应用J-Valve瓣膜经导管主动脉瓣置换术治疗高危单纯主动脉瓣反流多中心研究早期临床结果

目的探讨心尖经导管主动脉瓣置换术(TAVI)治疗高龄高危主动脉瓣关闭不全患者的早期安全性和有效性。方法前瞻性收集2014年4月至2018年5月国产J-Valve TM经心尖TAVI治疗高危单纯无钙化主动脉瓣反流的多中心临床研究资料,并对术后早期结果进行分析。共纳入82例患者:四川大学华西医院62例,复旦大学附属中山医院16例,中国医学科学院阜外医院4例。男55例、女27例,年龄61～90(73.8±6.3)岁。欧洲心脏手术危险评估系统评分10.0%～44.4%(17.5%±8.1%),所有患者均使用J-Valve TM系统行经心尖途径TAVI。分别于术前以及术后1个月对患者进行临床评估和超声心动图检查;出院前复查多层螺旋CT。结果手术中转开胸为体外循环下手术3例,术后1周因瓣周漏、心功能降低开胸1例,瓣膜手术植入成功率95.1%(78/82),器械成功率93.9%(77/82)。住院期间因中度瓣周漏合并多器官功能衰竭死亡l例,肺部感染死亡1例。术后82.1%(64/78)患者微量或者没有残余主动脉瓣反流;16.7%(13/78)例患者轻度瓣周漏,7.6%(6/78)例患者因Ⅲ°房室传导阻滞安置永久起搏器。左心室手术末期容积由术前的(197.7±66.8)mL减少至术后1个月的(147.2±53.3)mL(P0.05);术后1个月主动脉瓣平均跨瓣压差为(9.5±4.1)mm Hg。结论应用J-Valve system治疗高危单纯主动脉瓣反流患者,血流动力学表现和临床预后良好,证实了应用J-Valve瓣膜经心尖途径治疗单纯主动脉瓣反流的可行性和有效性。     

经心尖途径经导管主动脉瓣置换术治疗主动脉瓣关闭不全的早期疗效分析

目的 探讨经心尖经导管主动脉瓣置换术（transcatheter aortic valve replacement,TAVR）治疗主动脉瓣关闭不全的早期疗效。方法 回顾性纳入2020年10月—2022年10月在安徽医科大学第一附属医院心脏大血管外科行经心尖TAVR的主动脉瓣病变患者，其中主动脉瓣狭窄患者作为A组，单纯主动脉瓣关闭不全患者作为B组，分析术后早期心功能改善及手术并发症情况。结果 共纳入56例患者，其中男32例、女24例，平均年龄（73.34±5.10）岁。A组31例，B组25例。两组患者在年龄、性别、身高、体重、高血压、冠状动脉粥样硬化性心脏病、外周血管病史、慢性阻塞性肺疾病、肾功能不全、心功能分级方面差异均无统计学意义（P>0.05）。两组患者在植入永久起搏器、中转外科开胸手术、植入瓣中瓣、瓣周漏方面差异也无统计学意义（P>0.05）。与术前相比，两组患者术后30 d的左室舒张末期内径、左室射血分数、合并中度及以上二尖瓣反流、中度及以上三尖瓣反流均有显著改善（P<0.05），但组间比较差异均无统计学意义（P>0.05）。结论 使用介入瓣膜（J-Va...     

经股动脉经导管主动脉瓣置换术(TAVR)治疗单纯主动脉瓣关闭不全的临床疗效分析及术前评估北大核心CSCD

目的探讨经股动脉经导管主动脉瓣置换术(TAVR)治疗主动脉瓣单纯关闭不全的临床疗效和术前评估要点。方法回顾性分析阜外医院2019年5月至2020年10月行经股动脉TAVR 129例患者的临床资料,其中男83例、女46例,平均年龄(72.26±8.97)岁。根据疾病情况分为单纯主动脉瓣关闭不全组(17例)和主动脉瓣狭窄组(112例)。分析主动脉根部形态学特点、手术有效性及安全性。结果单纯主动脉瓣关闭不全组与主动脉瓣狭窄组比较,3MENSIO测量的瓣环[(25.75±2.21)mm vs.(24.70±2.90)mm,P=0.068]及流出道直径[(25.82±3.75)mm vs.(25.37±3.92)mm,P=0.514]差异无统计学意义。单纯主动脉瓣关闭不全组与主动脉瓣狭窄组相比,瓣中瓣发生率较高(47.0%vs.16.1%,P<0.01)。中转外科手术、术中使用体外循环辅助、术中左室破裂、术后使用体外膜肺氧合辅助、术后外周血管并发症、术后致残性脑卒中、死亡、术后起搏器植入两组差异无统计学意义。结论单纯主动脉瓣关闭不全患者行经股动脉TAVR可行。术前应重点评估瓣环平面直径、流出道直径以及流出道的形态。     

