One-year results of transcatheter aortic valve implantation as an alternative treatment for severe aortic stenosis in high-risk patients

BackgroundAortic valve replacement (AVR) remains the gold standard treatment for symptomatic severe aortic stenosis (AS). For the past 10 years, transcatheter aortic valve implantation (TAVI) has been applied in patients with high surgical mortality and morbidity risks. The preliminary results of our TAVI patients are presented in this study.MethodsTen high-risk patients with severe AS, for AVR, were referred and accepted for TAVI in the 6 month period from May 2010 to October 2010. The patient age, logistic EuroSCORE, femoral arterial diameter, aorta annulus size, aorta valve area (AVA), mean aortic pressure gradient (MPG), as well as coronary angiography results were all collected. Six patients were treated via the transapical approach in March 2010, whereas the other four were treated with the transfemoral approach, according to their femoral artery diameter and arterial quality. This study focuses on the immediate, 1 month, 3 month, and 1 year results of TAVI.ResultsThe average age of the 10 patients receiving TAVI was 81.5 years. The mean calculated EuroSCORE was 28.3 ± 7.9%. The mean AVA was 0.61 ± 0.19 cm². The MPG was 48 ± 16 mmHg. The surgical technical success achieved 100%. There was no reported moderate to severe postoperative paravalvular aortic regurgitation, permanent complete atrioventricular block, major access site complication, or embolic stroke. Chronic renal failure, which necessitated permanent hemodialysis, developed in 10% of the patients. One acute myocardial infarction and one case of pneumonia developed postoperatively. The AVA was increased by 251%, whereas the MPG was decreased by 80% at the 3 month follow-up. The 30-day mortality rate was 10%. The all-cause 1-year mortality rate was 20%.ConclusionThis new technique and device requires greater caution and needs more practice to accumulate sufficient experience. The studied patients were very fragile, due to old age and multiple comorbidities. Our results are similar to findings of multicenter trials. With careful patient screening and selection, TAVI can be a promising treatment for high-risk severe AS patients.     

Transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis: a meta analysis

Background Transcatheter aortic valve implantation (TAVI) has emerged as the treatment choice for non-operable patients with severe symptomatic aortic stenosis (AS) and may be a good alternative to sur...     

Transcatheter aortic valve replacement in the developing world: Lessons learnt and its implications for practice

BackrgroundTranscatheter aortic valve replacement (TAVR) has become an accepted modality of treatment in intermediate and high surgical risk patients of symptomatic severe calcific aortic stenosis (AS). We herein report Indian data of 84 intermediate and high-risk patients who underwent TAVR at two Armed Forces cardiac centres.MethodsMost of the patients underwent TAVR in cardiac catheterization lab by percutaneous transfemoral approach, under conscious sedation. Patients were followed up and echocardiographic parameters were assessed after six months of procedure.ResultsTotal of 84 intermediate and high-risk patients underwent TAVR between Jan 2017 and June 2021. Mean age of population was 71.5 ± 8.4 years; 28.5% of patients had bicuspid aortic valve and Mean STS score was 6.34 ± 2.08. Majority (92.8%) patients underwent the procedure under conscious sedation. Self-expanding valves were used in 72.6% and balloon expandable in 27.4% of patients. Predilatation was done in 64% patients while 13% cases underwent post dilatation. Procedural mortality was 2.3%. Rate of permanent pacemaker implantation was 4.9%. Ischemic stroke occurred in 1.1% of patents. There was no case of severe paravalvular leak. Emergency surgical aortic valve replacement was done in 2.4% patients. Procedural success in this study was 97.6%. All-cause mortality was 9.5% at 6 months.ConclusionsTAVR is an effective treatment modality in intermediate and high-risk Indian patients with severe aortic stenosis. Patients with bicuspid or previous bio prosthetic aortic valves also have a good outcome post TAVR.     

杂交技术治疗胸腹主动脉瘤和夹层

Background Hybrid procedures including debranching of visceral and renal arteries followed by endovascular exclusion of the thoracoabdominal aortic aneurysm (TAAA) have recently been proposed as a less...     

