保留主动脉瓣主动脉根部替换术的临床应用评价

目的评价保留自身主动脉瓣的主动脉根部替换的可行性和疗效。方法自1998年1月至2004年9月,对我院24例主动脉病变导致主动脉瓣关闭不全但瓣膜本身无明显异常的患者,实施了保留主动脉瓣的主动脉根部替换术,并术后随访观察主动脉瓣反流和心功能改善情况。结果全组无住院死亡。除1例仍为中度反流外,术后主动脉瓣反流均明显改善。随访中有2例非手术相关死亡,无主动脉瓣反流需再次手术者。全组心功能恢复满意。结论主动脉根部替换手术时,对由于主动脉根部瘤或升主动脉瘤导致的主动脉瓣反流者,可优选采用保留主动脉瓣的主动脉根部替换术。     

Replacement of a Congenital Bicuspid Aortic Valve in a Patient with Left Ventricular Noncompaction

Left ventricular noncompaction is a congenital cardiomyopathy, which is often first diagnosed in adults. The condition can be found in isolation, but it has also been described in association with other cardiac anomalies. We report here the 4th documented case of left ventricular noncompaction associated with a bicuspid aortic valve and the 1st of these cases in which the patient underwent aortic valve surgery.Key words: Aortic valve/abnormalities/surgery, cardiomyopathies/diagnosis/pathology/ultrasonography, echocardiography, heart defects, congenital, heart ventricles/abnormalities, magnetic resonance imaging, prognosisIsolated noncompaction of the ventricular myocardium is a rare disorder, with an incidence of 0.05% in the adult population.¹ It is recognized that there are associations with other congenital cardiac malformations, including bicuspid aortic valve.² An excessively prominent trabecular meshwork and deep trabecular recesses characterize myocardial noncompaction, which is caused by the arrest of compaction of myocardial fibers during embryogenesis.³ The echocardiographic criteria for noncompaction have been well described and include, for example, evidence of a 2-layer structure: a thick, noncompacted layer and a thin, compacted layer, displaying a maximal noncompacted-to-compacted thickness ratio of greater than 2.³Previous studies of noncompaction cardiomyopathy in adults have reported a poor prognosis, with high death and morbidity rates from heart failure, thromboembolic events, and ventricular arrhythmias.⁴ One study found that 48% of patients died or underwent cardiac transplantation during a mean follow-up period of 44 months. A more recent study, however, has suggested a more favorable prognosis: only 1 death among 45 patients studied during a mean follow-up period of 46 months.⁵ Notably, patients with impaired systolic function in this study experienced improvement in New York Heart Association (NYHA) functional class symptoms with medical treatment, and the cohort of patients with normal systolic function had no death or progression to heart failure. One of the reasons for this apparent discrepancy in findings is that the latter study appeared to enroll patients who had a milder phenotype or were in the asymptomatic phase of the disease. An even more recent study indicates a wider spectrum of disease progression, from a more severe prognosis (in association with elevated NYHA functional class at 1st observation and with a history of sustained ventricular tachycardia) to a more stable course (in association with an incidental finding of noncompaction).⁶     

Bicuspid Aortic Valve and Aortic Root Disease

Bicuspid aortic valve (BAV) is the most common form of congenital heart disease, with frequent and premature occurrence of cardiac events, dominated by significant valvular dysfunction. BAV has a high prevalence of aortic wall abnormalities such as ascending aortic dilatation. Because more rapid aortic dilatation can occur, once the ascending aorta reaches 40 mm, annual imaging with echocardiography or other imaging techniques is indicated. The most feared complication is aortic dissection. However, the actual incidence of this complication is low (4%). Although limited data exist regarding prophylactic intervention, it is suggested that elective surgical repair of BAV-associated aortic dilatation should be more aggressively recommended. In patients with BAV, the decision to indicate surgical treatment in aortic diameters between 50 and 55 mm should be based on patient age, body size, comorbidities, type of surgery, and the presence of additional risk factors.     

