Name: 2026年3月27日 本週心臟學焦點 (Mar 27 2026 This Week in Cardiology)
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You're listening to This Week in Cardiology from theheart.org, Medscape Cardiology.

這是來自 theheart.org、Medscape Cardiology 的「本週心臟學」節目。

This podcast is intended for healthcare professionals only.

本播客僅供醫療專業人士收聽。

Any views expressed are the presenter's own and do not necessarily reflect the views of WebMD or Medscape.

節目中表達的任何觀點僅代表講者個人，不一定反映 WebMD 或 Medscape 的觀點。

When every decision matters, you need trusted medical intelligence.

在每個決定都至關重要的時刻，您需要值得信賴的醫療情報。

Medscape AI synthesizes peer-reviewed evidence and Medscape's expert-validated content in seconds, delivering clinically verified answers you can trust.

Medscape AI 能在幾秒鐘內整合同行評審的證據和 Medscape 專家驗證的內容，提供您可信賴的臨床驗證答案。

Join over 13 million Medscape members on the world's leading platform for clinicians.

加入全球領先的臨床醫生平臺，成為超過 1300 萬 Medscape 會員的一份子。

Start using Medscape AI on the web or in the Medscape app.

立即開始使用網頁版或 Medscape App 中的 Medscape AI。

Medscape AI, trusted medical intelligence.

Medscape AI，值得信賴的醫療情報。

Hi everyone, this is John Mandrola from theheart.org Medscape Cardiology,

大家好，我是 John Mandrola，來自 theheart.org Medscape Cardiology，

and this is This Week in Cardiology for March 27, 2026.

這是 2026 年 3 月 27 日的「本週心臟學」。

This week: early aortic valve replacement and aortic stenosis, left atrial appendage occlusion in JAMA Cardiology, and

本週內容：早期主動脈瓣膜置換術與主動脈瓣狹窄、JAMA Cardiology 中的左心耳關閉術，以及

First up, let's talk about early aortic valve replacement.

首先，我們來談談早期主動脈瓣膜置換術。

New England Journal of Medicine published "Long-Term Follow-Up of the South Korean Recovery Trial of Early Aortic Valve Replacement for Conservative Care in Patients with Severe Aortic Stenosis." Now, the first publication of Recovery was in 2020,

New England Journal of Medicine 發表了「嚴重主動脈瓣狹窄患者早期主動脈瓣膜置換術韓國 Recovery Trial 的長期追蹤」。Recovery 的首次發表是在 2020 年，

Now, right there you're squinting, right, because most patients with aortic stenosis are near 80 years old.

看到這裡，你可能皺眉了，因為大多數主動脈瓣狹窄的患者年齡都接近 80 歲。

But that's one of the many interesting things about this trial.

但這也是這項試驗中許多有趣之處之一。

The mean age of patients was approximately 64 years.

The primary endpoint was operative mortality and CV death.

主要終點是手術死亡率和心血管死亡。

總共有 145 位病患被隨機分派，只有 145 位。

A primary endpoint event occurred in 2 of 73 patients, that's 3% in the early surgery group, and

主要終點事件發生在 73 位早期手術組的病患中有 2 位，也就是 3%，而

in 17 of 72, 24% in the conservative care group.

在 72 位保守治療組的病患中有 17 位，也就是 24%。

For a hazard ratio, get this: 0.10, 95% conference intervals to 0.02 to 0.43, and p-value very significant.

風險比，請聽好：0.10，95% 信賴區間是 0.02 到 0.43，p 值非常顯著。

Death from any cause occurred in 11 patients in the early surgery group, and

早期手術組有 11 位病患死於任何原因，而

in 23 patients, 32%, in the conservative care group.

保守治療組有 23 位病患，也就是 32%，死亡。

That hazard ratio is 0.42 and also highly significant.

這個風險比是 0.42，同樣非常顯著。

This is very similar to the report in 2020 where it was 1 versus 11 primary endpoints for a hazard ratio of 0.09.