单中心100例经导管主动脉瓣置换(TAVR)结果分析

目的 报道单中心100例经导管主动脉瓣置换术(transcatheteraortic valve replacement,TAVR)结果,总结相关经验。方法 连续入选2010年10月至2018年3月在我中心行TAVR的主动脉瓣狭窄患者100例,观察分析手术成功率、死亡率、术后并发症等结果。结果 患者平均年龄(78.1±6.8)岁,其中男性68例,胸外科协会(Society of Thoracic Surgeons's,STS)平均分数9.9±6.0。12例患者经颈动脉途径,87例经股动脉,1例经升主动脉。均使用自膨胀瓣膜,手术成功率97%。术中预扩张球囊平均大小(19.6±2.0) mm,后扩张球囊平均大小(21.4±2.2) mm,瓣膜植入平均深度为瓣环下(4.3±3.4) mm。术前、术后平均跨主动脉瓣压分别为(51.3±19.7) mmHg和(11.7±6.1) mmHg (P<0.001),术前、术后瓣口面积分别为(0.6±0.2) cm2和(1.7±0.5) cm2 (P<0.001)。随访30天内,死亡率为2%,中风发生率为1%,永久心脏起搏器植入率9%,TAVR术后起搏器植入组与非起搏器植入组的瓣膜植入深度分别为(7.2±3.1) mm和(4.2±3.3) mm (P=0.011)。二叶式主动脉瓣组与三叶式主动脉瓣组在并发症及血流动力学方面未见明显异常。结论 TAVR对我国主动脉瓣狭窄患者具有较高的安全性及有效性,二叶式与三叶式主动脉瓣膜的手术结果相似。TAVR永久性起搏器植入发生率较低,这与植入深度密切相关,可能与较小球囊扩张有关。     

超声心动图在主动脉瓣反流患者经心尖主动脉瓣植入术中的应用

目的 探讨超声心动图在主动脉瓣反流患者经心尖主动脉瓣植入(transcatheter aortic valve implantation, TAVI)术前、术中及术后的作用。方法 31例中-重度单纯主动脉瓣反流或以主动脉瓣反流为主的外科开胸手术高风险患者行经心尖TAVI术。术前经胸超声心动图（transthoracic echocardiograghy,TTE）评估主动脉瓣反流程度、测量主动脉根部相关指标、左室收缩功能;术中介入操作前经食管超声心动图 (transesophageal echocardiography,TEE)再次准确评估,瓣膜植入过程中TEE联合X光造影指导人工瓣膜植入、监测并发症,术后即刻评估有无瓣周反流及程度;术后1周、1月TTE随访人工瓣膜血流动力学参数、有无相关并发症、左室收缩功能。结果 31例患者中,29例成功完成经心尖TAVI术。术后微量或无瓣周反流23例,轻度瓣周反流6例。左室舒张期内径、左室质量指数术后1周较术前显著减小,术后1月进一步减小（ P均<0.05),左室大小基本恢复正常;左室射血分数术后1周较术前降低（ P<0.05),术后1月恢复至术前水平。结论 经心尖TAVI术对于外科开胸手术高风险的主动脉瓣反流患者是一种安全有效的治疗方式,超声心动图在TAVI术前筛查及测量、术中监测、引导和术后随访中起着不可或缺的作用。     

First transcatheter aortic valve implantation for severe pure aortic regurgitation in Asia

Transcatheter aortic valve implantation (TAVI) has become the standard of care for inoperable patients with symptomatic severe aortic stenosis (AS), and an alternative to open aortic valve replacement for patients at high surgical risk. TAVI has also been performed in several groups of patients with off-label indications such as severe bicuspid AS, and as a valve-in-valve therapy for a degenerated surgical bioprosthesis. Although TAVI with CoreValve® prosthesis is technically challenging, and global experience in the procedure is limited, the procedure could be a treatment option for well-selected patients with severe pure aortic regurgitation (AR). Herein, we report Asia''s first case of TAVI for severe pure AR in a patient who was at extreme surgical risk, with good clinical outcome at six months.     

