经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全

【摘要】 目的 探讨Venus-A支架瓣膜行经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者的可行性。方法 回顾性调阅2018年12月至2019年12月在阜外医院接受经股动脉经导管主动脉瓣置换术的15例单纯主动脉瓣关闭不全患者的床资料。其中男性12例, 女性3例,年龄68—83岁,平均年龄(74.65±5.52)岁。患者术前均有左心功能不全症状,且术前心脏超声诊断均为单纯主动脉瓣重度返流。结果 患者行经股动脉经导管主动脉瓣置换术。所有病例成功植入Venus-A支架瓣膜。全组病例无死亡。出院前对患者进行临床评估和超声心动图检查。术中行瓣中瓣治疗3例,少量瓣周返流2例。其余病人均无明显瓣周返流,并且顺利出院。结论 经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者是可行的,术后早期结果满意。     

Hybrid transcatheter tricuspid valve‐in‐valve placement of an Edwards Sapien XT valve in palliated hypoplastic left heart syndrome

Tricuspid regurgitation in the context of hypoplastic left heart syndrome (HLHS) carries a significant burden of both mortality and morbidity. We report successful hybrid trans‐atrial implantation of an Edwards Sapien XT valve into a dysfunctional bioprosthetic valve in the tricuspid position of a 9‐year‐old patient with HLHS. There was an immediate fall in the Fontan pressures combined with significant clinical improvement and the valve continues to function well nearly 3 years post implant. To the best of our knowledge, this is the first described implantation of a transcatheter valve in this specific position and anatomy.     

Transcatheter aortic valve implantation for severe aortic regurgitation in a stentless bioprosthetic valve with the core valve revalving system—Technical tips and role of the accutrak system

Transcatheter aortic valve implantation may offer a less invasive alternate to surgical reoperation in patients with failed aortic bioprosthetic valves. Prior reports have focussed on successful transcatheter treatment of stented bioprosthesis. Newer stentless valves offer unique technical challenges. In the absence of radiopaque markers, the deployment is carried out under angiographic control. Device stability is also an important issue in cases of severe regurgitation. We report on the first case of percutaneous replacement of a severely regurgitant degenerated stentless bioprosthesis treated with the new iteration of the core valve system incorporating the Accutrak stability layer. Salient technical expedients have been mentioned and discussed in detail. © 2011 Wiley‐Liss, Inc.     

经胸房间隔缺损堵闭术对房室瓣反流的影响

目的探讨经胸房间隔缺损封堵术对房室瓣反流的影响。方法回顾性分析2002年1月至2011年3月在南方医科大学珠江医院经胸微创房间隔缺损堵闭术患者的临床资料,其中资料完全者43例,40例在食道超声、2例在经胸超声辅助下行房间隔缺损堵闭术。患者术前、术后1个月及6个月经超声心动图检查,观察心脏各指标的变化和房室瓣反流程度。结果41例手术成功,手术成功率95．3％（41／43）;1例术中改为右侧开胸小切口体外循环下房间隔缺损修补术,1例术中并发心搏骤停。1例术后并发肾功能衰竭：12例术后即时有少量残余漏,1个月后超声复查消失。术后超声随访显示：右心室、右心房直径较前缩小,左心室直径较前增大,肺动脉瓣血流速度明显降低,差异有统计学意义（P〈0．05）;室间隔厚度、二尖瓣血流速度、主动脉瓣血流速度无明显改变,差异无统计学意义（P〉0．05）。房间隔缺损堵闭术后1个月、6个月,二尖瓣瓣膜反流程度较术前加重,差异有统计学意义（平均秩次：2．01VS．2．17vs1．77,x2=10．78,P=0．04）;而三尖瓣的瓣膜反流程度术前与术后1个月、6个月比较,差异无统计学意义（平均秩次：1．88vs2．11US．2．01,X2=4．23,P=0．134）。结论房间隔缺损封堵术后,可引起二尖瓣反流程度的加重,但对三尖瓣的反流程度近期影响不明显;二尖瓣中度以上或三尖瓣重度反流的患者或不适宜行单纯房间缺损封堵术。     

Clinical utility of a predictive model for paravalvular aortic regurgitation after transcatheter aortic valve implantation with a self-expandable prosthesis

Background

A predictive model for Paravalvular aortic regurgitation (PAR) integrating the left ventricular outflow tract-to-ascending aorta angle (LVOT-AO) and depth to the non-coronary cusp (NCC) after TAVI with CoreValve prosthesis (MCP) was retrospectively identified (2 × ∠LVOT-AO + [depth to NCC-10]2; cutoff = 50). However, the validity and clinical utility of this model remain unknown.

