Tratamiento de la estenosis valvular aórtica severa sintomática mediante implante de prótesis aórtica percutánea. Resultados tras diez años de experiencia en la Región de Murcia

Abstract

Introduction: Aortic valve stenosis is the most common valve disease being the degenerative etiology its main underlying cause. No medical treatment has proven useful to alter the natural history of the disease, remaining the surgical replacement the only therapeutic option until the beginning of the XXI century. In 2002, the transcatheter aortic valve implantation (TAVI) arose a novel therapeutic option for extreme high-risk patients. Aims: The TAVI program was implemented in Region de Murcia in 2008. The aims of this doctoral thesis are: -Chief aim: To analyse the results of the TAVI program in the last ten years: Characteristics of the patients, survival analysis and post interventional complications. -Secondary Aims: 1. To identify predictors of mortality at 30 days, 1 year and long follow-up. 2. To identify the predictors of the most common post-procedural complications. 3. To assess the clinical impact of the second generation devices. 4. To study the impact of surgical risks score in the prediction of 30-day and 1-year mortality. 5. To assess the long term durability of the transcatheter phrostheses Methods: Retrospective and observational design. All patients with severe symptomatic aortic stenosis underwent TAVI. All of them had been previously desestimated for surgery by the Heart Team on the grounds of their high operative risk. Conclusions: a.)The characteristics of the patients were similar to those previously published by other groups. b.) Vascular complications and bleeding were the commonest complications. Major vascular complications, life threatening bleeding, acute kidney injury and myocardial infarction reduce patients' survival. c.) Despite the high percentage of complications, the long term survival (median 4.2 years) is similar to that published by other groups. d.) Better outcomes and the progressive decline in the number of complications is a direct consequence of the operator's learning curve, the advent of new devices as well as the inclusion of no high-risk patients. e.) No clinical variables have been identified as predictors of mortality. However, the inclusion of some variables included in the STS risk score yield prognostic information. f.) We have identified some predictors of post-procedural complications: -The use of Edwards Sapien 3 phrostheses decreases the risk of vascular injury. -Low haemoglobin level and the presence of a vascular complication predict bleeding. -The presence of a porcelain aorta and/or low haemoglin level predict acute renal impairment -Baseline right bundle branch block, post-procedural left bundle branch block and old age predict subsequent pacemaker implantation. g.) The use of second generation devices reduced the in-hospital and medium-term mortality, vascular complications, bleeding and para-aortic regurgitation. h.) Either Euroscore II or STS are useful tools to predict 30-day and 1-year mortality although their power is modest. i) Although limited data are available, the transvalvular aortic gradients remain stable during a 3-year follow-up.