主动脉瓣心内膜炎伴瓣周脓肿的手术治疗

目的探讨手术治疗主动脉瓣心内膜炎合并瓣周脓肿的方法与疗效。方法1991年6月至2006年6月手术治疗21例主动脉瓣心内膜炎合并瓣周脓肿患者,其中男性14例、女性7例;平均年龄39.2岁(14~60岁);自体主动脉瓣心内膜炎15例,人造心脏瓣膜心内膜炎6例。术中采用补片修补主动脉壁及瓣周缺损者9例,其中包括升主动脉左侧壁脓肿清除后形成瘘道,致主动脉与主肺动脉相通者3例;1例因主动脉壁及瓣周组织破坏严重难以用补片修补者,行Bentall手术,3例以自体心包或牛心包片重建主动脉瓣环,8例未作补片修补。全组行主动脉瓣置换术20例,Bentall术1例,所用21只人造心脏瓣膜均为机械瓣。结果2例(9.5%)人造瓣膜心内膜炎患者,术后早期死于多器官衰竭。长期存活19例,术后随访3月~15年(平均5.7年),无晚期死亡,未见心内膜炎复发及瓣周漏。结论主动脉瓣心内膜炎合并瓣周脓肿手术治疗的原则为彻底清除感染病灶,妥善处理主动脉瓣病变,改善心脏等器官功能,应用有效的抗生素抗感染与预防再感染。     

Perioperative aortic dissection rupture after endovascular stent graft placement for treatment of type B dissection

Background  The perioperative aortic dissection (AD) rupture is a severe event after endovascular stent graft placement for treatment of type B AD. However, this life-threatening complication has not undergone systematic investigation. The aim of the study is to discuss the reasons of AD rupture after the procedure.

Methods  The medical record data of 563 Stanford type B AD patients who received thoracic endovascular repair from 2004 to December 2011 at our institution were collected and analyzed. Double entry and consistency checking were performed with Epidata software.

Results  Twelve patients died during the perioperation after thoracic endovascular repair, with an incidence of 2.1%, 66.6% were caused by aortic rupture and half of the aortic rupture deaths were caused by retrograde type A AD. In our study, 74% of the non-rupture surviving patients had the free-flow bare spring proximal stent implanted, compared with 100% of the aortic rupture patients (74% vs. 100%, P=0.213). The aortic rupture patients are more likely to have ascending aortic diameters ≥4 cm (62.5% vs. 9.0%, P=0.032), involvement the aortic arch concavity (62% vs. 27%, P=0.041) and have had multiple stents placed (P=0.039).

Conclusions  Thoracic AD endovascular repair is a safe and effective treatment option for AD with relative low in-hospital mortality. AD rupture may be more common in arch stent-graft patients with an ascending aortic diameter ≥4 cm and with severe dissection that needs multi-stent placement. Attention should be paid to a proximal bare spring stent that has a higher probability of inducing an AD rupture. Post balloon dilation should be performed with serious caution, particularly for the migration during dilation.

     

Grading system modification and management of blunt aortic injury

Background The traditional approach to blunt aortic injury (BAI) has been emergent intervention.This study aimed to utilize a modified imaging grading system that may allow us to categorize these injur...     

Fenestrated endovascular aortic repair for juxtarenal abdominal aortic aneurysm

Background Endovascular stent-graft with fenestration can improve proximal sealing in patients with juxtarenal abdominal aortic aneurysm (JAAA).The purpose of this study was to describe our primary exp...     

人工生物瓣膜替换术351例的长期随访

自1977年12月至1983年12月底为351例病人应用人工生物瓣膜施行了352次心脏瓣膜替换术。单瓣膜替换术的手术死亡率为11.4％,多瓣膜手术为15.0％。术后累计随访期在二尖瓣替换组和主动脉瓣替换组分别为872.7病人年和314.2病人年。人工瓣膜损坏率在二尖瓣替换术为1.15％/病人年,在主动脉瓣替换术为0.64％/病人年。牛心包瓣、猪瓣和同种硬脑膜瓣的损坏率分别为3.3％(8/240)、2.1％(3/145)和3.1％(1/32)。对人工生物瓣膜的优缺点进行了讨论。在应用弹性支架和纯化戊二醛处理后,生物瓣的牢固度可望获得较大的改进。     