Device closure of paravalvular defects following transcatheter aortic valve replacement with the Edwards Sapien valve

Paravalvular aortic insufficiency (AI) is observed in the majority of patients undergoing transcatheter aortic valve replacement (TAVR). While paravalvular AI is most commonly modest following TAVR, moderate or severe AI was seen in 10.5% and 6.8% of the PARTNER inoperable and high‐risk cohorts at 1 year and has been reportedly associated with dyspnea and diminished survival. We report two cases of transcatheter heart valve (THV) associated paravalvular defects closed using catheter delivered devices. Both patients derived hemodynamic and symptomatic improvement from device closure. Additional research is warranted to define the adverse consequences of THV associated AI, indications for treatment, and risks associated with device closure of these defects. © 2012 Wiley Periodicals, Inc.     

Management of asymptomatic chronic aortic regurgitation with left ventricular dysfunction

Study objective:To determine the optimal strategy for the timing of aortic valve replacement in patients with chronic, severe aortic regurgitation with left ventricular dysfunction. Design:Decision analysis comparing early surgery (timed at the onset of left ventricular dysfunction) with delayed surgery (timed at the onset of symptoms) using data from the literature and expert opinion for variables in a representative case scenario (40-year-old man with bicuspid aortic valve disease). Setting:Tertiary care center doing valve replacement surgery. Measurements and main results:The early-surgery approach was preferred based on quality-adjusted life years. Sensitivity analysis showed that the result was not affected by the following variables within their derived ranges: rate of symptom development after onset of left ventricular dysfunction for the delayed-surgery approach, perioperative mortality for both approaches, and occurrence of major monfatal stroke or congestive heart failure for both approaches. Although the decision was sensitive to the yearly postoperative mortality rates, the delayed-surgery operative mortality rate had to be almost as low as the early-surgery rate to change the preference to the delayed-surgery approach. The preference could also change if survival were much more important to the patient in the first five years than after five years or if the patient disliked living on anticoagulants enough to value a year on anticoagulants as worth only 80% of a year not on anticoagulants. Conclusion:This decision analysis provides quantitative support for the impression that patients similar to the case scenario do better with surgery timed at the onset of ventricular dysfunction than with surgery delayed until symptoms develop. It thus supports the practice of following these patients noninvasively in order to time surgery. Received from the Departments of Medicine and Health Administration, University of Toronto; Division of Cardiology, St. Michael’s Hospital; and Division of General Internal Medicine and Clinical Epidemiology, Toronto General Hospital, Toronto, Ontario, Canada. Supported in part by a National Health Research Award (Health and Welfare, Canada) to Dr. Detsky.     

Changes in mitral regurgitation after transcatheter aortic valve implantation

Objectives : To assess the acute and intermediate changes in mitral regurgitation (MR) severity after transcatheter aortic valve implantation (TAVI) with the CoreValve Revalving SystemTM (CRS). Background : Following surgical aortic valve replacement, improvement in MR is reported in 27–82% of the patients. The changes in MR severity following CRS implantation are unknown. Methods : Transthoracic echocardiography was performed in 79 consecutive patients before and after treatment, and at the first outpatient visit. Left ventricular dimensions and ejection fraction (LVEF), left atrial (LA) size, and aortic gradient were measured. MR was assessed by color flow mapping and was graded as none, mild, moderate, or severe. It was defined as organic or functional. The depth of CRS implantation was measured by angiography. Results : Post‐treatment, the mean gradient decreased from 48 ± 16 mm Hg to 9 ± 5 mm Hg (P < 0.0001). There was no significant change in the left ventricular dimensions, LA size, and LVEF. MR pretreatment was mild, moderate, or severe in 57%, 18%, and 1% of the patients, respectively. It was defined as organic in 27 patients (36%) and functional in 27 patients (36%). The degree of MR remained unchanged in 61% of the patients, improved in 17%, and worsened in 22%. MR improvement was associated with a lower baseline LVEF (P = 0.02). There was no association between the changes in MR severity and the depth of CRS implantation. Conclusions : Most patients who underwent TAVI had some degree of MR. Overall there was no change in the degree of MR post‐treatment. Patients in whom MR improved had a lower LVEF at baseline. © 2009 Wiley‐Liss, Inc.     