经导管主动脉瓣植入术的麻醉管理

背景 对于有临床症状的严重主动脉瓣狭窄患者而言,实施标准主动脉瓣置换术(surgical aortic valve replacement,SAVR)可能有禁忌或高风险.经导管主动脉瓣植入术(transcatheter aortic valve implantation,TAVI)是一种可供选择的治疗方式. 目的 阐述TAVI围手术期的麻醉管理与监测. 内容 实施TAVI患者的术前评估、风险分级、麻醉的准备和麻醉方法的选择以及行TAVI术中和术后监测管理. 趋向 设备更新与开发、进一步的研究和经验的积累将促使TAVI成为一种在心脏导管室开展的经皮入路微创手术,以后可以更加广泛地应用于有手术禁忌、合并并发症以及严重、不稳定心脏病的危重主动脉瓣狭窄患者.     

单个主动脉瓣叶牛心包置换术治疗儿童室间隔缺损合并主动脉瓣反流

目的 探讨儿童单个主动脉瓣叶牛心包置换在室间隔缺损合并严重主动脉瓣反流患儿中的疗效。 方法回顾性分析2006年3月至2009年9月武汉亚洲心脏病医院室间隔缺损合并严重主动脉瓣关闭不全42例患儿行单个主动脉瓣叶牛心包置换术的临床资料。其中男28例、女14例,平均年龄2～14 （9.0±3.6） 岁。所有心功能分级（NYHA）均为Ⅱ级。 结果 手术没有死亡以及并发症的发生。术后即刻经食管超声心动图提示手术成功修复主动脉瓣,瓣叶均对合正常。所有患者主动脉瓣反流均在轻度以内,跨主动脉瓣峰压差为（14.2±2.8） mm Hg。住院时间11 d,没有任何不良症状。全组患者随访32～72 （50±16） 个月。术后心功能均为Ⅰ级,无反流17例,轻度反流21例,中度反流4例。跨主动脉瓣峰压差为（12.4±3.2） mm Hg。随访中无死亡和需要二次手术患者。随访观察中未见牛心包瓣叶结构性衰败。 结论 对于室间隔缺损合并重度主动脉瓣关闭不全的患者,单个主动脉瓣叶牛心包置换术具有良好的血流动力学和中期效果。     

二叶式主动脉瓣疾病患者经心尖经导管主动脉瓣置换术后院内结局分析

目的 比较经心尖经导管主动脉瓣置换术(transapical transcatheter aortic valve replacement,TATAVR)治疗二叶式主动脉瓣(bicuspid aortic valve,BAV)和三叶式主动脉瓣(tricuspid aortic valve,TAV)患者的院内结局。方法 连续性纳入2014年7月—2020年7月在四川大学华西医院使用J-Valve ^TM瓣膜行TA-TAVR的患者(包括BAV和TAV患者)。分析患者的临床结果。结果 共纳入354例患者，其中BAV患者75例、TAV患者279例，男229例、女125例，平均年龄(72.2±6.0)岁。手术过程中无死亡发生，总技术成功率97.7%，全因住院死亡率为1.4%。20例(26.7%)BAV患者和46例(16.5%)TAV患者术后即刻出现轻度及以上瓣周漏；无BAV患者需植入永久起搏器，13例(4.7%)TAV患者术后需植入永久起搏器，总需起搏器植入率为3.7%;1例(1.3%)BAV患者和7例(2.5%)TAV患者术后出现急性肾损伤；1例(1.3%)BAV患者和1例...     