Current treatment status in patients with severe aortic valve stenosis and outcome of long term follow-up at advanced age: a Chinese single center study

Background  Surgical aortic valve replacement is the standard treatment for patients with severe aortic stenosis, but some registries have indicated that 30% to 60% of these patients are not treated surgically, usually due to advanced age and/or comorbidities. This single center study in China investigated the current treatment status in the patients with severe aortic stenosis and evaluated the long term clinical outcome in advanced age patients whether or not undergoing aortic valve replacement. 

Methods  Clinical data of 867 consecutive patients with severe aortic stenosis between January 2000 and December 2006 were retrospectively analyzed. The patients ≥65 years old were followed up by telephone or information from medical records. The primary end-point was all-cause mortality.

Results  The patients’ average age was (52±19) years (range, 1–91 years), and 34% were women. The percentages of the patients aged <15 years, between 15 and 34 years, between 35 and 54 years, between 55 and 64 years, between 65 and 74 years, and ≥75 years who underwent surgical aortic valve replacement were 82.3%, 87.2%, 88.8%, 78.2%, 65.3% and 22.2% respectively. In the patients (n=256) ≥65 years old, 43.4% had New York Heart Association class III and IV symptoms, 39.1% had hypertension, 33.2% had coronary heart disease, and 3.1% had stroke. In the patients not undergoing aortic valve replacement, 1.6% had renal insufficiency, 4.7% had chronic obstructive pulmonary disease, 2.0% had critical hematopathy, and 0.4% had mammary cancer. A total of 186 (72.7%) patients finished the follow-up, and the average duration of the follow-up was (60±26) months. In the patients between 65 and 74 years old, the total deaths and cardiac deaths in the patients undergoing aortic valve replacement decreased significantly compared with those with conservative treatment (10.3% vs. 53.7%, P <0.001 and 6.3% vs. 50.7%, P<0.001). Similarly, in the patients ≥75 years old, there was a significant difference between patients who had surgery and those who had conservative treatment in the total deaths and cardiac deaths (21.4% vs. 63.3%, P=0.007 and 14.3% vs. 46.9%, P=0.033). The total deaths in the patients aged between 65 and 74 years were significantly fewer compared with ≥75 years old patients (25.4% vs. 54.0%, P <0.001). Cox regression revealed that aortic valve replacement was the only independent predictor of mortality (HR 0.183; 95% CI, 0.101–0.332, P <0.001).

Conclusions  This single centre study showed that surgical aortic valve replacement was still the standard treatment for the patients with severe aortic stenosis and had a satisfying prognosis. However, the high risk patients with advanced age and comorbidities usually selected conservative treatment and had an unfavorable prognosis.

     

经导管主动脉瓣置换术的现状与发展趋势

目前,尽管严重主动脉狭窄的治疗指南仍以外科手术置换(surgical aortic valve replacement,SAVR)为治疗标 准,但随着大血管外科技术的不断发展,经导管主动脉瓣置换术(transcatheter aortic valve implantation,TAVI)逐渐成为 高危和禁忌SAVR患者的常规治疗措施。近年来各瓣膜厂商,包括国内医药公司,对瓣膜技术极力地推进,使得TAVI 技术取得了显著成效,加上其并发症也得到了有效控制,TAVI有望在治疗主动脉狭窄乃至关闭不全上取代传统术 式,应用前景可观。     