這跟 2020 年的報告非常相似，當時是 1 位對 11 位主要終點，風險比是 0.09。

The interesting thing about this long-term follow-up is that 85% of the conservative arm crossed over and got AVR.

這項長期追蹤有趣的地方在於，85% 的保守組病患後來接受了主動脈瓣膜置換術。

Only 11 of 72, or 15% of patients in the conservative arm, did not get surgery, which is shocking when I tell you the entry criteria.

在保守組的 72 位病患中，只有 11 位，也就是 15% 的病患沒有接受手術，當我告訴你納入標準時，這點令人震驚。

Patients had to have very, very severe stenosis, an aortic valve area less than 0.75, a peak velocity greater than 4.5.

病患必須有非常非常嚴重的主動脈瓣狹窄，瓣膜面積小於 0.75，尖峰流速大於 4.5。

But the enrolled population were even worse.

The mean aortic valve area was 0.63, and the mean peak velocity was 5.1 meters per second.

平均瓣膜面積是 0.63，平均尖峰流速是每秒 5.1 公尺。

I think this plays into why there's a 90% reduction in the primary endpoint.

我想這解釋了為什麼主要終點降低了 90%。

These were relatively young people with few comorbidities, hence only two primary outcome events in 12 years in the early AVR group.

這些病患相對年輕，合併症很少，是以在早期主動脈瓣膜置換術組的 12 年裡，只有兩起主要預後事件。

The severity of this "asymptomatic" aortic stenosis in quotes is also in question because 10 patients died before getting their valve replaced,

這些「無症狀」主動脈瓣狹窄的嚴重性也受到質疑，因為有 10 位病患在接受瓣膜置換前就死亡了，

and 20% of those who crossed over, 1 in 5, had urgent aortic valve replacement.

而且在轉為手術的病患中，有 20%，也就是五分之一，接受了緊急主動脈瓣膜置換術。

That's kind of strange to go from asymptomatic to urgent AVR.

從無症狀變成緊急主動脈瓣膜置換術，這有點奇怪。

Another curious thing about this trial is the tiny number of events, 2 versus 17.

這項試驗另一個令人好奇的地方是事件數非常少，2 件對比 17 件。

I calculated a fragility index, and it was only 3.

我計算了脆弱性指數，結果只有 3。

Three events would have changed it to non-significant, despite a hazard ratio of 0.10.

只要再多 3 件事件，就算風險比是 0.10，結果也會變得沒有統計學意義。

Now look, I don't disbelieve the results.

好了，我不是不相信這個結果。

What I do question is, were these patients really asymptomatic?

我只是質疑，這些病患真的沒有症狀嗎？

This trial assessed symptoms by history alone, and everyone knows that aortic stenosis is slowly progressing,

這項試驗單純靠病史來評估症狀，大家都知道主動脈瓣狹窄是緩慢進展的，

and it gives time for people to adjust their activity.

這也讓人們有時間去調整活動量。

So in the end, what I take from this paper is that if you have someone like these patients, a literal pinhole, I'd be darn sure they don't have symptoms.

所以總結來說，我從這篇論文得到的啟示是，如果你遇到像這些病患一樣，症狀非常輕微的人，我會非常確定他們沒有症狀。

And if they truly did not have symptoms, say they passed the treadmill, then I would follow them very closely.

如果他們真的沒有症狀，像是通過了跑步機測試，那我會非常密切地追蹤他們。

Based on the small number of patients, two-thirds of whom had bicuspid valves, and

考量到病患人數很少，其中三分之二有二葉式瓣膜，

the extreme severity of the AS in these cases, along with their low comorbidity, I would not use this study as a reason to do early aortic valve interventions in a more common aortic stenosis patient who is elderly, more complex,

還有這些病例中極嚴重的主動脈瓣狹窄，加上他們的共病症很少，我不會把這項研究當作早期對一般高齡、病情較複雜、

and has lesser degrees of aortic stenosis.

主動脈瓣狹窄程度較輕的病患進行主動脈瓣膜介入治療的理由。

And I certainly wouldn't use this data to translate it to doing early TAVR in patients in their mid-60s, that young of an age.

