那些患者適合行血管內(nèi)瓣膜植入術(shù)

1、會(huì)計(jì)學(xué)1那些患者適合行血管內(nèi)瓣膜植入術(shù)那些患者適合行血管內(nèi)瓣膜植入術(shù)CoreValveEdwards Sapien THV經(jīng)股動(dòng)脈 (TF)經(jīng)心尖(TA)心內(nèi)科醫(yī)生- 是! 但是我們見(jiàn)到的患者中，至少有的患者沒(méi)有被轉(zhuǎn)診結(jié)論結(jié)論 嚴(yán)重的有癥狀的老年患者中有的患者被拒絕手術(shù)治療。高齡和左室功能障礙是被拒絕進(jìn)行手術(shù)的最常見(jiàn)的原因，而其他的并發(fā)癥影響并不是特別大Annals Thoracic Surgery, 2006%死亡率年齡年齡 (90) 和危險(xiǎn)因素相同糖尿病，房顫 高血壓，輕度的腎功能受損年齡 (90) 和預(yù)計(jì)風(fēng)險(xiǎn) (12%)相同一位通過(guò)“眼球試驗(yàn)”，另一位沒(méi)通過(guò)由于多個(gè)生理系統(tǒng)

2、機(jī)能下降導(dǎo)致對(duì)外界應(yīng)激因子的抵抗能力及儲(chǔ)備下降的生物學(xué)綜合征，從而使機(jī)體對(duì)不良事件的耐受能力下降。什么是衰弱?Fried LP et al, J Gerontology 2001;56A:M146-56Craig Smith, M.D.副作用 ( Death or Institutionalization)根據(jù) “虛弱指數(shù)”Craig Smith, M.D.健康狀況沒(méi)有受損完全依靠護(hù)理人員，無(wú)法活動(dòng)17年齡90STS 風(fēng)險(xiǎn)12%虛弱指數(shù)年齡90STS 風(fēng)險(xiǎn) 12%虛弱指數(shù) 1Population: High Risk/Non-OperableSymptomatic, Critical Calc

3、ific Aortic StenosisNoNot in StudyNo VSTrans apicalAVR Control1:1 RandomizationCohort A TAPowered to be Pooled with TFYesCohort BNoASSESSMENT: OperabilityCohort An= up to 690 ptsn=350 ptsTotal n= 1040ASSESSMENT: Transfemoral AccessTransfemoralAVR Control VSYes1:1 RandomizationCohort A TFPowered Inde

4、pendentlyPrimary Endpoint: All Cause Mortality(Non-inferiority)Medical Management ControlASSESSMENT: Transfemoral Access VSTransfemoral1:1 RandomizationYesPrimary Endpoint: All Cause Mortality(Superiority)Two Trials: Individually Powered Cohorts(Cohorts A & B)Update SEPT 2008Ann Thorac SurgNovem

5、ber 2008CoreValveEdwards Sapien THVTransfemoral (TF)Transapical (TA)Cardiologist- True! But we never refer at least 1/3 of the patients with AS we seeConclusion Surgery was denied in 33% of elderly patients with severe, symptomatic AS. Older age andLV dysfunction were the most striking characteristi

6、cs of patients who were denied surgery, whereas comorbidity played a less important role.Annals Thoracic Surgery, 2006%MortalityAgeSame age (90) and risk factorsDiabetes, atrial fibrillation, hypertension, mild renal Same age (90) and predicted risk (12%)One passes the “eyeball t

7、est”; one doesntA biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes.What is Frailty?Fried LP et al, J Gerontology 2001;56A:M146-56Craig Smith, M.D.Adverse Outcomes

8、( Death or Institutionalization)Based on “Fraility Index”Craig Smith, M.D.Healthy,no impairmentTotally dependent on caregivers, immobile17Age 90STS Risk 12%Frailty Index 7Age 90STS Risk 12%Frailty Index 1Population: High Risk/Non-OperableSymptomatic, Critical Calcific Aortic StenosisNoNot in StudyNo

9、 VSTrans apicalAVR Control1:1 RandomizationCohort A TAPowered to be Pooled with TFYesCohort BNoASSESSMENT: OperabilityCohort An= up to 690 ptsn=350 ptsTotal n= 1040ASSESSMENT: Transfemoral AccessTransfemoralAVR Control VSYes1:1 RandomizationCohort A TFPowered IndependentlyPrimary Endpoint: All Cause

10、 Mortality(Non-inferiority)Medical Management ControlASSESSMENT: Transfemoral Access VSTransfemoral1:1 RandomizationYesPrimary Endpoint: All Cause Mortality(Superiority)Two Trials: Individually Powered Cohorts(Cohorts A & B)Update SEPT 2008Ann Thorac SurgNovember 2008年齡 (90) 和預(yù)計(jì)風(fēng)險(xiǎn) (12%)相同

11、一位通過(guò)“眼球試驗(yàn)”，另一位沒(méi)通過(guò)Population: High Risk/Non-OperableSymptomatic, Critical Calcific Aortic StenosisNoNot in StudyNo VSTrans apicalAVR Control1:1 RandomizationCohort A TAPowered to be Pooled with TFYesCohort BNoASSESSMENT: OperabilityCohort An= up to 690 ptsn=350 ptsTotal n= 1040ASSESSMENT: Transfemoral AccessTransfemoralAVR Control VSYes1:1 RandomizationCohort A TFPowered IndependentlyPrimary Endpoint: All Cause Mortality(Non-inferiority)Medical Management ControlASSESSMENT: Transfemoral Access VSTr