Valve Replacement with a Sutureless Aortic Prosthesis in a Patient with Concomitant Mitral Valve Disease and Severe Aortic Root Calcification

Aortic valve replacement with concomitant mitral valve surgery in the presence of severe aortic root calcification is technically difficult, with long cardiopulmonary bypass and aortic cross-clamp times.We performed sutureless aortic valve replacement and mitral valve annuloplasty in a 68-year-old man who had severe aortic stenosis and moderate-to-severe mitral regurgitation. Intraoperatively, we found severe calcification of the aortic root. We approached the aortic valve through a transverse aortotomy, performed in a higher position than usual, and we replaced the valve with a Sorin Perceval S sutureless prosthesis. In addition, we performed mitral annuloplasty with use of an open rigid ring.The aortic cross-clamp time was 63 minutes, and the cardiopulmonary bypass time was 83 minutes. No paravalvular leakage of the aortic prosthesis was detected 30 days postoperatively.Our case shows that the Perceval S sutureless bioprosthesis can be safely implanted in patients with aortic root calcification, even when mitral valve disease needs surgical correction.     

Transcatheter Aortic Valve Replacement in Bicuspid Aortic Stenosis Using Lotus Valve System

Bicuspid aortic stenosis (BAS) has been excluded in clinical trials on transcatheter aortic valve replacement (TAVR) due to the presumed uneven expansion of the aortic prosthesis, leading to significant paravalvular regurgitation (PVR). There is no transcatheter heart valve (THV) commercially approved for treating BAS. The Lotus Valve System mitigates PVR by possessing an adaptive seal and being fully re‐positionable. The latter is also important in preventing embolization, as the location of prosthesis fixation in BAS could be variable due to the presence of less expandable raphe. We report our early experience with the Lotus Valve System in three consecutive TAVR for BAS. They all provide good clinical and hemodynamic results without significant PVR. We conclude that the use of Lotus Valve System for treating BAS is feasible and safe, and may have advantages over the previous generation TAVR systems. © 2016 Wiley Periodicals, Inc.     

Transcatheter Aortic Valve Replacement in Low-Risk Patients With Symptomatic Severe Bicuspid Aortic Valve Stenosis

ObjectivesThe aim of this study was to evaluate clinical outcomes and transcatheter heart valve hemodynamic parameters after transcatheter aortic valve replacement (TAVR) in low-risk patients with bicuspid aortic stenosis (AS).BackgroundTAVR is approved for low-risk patients in the United States. However, patients with bicuspid AS were excluded from the randomized cohorts of the pivotal low-risk trials.MethodsThe LRT (Low Risk TAVR) trial was an investigator-initiated, prospective, multicenter study and was the first and only U.S. Food and Drug Administration–approved investigational device exemption trial to evaluate the feasibility of TAVR with either balloon-expandable or self-expanding valves in low-risk patients with bicuspid AS. The primary endpoint was all-cause mortality at 30 days. Baseline and follow-up echocardiography and computed tomography to detect leaflet thickening were analyzed in an independent core laboratory.ResultsSixty-one low-risk patients with symptomatic, severe AS and bicuspid aortic valves (78.3% Sievers type 1 morphology) underwent TAVR at 6 centers from 2016 to 2019. The mean age was 68.6 years, and 42.6% were men. At 30 days, there was zero mortality and no disabling strokes. The rate of new permanent pacemaker implantation was 13.1%; just 1 patient had a moderate paravalvular leak at 30 days. Hypoattenuated leaflet thickening was observed in 10% of patients at 30 days.ConclusionsTAVR appears to be safe in patients with bicuspid AS, with short length of hospital stay, zero mortality, and no disabling strokes at 30 days. Subclinical leaflet thrombosis was observed in a minority of patients at 30 days but did not appear to be associated with clinical events.     