而且我絕對不會用這些數據來推論，在六十幾歲、這麼年輕的病患身上進行早期的 TAVR。

All right, next topic is major bleeding with an Amulet and Watchman trial in JAMA Cardiology.

好的，下一個主題是 JAMA Cardiology 上關於 Amulet 和 Watchman 試驗的主要出血事件。

This was a secondary analysis of the Amulet IDE trial conducted from 2016 to 2019.

這是對 2016 年到 2019 年進行的 Amulet IDE 試驗進行的次要分析。

Now, rather than reporting on the primary device comparison between Amulet and Watchman 2.5, the authors report on major bleeding events.

現在，作者們報告的不是 Amulet 和 Watchman 2.5 之間的初級裝置比較，而是主要出血事件。

The original Amulet IDE trial was a head-to-head comparison of the two different left atrial appendage closures devices.

最初的 Amulet IDE 試驗是兩種不同左心耳封堵裝置的正面對決比較。

The five-year results of the original Amulet versus Watchman 2.5 device were published in JAC in 2024.

最初 Amulet 與 Watchman 2.5 裝置的五年結果於 2024 年發表在 JAC 上。

Stroke and systemic embolism were similar at 7.4 versus 7.1%, as was major bleeding at 20.1 versus 20.0, basically the same.

中風和全身性栓塞的比例相似，分別為 7.4% 和 7.1%，主要出血比例也相似，分別為 20.1% 和 20.0%，基本上是相同的。

This paper, the one in JAMA Cardiology, combined all 1,800 patients in both arms to assess predictors and outcomes of major bleeding.

這篇發表在 JAMA Cardiology 上的論文，結合了兩組共 1,800 名病患，來評估主要出血的預測因子和結果。

The authors felt justified in doing this because the hazard ratio on the device arms was 1.0, so it was no different.

作者們認為這樣做是合理的，因為裝置組別的風險比是 1.0，沒有差別。

Briefly, these were 76-year-old patients with a mean CHADS-VASc score of 4.8.

簡單來說，這些病患平均年齡 76 歲，平均 CHADS-VASc 分數為 4.8。

The first was that major bleeding occurred in roughly 1 in 5 patients, approximately 18%, which seems like a lot.

第一項是，大約有五分之一的病患發生主要出血，約 18%，這聽起來很多。

Second finding, the timing pattern of major bleeding was very distinct.

第二項發現，主要出血的發生時間模式非常明顯。

In the first six months after the procedure, the annualized major bleeding rate was 20.5% per year.

在手術後的前六個月，年化主要出血率為每年 20.5%。

After six months through year three, it was 3.9% per year.

在六個月到第三年之間，年化率為每年 3.9%。

I want to insert a note here that patients cannot exclude their peri-procedural time.

我想在這裡補充說明，病患無法排除其手術周圍的時間。

Though proponents like to talk about less bleeding in the later part of a study, the patients are part of both parts.

雖然支持者喜歡談論研究後期出血較少，但病患同時屬於這兩個時期。

Third finding, most of the bleeds were GI, 57%.

第三項發現，大部分出血是腸胃道出血，佔 57%。

Fourth, predictors of the bleeds will not surprise you.

第四項，出血的預測因子應該不會讓大家驚訝。

Older age, female sex, diabetes, previous bleeding, kidney disease.

年紀較大、女性、糖尿病、先前有出血史、腎臟病。

Notably, the device type, the antithrombotic regimen at discharge, and

值得注意的是，裝置的類型、出院時的抗血栓治療方案，以及

device-related imaging findings did not, did not predict bleeding.

與裝置相關的影像學發現，並未預測出血。

This suggests to the authors that bleeding risk lives in the patient more so than in the procedure.

這對作者來說，暗示出血風險更多存在於病人身上，而非手術本身。

perhaps most notable finding of this entire study is that nearly half, 47%, of the major bleeds occurred in patients on no antithrombotic therapy.