Bailout perventricular pulmonary valve implantation following failed percutaneous attempt using the Edwards Sapien transcatheter heart valve

Percutaneous pulmonary valve implantation has emerged as an attractive and less invasive alternative to open‐heart surgery. Nevertheless, major technical challenges and procedural complications may still occur. We report a 44‐year‐old woman with severe dextroscoliosis, and history of Tetralogy of Fallot repair, who underwent an attempt at percutaneous implantation of a 23‐mm Edwards SAPIEN transcatheter heart valve (THV) for recurrent stenosis of the right ventricle to pulmonary artery conduit. The procedure was complicated by valve migration into the right ventricle requiring emergent surgical removal using inflow‐occlusion technique to avoid cardiopulmonary bypass. A hybrid off‐pump perventricular approach was then used in the operating room to successfully implant a 26‐mm Edwards Sapien THV under fluoroscopic guidance. © 2010 Wiley‐Liss, Inc.     

Transcatheter aortic valve implantation through the left subclavian artery with a patent LIMA graft

We report the case of an 80‐year‐old male with severe aortic valve stenosis previously submitted to surgical myocardial revascularization with patent mammary graft treated by TAVI through left‐transaxillary approach because of unsuitable transfemoral and transapical approaches.© 2010 Wiley‐Liss, Inc.     

Urgent transcatheter aortic valve replacement for severe acute aortic regurgitation following open mitral valve surgery

Transcatheter aortic valve replacement (TAVR) is not currently approved for pure native valve aortic incompetence, and is typically performed on a compassionate basis in selected patients who are at high risk for conventional surgery. We describe the first use of TAVR to treat iatrogenic severe acute pure aortic incompetence following mitral valve surgery. A 71‐year‐old gentleman developed life‐threatening acute aortic regurgitation (AR) within hours of a very challenging fifth open heart mitral valve replacement. Careful inspection of echocardiographic and computed tomographic imaging identified the cause as a disrupted left coronary cusp at the commissure caused by the surgical mitral annular reconstruction. Medical management with afterload reduction failed with recurrent pulmonary edema, and a sixth open heart surgery was deemed prohibitively high risk. The lack of aortic annular calcium onto which anchors a transcatheter valve was a concern for TAVR. However, we postulated that the struts of the mitral valve bioprosthesis would offer some support to the TAVR valve. We opted for a self‐expanding system because of concerns about potential unfavorable interaction between the balloon onto which balloon‐expandable bioprosthesis is mounted and the struts of the mitral bioprosthesis, and because the Evolut R system has additional anchoring points at the crown which might enhance transcatheter valve stability in the non‐calcified annulus, compared with the Edwards Sapien system. Transfemoral TAVR, performed with a Medtronic Evolut R 34 mm system under general anesthesia and using moderately rapid ventricular pacing, was successful with minimal residual AR. On follow‐up 1 month later the patient was asymptomatic, and the aortic and mitral bioprostheses were functioning normally on echocardiogram.     

Mixed aortic valve disease treated with transcatheter aortic valve replacement in a high risk patient presenting with acute decompensated heart failure

Mixed aortic valve disease refers to the combination of aortic regurgitation (AR) and aortic stenosis (AS). Commonly etiologies include a bicuspid aortic valve, rheumatic heart disease, and endocarditis superimposed upon a stenotic aortic valve. Treatment depends upon the severity of disease, the presence of symptoms and the size and function of the left ventricle. We present a case of a young patient that presented with new onset acute decompensated heart failure with mixed aortic valve disease that was successful treated with transcatheter aortic valve replacement (TAVR). Invasive hemodynamics at baseline and following TAVR provide an insight into the characteristic features of mixed aortic valve disease. TAVR represents a new treatment option for critically ill patients deemed high risk or nonoperable for surgical aortic valve replacement.     

Electrocardiographic changes and conduction disturbances after transfemoral aortic valve implantation with Edwards Sapien 3 prosthesis

Objectives

The aim of this study is to describe electrocardiographic changes and conduction abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI).