重度主动脉瓣狭窄伴急性瓣膜综合征的超快速门诊 TAVI 路径评估
本研究为单中心队列研究，纳入 TAVI 转诊的急性瓣膜综合征患者，比较超快速门诊路径实施前后结局。路径实施后 105 例患者中 55.2% 符合门诊治疗标准并出院等待 TAVI。结果显示门诊路径可显著缩短总住院时间，且 TAVI 前死亡或急性失代偿发生率无显著差异。
要点
- 精选稳定的急性瓣膜综合征患者可经超快速门诊路径在 2 周内完成 TAVI。
- 门诊路径较住院路径中位总住院时间显著缩短，未增加 TAVI 前安全事件。
- 转诊至 TAVI 的中位时间在门诊与住院路径间无显著差异。
核心结论
- 针对经过选择的急性瓣膜综合征 TAVI 患者，超快速门诊路径可减少总住院时间。
- 门诊路径与住院路径在 TAVI 前死亡或急性失代偿发生率方面无显著差异。
研究设计与样本
- 单中心队列研究，采用路径实施前 6 个月与实施后 12 个月的前后比较设计。
- 共纳入 183 例转诊 TAVI 的急性瓣膜综合征患者，其中 105 例在路径引入后接受门诊治疗评估。
主要发现
- 105 例患者中 58 例（55.2%）符合门诊治疗标准，其余 47 例（44.8%）按住院管理。
- 门诊路径中位总住院时间为 12 天（IQR 7–17），住院路径为 20 天（IQR 15–32），p<0.0001。
- 门诊路径估计节省约 210 个住院床日。
- 转诊至 TAVI 的中位时间门诊路径为 15 天（IQR 13–20），住院路径为 14 天（IQR 10–18），p=0.22。
- TAVI 前安全终点发生率门诊路径为 6.9%，住院路径为 6.4%，HR 0.97（95% CI 0.22 to 4.34），p=0.97。
关键数值与推荐
- 符合预设标准的稳定急性瓣膜综合征患者出院回家，在 2 周内完成检查并接受 TAVI。
- 主要疗效终点为住院时间，主要安全终点为 TAVI 前死亡或急性失代偿。
临床怎么用
- 对稳定的急性瓣膜综合征患者可考虑采用超快速门诊路径进行 TAVI 前评估与治疗。
- 该路径适用于符合预设标准的患者，需进一步研究验证其可推广性。
局限性
- 本研究为单中心前后对照设计，样本量有限。
- 门诊路径的患者选择依赖预设标准，可能存在选择偏倚。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
Background Up to 30% of patients undergoing transcatheter aortic valve implantation (TAVI) have presented to hospital with acute decompensation of aortic stenosis (acute valve syndrome, (AVS)). Such patients conventionally undergo inpatient work-up and treatment by TAVI, associated with prolonged hospital stays, deconditioning and delayed recovery. This study aimed to evaluate the impact and feasibility of an ultra-rapid outpatient pathway for selected, stabilised AVS patients undergoing treatment by TAVI. Methods This single-centre cohort study with preimplementation and postimplementation comparison included consecutive AVS patients referred for TAVI over 6 months pre-pathway implementation and 12 months post-pathway implementation. Those meeting prespecified criteria were discharged home for completion of work-up and treatment by TAVI within 2 weeks. The primary efficacy endpoint was length of hospital stay. The primary safety endpoint was death or acute decompensation prior to TAVI. Results 183 patients were included, of which 105 were evaluated for outpatient treatment after ultra-rapid pathway introduction. 58/105 (55.2%) met criteria for outpatient treatment, the remaining 47/105 (44.8%) were managed as inpatients. There was no significant difference in demographic or echocardiographic characteristics between management pathways. Patients treated as an outpatient had a shorter median total length of hospital stay (outpatient 12 days (IQR 7–17) vs inpatient 20 days (IQR 15–32), p<0.0001), saving an estimated 210 hospital bed-days. There was no significant difference in median time from referral to TAVI (outpatient 15 days (IQR 13–20) vs inpatient 14 days (IQR 10–18), p=0.22), nor in the incidence of the safety endpoint prior to TAVI between pathways (outpatient 6.9% vs inpatient 6.4%, HR 0.97, 95% CI 0.22 to 4.34, p=0.97), or after new pathway implementation (pre-pathway 6.7%, post-pathway 6.7%, HR 0.70, 95% CI 0.17 to 2.80, p=0.61). Conclusions An ultra-rapid outpatient pathway for selected AVS patients undergoing treatment by TAVI can successfully reduce total length of hospital stay. Further work is required to validate this approach.
引用
- Open Heart：Ultra-rapid outpatient treatment of patients with severe aortic stenosis presenting with acute valve syndrome: evaluation of a novel pathway for urgent TAVI
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。