或許是這整個研究中最值得注意的發現是，將近一半，47% 的主要出血發生在沒有接受抗血栓治療的病人身上。

Sixth finding, in a comparison between patients who had a major bleed versus those who did not, patients who had major bleeding had significantly higher rates of everything bad: stroke, systemic embolism, cardiovascular death, 32.5% versus 18%.

第六項發現，比較有主要出血和沒有主要出血的病人，有主要出血的病人發生各種不良事件的機率顯著較高：中風、全身性栓塞、心血管死亡，32.5% 對比 18%。

And this was driven by higher strokes, so patients with major bleeding have more than double the number of strokes.

而這主要是因為中風的增加，所以主要出血的病人在中風的機率上是兩倍以上。

All-cause mortality was also higher in patients with major bleeding.

主要出血病人的全因死亡率也比較高。

And major bleeding was fatal, BARC score of 5 in 25 patients or 1.4%.

而主要出血是致命的，BARC 分數為 5 的有 25 位病人，也就是 1.4%。

And the authors concluded that major bleeding was common in this high-risk population, largely related to the underlying patient factors.

作者們是以結論，在這個高風險族群中，主要出血是很常見的，而且大部分都跟潛在的病人因素有關。

Early major bleeding was highest in the six months after appendage occlusion.

在 Appendage occlusion 後的六個月內，早期主要出血的發生率最高。

Most events were GI bleeding and occurred even in patients on minimal or no antithrombotic therapy.

大部分的事件是腸胃道出血，即使是接受極少或未接受抗血栓治療的病人也發生了。

Major bleeding after appendage closure was strongly associated with all bad outcomes, including stroke and mortality.

Appendage closure 後的主要出血，與包括中風和死亡在內的所有不良預後都有強烈關聯。

我覺得這是一篇很有趣的論文。

First, you have a relatively low annualized stroke rate of about 1.5 to 3% per year, but

首先，你每年中風的機率大約是 1.5% 到 3%，但

nearly a 6% annualized rate of major bleeding.

主要出血的年化機率卻將近 6%。

Patients who had major bleeding clearly did worse in all aspects, including thrombotic events like stroke and CV death and all-cause death.

發生主要出血的病患，無論是中風、心血管死亡等血栓事件，或是全因死亡，預後都明顯變差。

What this tells me is that we should definitely have a trial in older, sicker patients who have a high bleeding risk of left atrial appendage closure versus no antithrombotic.

這告訴我，我們絕對應該針對高出血風險的年長、體弱病患，進行一項左心耳封堵術對比未接受抗血栓治療的試驗。

Now, every time I discuss this at meetings, people worry about, "You wouldn't do anything for the patient?

現在，每次我在會議上討論這個議題時，大家都會擔心：「你什麼都不做，

不給藥嗎？」我經常聽到這個問題。

But this study I'm discussing, from some of the best centers in the world, finds a super, super high rate of major bleeding in the first six months, annualized at 20% per year.

但我正在討論的這篇研究，來自世界上一些頂尖的中心，發現在前六個月內，主要出血的年化機率高達 20%。

So therefore, the patient randomized to the nothing arm starts far ahead in the probability game of stroke and bleeding.

是以，被隨機分派到未接受治療組的病患，在預防中風和出血的機率遊戲中，一開始就佔了很大的優勢。

In such a trial of appendage closure versus no antithrombotic, the left atrial appendage occlusion arm has to overcome a very high major bleeding risk in the first six months.

在這種封堵術對比未接受抗血栓治療的試驗中，左心耳封堵術組必須克服前六個月非常高的主要出血風險。

And since no study that I know of finds that appendage closure reduces ischemic stroke, and

而且，據我所知，沒有研究發現心耳封堵術能降低缺血性中風，

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2026年3月27日本週心臟學焦點 (Mar 27 2026 This Week in Cardiology)

2026年3月27日 本週心臟學焦點 (Mar 27 2026 This Week in Cardiology)

2026年3月27日本週心臟學焦點 (Mar 27 2026 This Week in Cardiology)