经导管主动脉瓣植入术治疗单纯主动脉瓣反流的系统评价与Meta分析

目的 评价经导管主动脉瓣植入术（transcatheter aortic valve implantation,TAVI）治疗单纯主动脉瓣反流的疗效与安全性。方法 计算机检索The Cochrane Library、PubMed、EMbase、Cochrane对照试验注册库、ClinicalTrials.gov和中国生物医学文献数据库。检索时限为2002年1月—2021年5月。收集TAVI或经导管主动脉瓣置换术治疗单纯主动脉瓣反流的文献，由2名评价员独立按照纳入和排除标准筛选文献、提取资料和评估文献质量，采用STATA 14.0软件进行Meta分析。结果 共纳入15项回顾性队列研究，含1 394例患者。纳入研究的纽卡斯尔-渥太华量表评分均≥6分。人工瓣膜植入成功率为72.0%～100.0%，未见手术死亡、心肌梗死或瓣环破裂等严重并发症报道。30 d全因死亡率为6.3%[95%CI(3.4%,9.1%)],30 d内卒中发生率和术后永久起搏器植入率均在可接受范围内，分别为2.0%[95%CI(1.0%,4.0%)]和6.0%[95%CI(4.0%,10.0%)]。结论 对于单纯高危主动脉...     

风湿性瓣膜病二尖瓣与主动脉瓣置换术1154例长期效果分析

目的　评价风湿性联合瓣膜病二尖瓣与主动脉瓣双瓣置换术的近期与远期疗效 ,分析影响手术疗效的因素。　方法　回顾性分析 1981年 5月～ 2 0 0 1年 5月 2 0年间 ,115 4例风湿性心脏病患者行双瓣膜置换术的临床资料和长期随访结果 ,其中二尖瓣与主动脉瓣均为狭窄病变者 2 5 3例 ,二尖瓣狭窄合并主动脉瓣关闭不全者 345例 ,二尖瓣关闭不全合并主动脉瓣狭窄者 119例 ,二尖瓣与主动脉瓣均为关闭不全者 437例 ;合并三尖瓣病变的占 5 4 0 0 %( 75 7例 ) ,其中器质性病变 7 2 7%( 84例 ) ,功能性关闭不全 5 8 31%( 6 73例 ) ;合并中度以上肺动脉高压者 339例 ;术前NYHA心功能分级Ⅲ级与Ⅳ级者分别为 873例和 186例。应用侧倾碟瓣或双叶机械瓣施行瓣膜置换术 ,合并三尖瓣功能或器质性病变者 ,同期行瓣膜成形手术。　结果　本组患者术后住院病死率为 6 5 0 %( 75 / 115 4)。早期死亡的主要原因为低心排出量综合征、顽固性心律失常、肾功能或呼吸功能衰竭 ,以及抗凝有关的出血等。长期生存 10 79例 ,随访时间为 8个月～ 2 0年 ,平均随访时间为 4 5 %病人·年。晚期死亡 6 6例 ( 0 39%病人·年 ) ;5、10与 15年累计生存率分别为 ( 89 46± 1 35 ) %、( 86 5 0± 1 91) %与 ( 6 7 86±6 16 ) %。生存的 92 9例患     

经导管主动脉瓣置换术麻醉进展

背景 对于手术禁忌或高风险手术的重度主动脉瓣狭窄患者,经导管主动脉瓣植入术(transcatheter aortic valve implantation,TAVI)已作为开放性手术的替代疗法.麻醉是保证手术成功的关键. 目的 总结目前关于TAVI麻醉监测管理的最新进展,为临床医师提供参考. 内容 从术前评估、麻醉方法、术中监测、术中以及术后管理等5个方面综述TAVI的麻醉进展. 趋向 目前国内TAVI麻醉研究较少,麻醉医师安全有效地监测管理是保证手术成功的关键因素.     

主动脉瓣成形术治疗先天性主动脉瓣关闭不全12例

2001年12月至2003年8月,我们对12例先天性主动脉瓣关闭不全(A I)患者采用主动脉瓣成形术(AVP)治疗,取得了较好的手术结果。1临床资料与方法本组共12例,男8例,女4例;年龄11~28岁,平均年龄20.5岁。所有患者均为先天性A I,合并室间隔缺损(V SD)2例、双腔右心室1例、感染性心内膜炎     

Delirium after transcatheter aortic valve implantation via the femoral or apical route

