Effect of Mechanically Expanded vs Self-Expanding Transcatheter Aortic Valve Replacement on Mortality and Major Adverse Clinical Events in High-Risk Patients With Aortic Stenosis The REPRISE III Randomized Clinical Trial

被引:138
作者
Feldman, Ted E. [1 ]
Reardon, Michael J. [2 ]
Rajagopal, Vivek [3 ]
Makkar, Raj R. [4 ]
Bajwa, Tanvir K. [5 ]
Kleiman, Neal S. [6 ]
Linke, Axel [7 ,8 ]
Kereiakes, Dean J. [9 ]
Waksman, Ron [10 ]
Thourani, Vinod H. [10 ]
Stoler, Robert C. [11 ]
Mishkel, Gregory J. [12 ]
Rizik, David G. [13 ,14 ]
Iyer, Vijay S. [15 ]
Gleason, Thomas G. [16 ]
Tchetche, Didier [17 ]
Rovin, Joshua D. [18 ]
Buchbinder, Maurice [19 ]
Meredith, Ian T. [20 ]
Gotberg, Matthias [21 ]
Bjursten, Henrik [22 ]
Meduri, Christopher [3 ]
Salinger, Michael H. [1 ]
Allocco, Dominic J. [20 ]
Dawkins, Keith D. [20 ]
机构
[1] Northshore Univ Hlth Syst, Evanston Hosp, Div Cardiol, Evanston, IL USA
[2] Houston Methodist DeBakey Heart & Vasc Ctr, Dept Cardiovasc Surg, Houston, TX USA
[3] Piedmont Heart Inst, Atlanta, GA USA
[4] Cedars Sinai Heart Inst, Los Angeles, CA USA
[5] Aurora St Lukes Med Ctr, Milwaukee, WI USA
[6] Houston Methodist DeBakey Heart & Vasc Ctr, Dept Cardiol, Houston, TX USA
[7] Univ Leipzig, Heart Ctr, Leipzig, Germany
[8] Leipzig Heart Inst, Leipzig, Germany
[9] Christ Hosp, Heart & Vasc Ctr, Lindner Res Ctr, Cincinnati, OH 45219 USA
[10] Washington Hosp Ctr, Washington, DC 20010 USA
[11] Baylor Heart & Vasc Hosp, Dallas, TX USA
[12] St Johns Hosp, Springfield, IL USA
[13] HonorHealth, Scottsdale, AZ USA
[14] Scottsdale Lincoln Hlth Network, Scottsdale, AZ USA
[15] Univ Buffalo, Gates Vasc Inst, Buffalo, NY USA
[16] Univ Pittsburgh, Med Ctr, Pittsburgh, PA USA
[17] Clin Pasteur, Toulouse, France
[18] Morton Plant Mease Healthcare Syst, Clearwater, FL USA
[19] Stanford Univ, Fdn Cardiovasc Med, Stanford, CA 94305 USA
[20] Boston Sci Corp, Marlborough, MA USA
[21] Lund Univ, Skane Univ Hosp, Dept Cardiol, Clin Sci, Lund, Sweden
[22] Lund Univ, Skane Univ Univ Hosp, Dept Cardiothorac Surg, Clin Sci, Lund, Sweden
来源
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION | 2018年 / 319卷 / 01期
关键词
PERMANENT PACEMAKER IMPLANTATION; END-POINT DEFINITIONS; IMPACT; REGURGITATION; OUTCOMES; INSIGHTS; BIOPROSTHESIS; PREDICTORS;
D O I
10.1001/jama.2017.19132
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
IMPORTANCE Transcatheter aortic valve replacement (TAVR) is established for selected patients with severe aortic stenosis. However, limitations such as suboptimal deployment, conduction disturbances, and paravalvular leak occur. OBJECTIVE To evaluate if a mechanically expanded valve (MEV) is noninferior to an approved self-expanding valve (SEV) in high-risk patients with aortic stenosis undergoing TAVR. DESIGN, SETTING, AND PARTICIPANTS The REPRISE III trialwas conducted in 912 patients with high or extreme risk and severe, symptomatic aortic stenosis at 55 centers in North America, Europe, and Australia between September 22, 2014, and December 24, 2015, with final follow-up on March 8, 2017. INTERVENTIONS Participants were randomized in a 2: 1 ratio to receive either an MEV(n = 607) or an SEV (n = 305). MAIN OUTCOMES AND MEASURES The primary safety end point was the 30-day composite of all-cause mortality, stroke, life-threatening or major bleeding, stage 2/3 acute kidney injury, and major vascular complications tested for noninferiority (margin, 10.5%). The primary effectiveness end point was the 1-year composite of all-cause mortality, disabling stroke, and moderate or greater paravalvular leak tested for noninferiority (margin, 9.5%). If noninferiority criteria were met, the secondary end point of 1-year moderate or greater paravalvular leak was tested for superiority in the full analysis data set. RESULTS Among 912 randomized patients (mean age, 82.8 [SD, 7.3] years; 463 [51%] women; predicted risk of mortality, 6.8%), 874 (96%) were evaluable at 1 year. The primary safety composite end point at 30 days occurred in 20.3% of MEV patients and 17.2% of SEV patients (difference, 3.1%; Farrington-Manning 97.5% CI, -infinity to 8.3%; P = .003 for noninferiority). At 1 year, the primary effectiveness composite end point occurred in 15.4% with the MEV and 25.5% with the SEV (difference, -10.1%; Farrington-Manning 97.5% CI, -infinity to -4.4%; P<.001 for noninferiority). The 1-year rates of moderate or severe paravalvular leak were 0.9% for the MEV and 6.8% for the SEV (difference, -6.1%; 95% CI, -9.6% to -2.6%; P<.001). The superiority analysis for primary effectivenesswas statistically significant (difference, -10.2%; 95% CI, -16.3% to -4.0%; P<.001). The MEV had higher rates of new pacemaker implants (35.5% vs 19.6%; P<.001) and valve thrombosis (1.5% vs 0%) but lower rates of repeat procedures (0.2% vs 2.0%), valve-in-valve deployments (0% vs 3.7%), and valve malpositioning (0% vs 2.7%). CONCLUSIONS AND RELEVANCE Among high-risk patients with aortic stenosis, use of the MEV compared with the SEV did not result in inferior outcomes for the primary safety end point or the primary effectiveness end point. These findings suggest that the MEV may be a useful addition for TAVR in high-risk patients.
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收藏
页码:27 / 37
页数:11
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