那些患者适合行血管内瓣膜植入术

1、会计学1那些患者适合行血管内瓣膜植入术那些患者适合行血管内瓣膜植入术CoreValveEdwards Sapien THV经股动脉 (TF)经心尖(TA)心内科医生- 是! 但是我们见到的患者中，至少有的患者没有被转诊结论结论 严重的有症状的老年患者中有的患者被拒绝手术治疗。高龄和左室功能障碍是被拒绝进行手术的最常见的原因，而其他的并发症影响并不是特别大Annals Thoracic Surgery, 2006%死亡率年龄年龄 (90) 和危险因素相同糖尿病，房颤 高血压，轻度的肾功能受损年龄 (90) 和预计风险 (12%)相同一位通过“眼球试验”，另一位没通过由于多个生理系统

2、机能下降导致对外界应激因子的抵抗能力及储备下降的生物学综合征，从而使机体对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)根据 “虚弱指数”Craig Smith, M.D.健康状况没有受损完全依靠护理人员，无法活动17年龄90STS 风险12%虚弱指数年龄90STS 风险 12%虚弱指数 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年龄 (90) 和预计风险 (12%)相同

11、一位通过“眼球试验”，另一位没通过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