We thought that delirium might be less frequent after transcatheter aortic valve implantation via the femoral artery compared with via the cardiac apex. We reviewed 210 patients who underwent transcatheter aortic valve implantation between January 2009 and October 2014. The proportion (95% CI) of patients who suffered delirium in the 3 days after valve implantation were: 10 (3–16%) in 105 patients who had transfemoral implantation; and 35 (25–45%) in 105 patients who had transapical implantation, p = 0.0001. The variables that independently associated with postoperative delirium were age, male sex and the transapical approach. The median (IQR [range]) hospital stay was 7 (5–13 [2–41]) days and 10 (7–15 [2–64]) days, respectively, p = 0.004. Future trials should focus on different peri‐operative management strategies to reduce delirium rates after transcatheter aortic valve implantation, particularly in older men having implantations via the cardiac apex.     

A staged approach to transcatheter aortic valve implantation and mitral valve-in-valve implantation for a degenerated bioprosthesis in a high-risk patient

Recently, small case series have described the successful off-label use of transcatheter valve implantation in patients with degenerated bioprosthetic valves in the mitral position. We report here the case of a 78-year old female patient who underwent transcatheter aortic valve implantation for severe aortic stenosis and transapical valve-in-valve implantation for a degenerated mitral bioprosthesis. There was no evidence of intraprosthetic regurgitation and/or paraprosthetic leakages on control angiography and transoesophageal echocardiography. The postoperative course was uneventful. Following accurate patient selection and evaluation by an experienced multidisciplinary team, the transcatheter approach to double-valve implantation in the aortic and mitral positions may represent a viable treatment option for those high-risk patients who would otherwise be inoperable. We preferred a two-step approach, considering a single procedure to be high-risk.     

Aortic regurgitation after transcatheter aortic valve implantation of the edwards SAPIENtm valve

Abstract

Introduction. Transcatheter aortic valve implantation (TAVI) is established as an attractive treatment option for high-risk patients with aortic valve stenosis. One concern is the high risk of prosthetic valve regurgitation. This study aimed to examine for potential preoperative risk factors for postprocedural transcatheter heart valve regurgitation and to quantify the risk, degree, and consequences of postprocedural regurgitation. Materials and methods. 100 consecutive patients who underwent femoral (n = 22) or transapical (n = 78) TAVI were retrospectively reviewed. Echocardiographic valve regurgitation and clinical parameters were analyzed over the first year after TAVI. Results. Seventy-five percent of all patients had prosthetic valve regurgitation. It was, however, only mild or absent in 64% of patients and did not require re-intervention in any of the patients in the series. The severity of the regurgitation appeared unchanged over the one-year follow-up period. Moderate to severe regurgitation was associated with significant yet stable dilatation of the left ventricle over one year and lesser NYHA class improvement three months after TAVI. Asymmetrical native valve calcification increased the risk of paravalvular regurgitation non-significantly. Conclusion. Transcatheter heart valve regurgitation seems to be mild in the majority of cases and unchanged over a 12 months follow-up period. While affecting left ventricular dimensions in moderate or severe cases, we observed no obvious undesirable consequences of the prosthetic valve regurgitation within the first year.     

Transapical aortic valve implantation following a left pneumonectomy

Transapical transcatheter aortic valve implantation is an emerging technique for high-risk patients with symptomatic aortic valve stenosis, peripheral vascular disease, and severe concomitant comorbidities. However, a previous major surgical intervention involving the left hemithorax and the lung has always been considered a technical surgical challenge or even a potential contraindication for this minimally invasive procedure. With this report, we demonstrate, for the first time, that a previous left pneumonectomy followed by mediastinal radiotherapy does not affect the feasibility of transapical transcatheter aortic valve implantation, and we discuss the preoperative workup and the peculiar intraoperative cardiac imaging and surgical assessment.     

Procedural, 30-day and one year outcome following CoreValve or Edwards transcatheter aortic valve implantation: results of the Belgian national registry