国产GK-2型人造心脏瓣膜20年临床应用的随访观察

目的总结20年间应用413枚GK2型人造心脏瓣膜的治疗效果,评价国产GK2型单叶式机械瓣膜的远期疗效。方法对1985年初至2004年间施行的327例心脏瓣膜替换术患者进行随访观察,男123例,女204例。年龄1.6～68岁(38.62岁±10.14岁)。心功能Ⅱ级21例,Ⅲ级216例,Ⅳ90例。术式为二尖瓣置换(MVR)205例(62.69%),二尖瓣及主动脉瓣置换(DVR)86例(26.30%),主动脉瓣置换(AVR)31例(9.48%),三尖瓣置换(TVR)5例(1.52%)。共使用GK2型二尖瓣296枚,主动脉瓣117枚。随访0.5～19.6年(9.05年±4.59年),总随访人年数为2440.7患者年。结果早期死亡11例,死亡率为3.36%(11/327)。远期死亡24例,死亡率0.98%患者年。5年、10年、15年生存率分别为93.31%±0.03%、89.59%±2.1%及83.61%±6.09%。12例发生出血事件(0.49%患者年),7例发生瓣膜血栓形成或栓塞(0.29%患者年)。91.98%的患者(241/262)心功能恢复至(NYHA)I、II级。结论连续20年的临床应用和长期随访表明,该型瓣膜具有多项优点,瓣膜相关事件发生率处于较低水平,远期效果满意。     

Transcatheter aortic valve implantation: preliminary experience in West China Hospital

Transcatheter aortic valve implantation (TAVI) is a promising alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis (AS) who were deemed at a high surgical risk.This novel technique has kept evolving rapidly throughout the world in the past decade,but was not introduced to China until recently.Here we report our clinical experience in TAVI based on the largest cohort of Chinese patients in a single center.     

Evaluation of acute kidney injury as defined by the risk, injury, failure, loss, and end-stage criteria in critically ill patients undergoing abdominal aortic aneurysm repair

Background  Acute kidney injury (AKI) is considered as a common and significant complication following abdominal aortic aneurysm (AAA) repair. This study aimed to assess the associated risk factors of AKI in the critically ill patients undergoing AAA repair and to evaluate the appropriate AKI management in the specific population.

Methods  We retrospectively examined data from all critically ill patients undergoing AAA repairs at our institution from April 2007 to March 2012. Multivariable analysis was used to identify factors associated with postoperative AKI, which was defined by risk, injury, failure, loss and end-stage (RIFLE) kidney disease criteria. The goal-directed hemodynamic optimization (maintenance of optimal hemodynamics and neutral or negative fluid balance) and renal outcomes were also reviewed.

Results  Of the 71 patients enrolled, 32 (45.1%) developed AKI, with 30 (93.8%) cases diagnosed on admission to surgical intensive care unit (SICU). Risk factors for AKI were ruptured AAA (odds ratio (OR)=5.846, 95% confidence interval (CI): 1.346-25.390), intraoperative hypotension (OR=6.008, 95% CI: 1.176 to 30.683), and perioperative blood transfusion (OR=4.611, 95% CI: 1.307-16.276). Goal-directed hemodynamic optimization resulted in 75.0% complete and 18.8% partial renal recovery. Overall in-hospital mortality was 2.8%. AKI was associated with significantly increased length of stay ((136.9±24.5) hours vs. (70.4±11.3) hours) in Surgical Intensive Care Unit.

Conclusions  Critically ill patients undergoing AAA repair have a high incidence of AKI, which can be early recognized by RIFLE criteria. Rupture, hypotension, and blood transfusion are the significant associated risk factors. Application of goal-directed hemodynamic optimization in this cohort appeared to be effective in improving renal outcome.

     

Impact of angina prior to acute ST-elevation myocardial infarction on short-term outcomes after primary percutaneous coronary intervention: results from the Shanghai Registry of Acute Coronary Syndrome (SRACE)

Background  The clinical significance of ischemic chest pain before acute ST-elevation myocardial infarction (STEMI) remains an interesting issue of investigation particularly in the era of percutaneous coronary intervention (PCI). This study aimed to assess the impact of angina prior to STEMI on short-term clinical outcomes in patients with acute STEMI undergoing primary PCI.

Methods  Among a total of 875 consecutive patients with STEMI undergoing primary PCI, 292 had episodes of angina within 24 hours of STEMI (PA group) and the remaining 583 were free of anginal symptoms (non-PA group). Clinical characteristics, angiographic and procedural features, and in-hospital and 30-day outcomes were compared between the two groups.