Sex Difference in Outcomes Following Transcatheter Aortic Valve Replacement in Bicuspid Aortic Stenosis

BackgroundIt is unknown whether the sex difference whereby female transcatheter aortic valve replacement (TAVR) candidates had a lower risk profile, a higher incidence of in-hospital complications, but more favorable short- and long-term survival observed in tricuspid cohorts undergoing TAVR would persist in patients with bicuspid aortic valves (BAVs).ObjectivesThe aim of this study was to reexamine the impact of sex on outcomes following TAVR in patients with BAVs.MethodsIn this single-center study, patients with BAVs undergoing TAVR for severe aortic stenosis from 2012 to 2021 were retrospectively included. Baseline characteristics, aortic root anatomy, and in-hospital and 1-year valve hemodynamic status and survival were compared between sexes.ResultsA total of 510 patients with BAVs were included. At baseline, women presented with fewer comorbidities. Men had a greater proportion of Sievers type 1 BAV, higher calcium volumes (549.2 ± 408.4 mm³ vs 920.8 ± 654.3 mm³; P < 0.001), and larger aortic root structures. Women experienced more vascular complications (12.9% vs 4.9%; P = 0.002) and bleeding (11.1% vs 5.3%; P = 0.019) and higher residual gradients (16.9 ± 7.7 mm Hg vs 13.2 ± 6.4 mm Hg; P < 0.001), while men were more likely to undergo second valve implantations during index TAVR (6.3% vs 15.9%; P = 0.001). Death at 1 year was not significantly different between sexes (HR: 1.15; 95% CI: 0.56-2.35; P = 0.70). Bleeding (adjusted HR: 4.62; 95% CI: 1.51-14.12; P = 0.007) was the single independent predictor of 1-year death for women.ConclusionsIn patients with BAVs undergoing TAVR, women presented with fewer comorbidities, while men had a greater proportion of type 1 BAV, more calcification, and larger aortic roots. In-hospital outcomes favored men, with fewer complications except for the need for second valve implantation, but 1-year survival was comparable between sexes.     

Transcatheter Aortic Valve Replacement in Low-Risk Bicuspid and Tricuspid Patients: Meta-Analysis

BackgroundMost pivotal transcatheter aortic valve replacement (TAVR) trials have excluded patients with bicuspid aortic stenosis (AS). This study compared TAVR in low-risk patients with bicuspid AS to those with tricuspid AS, incorporating data from prospective trials.MethodsWe selected prospective US low-risk TAVR trials containing a bicuspid arm for this meta-analysis, examining outcomes at 30 days. Study results were pooled using a hierarchical Bayesian random-effects model.ResultsIncluded were 3 Food and Drug Administration (FDA)-approved investigational device exemption (IDE) trials that enrolled a total of 1810 low-risk patients with symptomatic severe AS for TAVR. We compared 380 bicuspid patients with 1430 tricuspid patients. Event rates at 30 days overall were low, with similar mortality (odds ratio [OR], 0.38; 95% credible interval [CrI]: 0.08, 1.78; I², 0%), non-disabling stroke (OR, 0.45; 95% CrI: 0.15, 1.07; I², 9%), and permanent pacemaker implantation (OR, 0.86; 95% CrI: 0.41, 1.47; I², 59%). There were statistically significant differences in disabling stroke (OR, 0.16; 95% CrI: 0.01, 0.90; I², NA) and coronary obstruction (OR, 0.21; 95% CrI: 0.05, 0.91) that disappeared after sensitivity analysis by adding a single event to the tricuspid arm. Hemodynamics were similar at 30 days.ConclusionsPreliminary data from the FDA-approved IDE trials of low-risk patients with bicuspid AS undergoing TAVR demonstrated 30-day outcomes comparable to low-risk tricuspid patients, except for a trend toward higher stroke in bicuspid patients. Randomized trials are warranted to reassure the safety and long-term outcome of TAVR in patients with severe bicuspid AS.