We report clinical outcomes following transcatheter aortic valve implantation (TAVI), using the CoreValve revalving system (18 Fr transfemoral or subclavian) or the Edwards Sapien valve (22 Fr transfemoral or 24 Fr transapical) as part of a Belgian prospective non-randomized multicentre registry. All 15 Belgian centres performing TAVI participated to this registry (seven exclusively Edwards Sapien, eight exclusively CoreValve). All consecutive high-risk symptomatic patients with severe aortic stenosis were evaluated by a heart team and screened for eligibility for TAVI. Three hundred and twenty-eight patients underwent TAVI with CoreValve (n = 141; eight subclavian and 133 transfemoral) or Edwards Sapien (n = 187; 99 transfemoral and 88 transapical) up to April 2010. Procedural success was 97%. One-month survival was 88% for the Edwards and 89% for the CoreValve treated patients. One-month mortality was both related to cardiac and non-cardiac reasons. Overall one-year survival was 78% in the CoreValve transfemoral treated patients, 100% in the CoreValve subclavian treated patients, 82% in the Edwards transfemoral treated patients and 63% in the Edwards transapical treated patients. This mid-term mortality was mainly related to age-related, non-cardiac complications.     

Successful combined minimally invasive direct coronary artery bypass and transapical aortic valve implantation

Transapical aortic valve implantation is indicated in high-risk patients with aortic stenosis and peripheral vascular disease requiring aortic valve replacement. Minimally invasive direct coronary artery bypass grafting is also a valid, minimally invasive option for myocardial revascularization in patients with critical stenosis on the anterior descending coronary artery. Both procedures are performed through a left minithoracotomy, without cardiopulmonary bypass, aortic cross-clamping, and cardioplegic arrest. We describe a successful combined transapical aortic valve implantation and minimally invasive direct coronary bypass in a high-risk patient with left anterior descending coronary artery occlusion and severe aortic valve stenosis.     

Management of aortic valve dysfunction after transapical approach using the technique "valve after valve"

We report a case of a 77-year-old patient with severe aortic stenosis who underwent transapical aortic valve implantation with a 23-mm Edwards Sapien valve (Edwards Lifesciences Inc, Irvine CA). This procedure was complicated with the occurrence of an acute regurgitation due to entrapment of one of the leaflets that was successfully managed by valve after valve technique.     

Congenital quadricuspid aortic valve: report of nine surgical cases.

We report the clinicopathologic characteristics of the congenital quadricuspid aortic valve necessitating surgery. Among 616 patients for whom we performed an aortic valve operation over the past 20 years, nine patients (1.46%) (five men and four women, mean age 60 years) with quadricuspid aortic valve were encountered. All had aortic regurgitation (AR) except one with aortic stenosis and mild regurgitation (ASr). All were free of cardiac anomaly including that of the coronary arterial system. Macroscopically, severe calcification of the valve was seen in the one case of ASr. Fenestration of the cusp was seen in five cases of AR. Infective endocarditis was not seen. Histological study disclosed fibrous thickening and myxoid degeneration in the AR cases. In accordance with the Hurwitz and Roberts classification, four valves were type b (three equal-sized cusps and one smaller cusp), two valves were type a (four equal-sized cusps), two valves were type d (one large, two intermediate, and one small cusp), and one valve was type g (four unequal-sized cusps). Valve repair failed in one patient and was converted to valve replacement during the operation. All patients underwent successful aortic valve replacement (AVR).     

Combined off-pump transapical transcatheter aortic valve implantation and minimally invasive direct coronary artery bypass

Transcatheter aortic valve implantation has been shown to be an effective treatment for severe aortic stenosis in high-risk surgical patients. Many of these patients have significant coexisting coronary artery disease. We report the first case of combined off-pump transapical aortic valve implantation and minimally invasive direct coronary artery bypass via a left mini-thoracotomy in an 82-year-old man with significant comorbidities. This combined procedure is technically feasible and can be performed safely in selected patients with aortic stenosis and left anterior descending artery lesion that is not suitable for percutaneous intervention.     

Transcatheter aortic valve-in-valve-in-valve implantation for a failed xenograft

A 78-year-old gentleman with a diagnosis of symptomatic severe xenograft aortic stenosis with multiple comorbidities was referred for transcatheter aortic valve implantation, that is, a "valve-in-valve" procedure. Transcatheter aortic valve implantation was performed by transapical approach using a balloon-expandable bioprosthesis. During valve deployment, the prosthesis moved toward the left ventricle and a second balloon-expandable valve was implanted within the first one-a "valve-in-valve-in-valve" to avoid further ventricular embolization of the first bioprosthesis. Echocardiography at hospital discharge showed a residual mean transvalvular gradient of 17 mm Hg and trivial paravalvular aortic regurgitation. At 1 year follow-up, the patient was in New York Heart Association functional class II.