Results  Diabetes was less common (17.5% vs. 23.3%, P=0.04) and symptom-to-door time was shortened ((191.6±96.8) minutes vs. (357.2±341.9) minutes, P <0.001) in the PA group than in the non-PA group. Patients with angina prior to STEMI had fewer totally or nearly totally occluded infarct-related artery (TIMI flow grade 0–1) at initial angiography (75.0% vs. 90.7%, P <0.001), and achieved more TIMI flow grade 3 after primary PCI (84.2% vs. 78.2%, P=0.04). These were associated with higher rates of overall procedural success (95.9% vs. 91.8%, P=0.02) and of complete ST-segment resolution at 90 minutes after the procedure (51.7% vs. 40.3%, P=0.001). During a 30-day clinical follow-up, the left ventricular ejection fraction was significantly improved ((53.0±8.6)% vs. (51.1±9.7)%, P=0.002) and the primary endpoint of major adverse cardiac events was reduced in the PA group (7.2% vs. 12.7%, P=0.01).

Conclusion  Presence of angina prior to acute STEMI is associated with better outcome at a 30-day clinical follow-up in patients undergoing primary PCI.

     

白塞氏病致主动脉瓣关闭不全的外科治疗

目的总结白塞氏病所致主动脉瓣关闭不全的外科疗效,探讨相关手术方式.方法回顾性分析1997年4月～2004年5月在我院收治的白塞氏病所致主动脉瓣关闭不全的病例8例,其中外院术后再次入院2例,我院首次收治6例.外院2例首次均在外院行主动脉瓣替换术(AVR),转入我院后1例行AVR,1例行同种主动脉Bentall手术.我院首次收治6例中,3例行AVR,3例行主动脉根部替换术(ARR),ARR中Bentall手术2例,Cabrol手术1例.结果住院期间1例患者因左心衰竭死亡.随访3～36个月(平均26个月间),无1例患者死亡.首次AVR术后5例,因机械瓣松动二次手术2例;三次手术2例,包括1例二次行同种主动脉Bentall手术后再次行AVR;余1例瓣膜松动尚未手术.首次即行根部替换术的3例,术后无瓣膜松动和瓣周漏发生.结论白塞氏病所致主动脉瓣关闭不全应首选主动脉根部替换术.     

二维超声心动图评价经导管主动脉瓣置入术后早期左心形态及收缩功能

目的 利用二维超声心动图监测并分析经导管主动脉瓣置入术（TAVI）术后早期患者心脏形态及功能状态。方法 选择2017年12月至2019年12月在我院心血管外科就诊并行TAVI的33例患者,收集患者年龄、性别、NYHA心功能分级、既往心脏外科手术史、美国胸外科医师学会（STS）评分、手术入路、并发疾病等基本资料,以及术前和术后早期（0~2个月）超声心动图检查数据。结果 33例患者中重度主动脉瓣狭窄（SAS）组20例,重度主动脉瓣反流（SAR）组8例,SAS合并SAR组（合并组）5例。术后早期SAS组1例患者2次因心律失常加重心力衰竭再次住院治疗,4例患者出现微量瓣周漏,1例患者出现大量瓣周漏;SAR组1例患者出现中度瓣周漏;合并组1例患者出现轻度瓣周漏。与术前相比,术后早期33例患者总体左心室舒张末期容积（LVEDV）、左心房容积（LAV）、最大主动脉瓣跨瓣压差（AVPG_max）均下降（P均<0.01）,主动脉瓣有效瓣口面积（AVA）增加（P<0.01）,左心室射血分数（LVEF）、室间隔厚度（IVST）、后壁厚度（PWT）均未发生明显变化（P均>0.05）;SAS组LVEF升高（P<0.05）,LAV、AVPG_max均下降（P<0.05,P<0.01）,AVA增加（P<0.01）;SAR组LVEDV、LAV均下降（P均<0.01）,IVST增加（P<0.05）;合并组LVEDV、LAV、AVPG_max均下降（P均<0.05）,AVA增加（P<0.01）。结论 对于SAS、SAR和SAS合并SAR患者,TAVI术后早期心脏逆重构、收缩功能均有不同程度改善。单纯SAR及合并SAS的高危患者可从TAVI获益。