001 and 4 vs 2 vs 2 days, P < .001) than patients with LVEF 40% to 49% or greater than 50%, respectively. Patients with LVEF <40% had more reoperations for bleeding (18% vs 5.0% vs 5.8%, P = .004), postoperative respiratory failure (16% vs 6.7% vs 4.9%, P = .008), and need for mechanical circulatory support (8.0% vs 5.0% vs 1.4%, P = .005). Using multivariable Cox proportional hazards analysis, we found that reduced LVEF, age, previous, cardiac surgery, and type A dissection were independent predictors of mortality. CONCLUSIONS: Reduced LVEF negatively impacts mortality as well as in-hospital death and perioperative morbidity after aortic root replacement. Careful patient selection and risk discussion are vital in this high-risk population.
Asunto(s)
Aorta/cirugía , Aneurisma de la Aorta/cirugía , Implantación de Prótesis Vascular/efectos adversos , Volumen Sistólico , Disfunción Ventricular Izquierda/mortalidad , Anciano , Procedimientos Quirúrgicos Cardiovasculares/efectos adversos , Endocarditis/cirugía , Femenino , Mortalidad Hospitalaria , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Disfunción Ventricular Izquierda/complicaciones , Disfunción Ventricular Izquierda/epidemiologíaRESUMEN
There are few case reports in the literature of transcatheter aortic valve replacement used as emergent therapy for aortic insufficiency. We present a case in which transcatheter aortic valve replacement was implemented successfully as a salvage therapy in a hemodynamically unstable patient having aortic insufficiency as a result of a torn bioprosthetic leaflet during an unrelated abdominal operation. The successful use of this technique in a noncardiac operating room allowed the patient to be placed on extracorporeal support and ultimately to be discharged home.