经导管主动脉瓣置换术治疗二叶式主动脉瓣狭窄的术中投照角度预测值分析

目的在二叶式主动脉瓣(BAV)行经导管主动脉瓣置换术(TAVR)中,分析术前多排螺旋CT(MDCT)预测的最佳导丝跨瓣角度、球囊预扩张角度和瓣膜释放角度规律,总结三种投照角度预测值的规律。方法回顾性分析2019年7月至2020年6月在复旦大学附属中山医院因严重症状性重度主动脉瓣狭窄(AS)而行TAVR的BAV患者31例。收集基线资料、术前评估和手术情况。使用MDCT预测TAVR最佳导丝跨瓣角度、球囊预扩张角度和瓣膜释放角度,按照横裂式BAV和纵裂式BAV分组,比较两组之间的差异和规律。结果最佳导丝跨瓣角度,横裂式BAV为右前斜(RAO)8°(18°,3°)、足位(CAU)25°(29°,17°),纵裂式BAV为左前斜(LAO)26°(21°,34°)、头位(CRA)13°(6°,22°),两者差异均有统计学意义(均P<0.001);最佳球囊预扩张角度(显示左冠状动脉开口),横裂式BAV为LAO 11°(9°,26°)、CRA 8°(1°,19°),纵裂式BAV为LAO 36°(30°,39°)、CRA 22°(14°,25°),两者差异均有统计学意义(均P<0.05);最佳球囊预扩张角度(显示右冠状动脉开口),横裂式BAV为LAO 48°(43°,60°)、CRA 26°(3°,29°),纵裂式BAV为LAO 48°(39°,70°)、CRA 25°(22°,33°),两者差异均无统计学意义(P=0.320、P=0.560);最佳瓣膜释放角度,横裂式BAV为RAO 12°(16°,4°)、CAU 25°(28°,19°),纵裂式BAV为LAO 21°(17°,26°)、CRA 3°(-2°,12°),两者差异均有统计学意义(均P<0.001)。结论术前MDCT可预测BAV行TAVR的最佳导丝跨瓣、球囊预扩张和瓣膜释放投照角度,这些角度与BAV为横裂式还是纵裂式相关,存在明显规律。     

Optimal projection estimation for transcatheter aortic valve implantation based on contrast‐aortography

We investigate the accuracy of a new software system (C‐THV, Paieon) designed to calculate the optimal projection (OP) view for transcatheter aortic valve implantation (TAVI) based on two aortograms, and its agreement with the operator's choice. An optimal fluoroscopic working view projection with all three aortic cusps depicted in one line, is crucial during TAVI. In our institution selection of the OP is based on multislice computed tomography (MSCT). Seventy‐three consecutive patients referred for TAVI were divided into two groups. For the first group (53 patients, retrospective cohort) we compared the OP views estimated by C‐THV with the ones estimated by MSCT. For the second group (20 patients, prospective cohort), we compared the OP views estimated by C‐THV with the operator's choice during TAVI. For the retrospective cohort, the mean absolute difference (mean ± SD) between C‐THV and MSCT was 6.6 ± 4.9 degrees. In 77% of the cases the mean difference between C‐THV and MSCT was <10 degrees. For the prospective cohort, the mean absolute difference (mean ± SD) between C‐THV and the operator's choice was 5.5 ± 3.4 degrees. A mean difference of <10 degrees was found in 90% of the cases. In this study we found that the C‐THV software estimated the OP view for TAVI with good accuracy. The level of agreement between C‐THV and either the MSCT or the operator's choice was deemed satisfactory, with the vast majority of observed differences being <10 degrees. © 2010 Wiley‐Liss, Inc.     

Identification of less-irradiating tube angulations in invasive cardiology

OBJECTIVES: We sought to identify tube angulations in invasive cardiology, which promise minimal radiation exposure to patients and operators. BACKGROUND: Radiation exposure in invasive cardiology is high. METHODS: We mapped the fluoroscopic dose-area product per second (DAP/s), applied to an anthropomorphic Alderson-Rando phantom and, in absence of radiation protection devices, the mean personal dose in the operator's position in 10 degrees steps from the 100 degrees right anterior oblique (RAO) to the 100 degrees left anterior oblique (LAO) projection, as well as for all geometrically feasible craniocaudal tube angulations. RESULTS: For our specific setting conditions RAO 20 degrees /0 degrees tube angulation generated the lowest DAP/s and operator's personal dose. The mean patient DAP/s and operator personal dose for all postero-anterior (PA) projections, cranialized and caudalized together, rose significantly: 3.7 and 10.6 times the PA 0 degrees baseline values toward LAO 100 degrees and 3.7 and 2.4 times toward RAO 100 degrees , respectively. Patient and operator values for all PA projections, angulated to the right and left, increased approximately 2.5 times toward 30 degrees craniocaudal angulations. Caudal PA 0 degrees /30 degrees - angulation instead of caudal LAO 60 degrees /20 degrees - angulation for the left coronary main stem and cranial PA 0 degrees /30 degrees + view in place of cranial LAO 60 degrees /20 degrees + view for the left anterior descending coronary artery bifurcation enable 2.6-fold dose reductions to the patient and eight- and five-fold dose reductions to the operator, respectively. CONCLUSIONS: The PA views and RAO views >or=40 degrees , heretofore unconventional in clinical routine, should be favored over steep LAO projections >or=40 degrees whenever possible. Tube angulations that are radiation intensive to the patient exponentially increase the operator's radiation risk.     

Impact of implantation technique on conduction disturbances for TAVR with the self-expanding portico/navitor valve

Background

Use of a right−left (R−L) cusp overlap view for transcatheter aortic valve replacement (TAVR) with self-expanding valves has recently been proposed aiming to reduce permanent pacemaker implantation (PPMI). An objective, data-driven explanation for this observation is missing.

Aims

To assess the impact of different implantation techniques on the risk of PPMI following TAVR with the Portico/Navitor^TM transcatheter heart valve (THV; Abbott).

Methods

A TAVR-population treated with Portico/Navitor^TM had the THV implanted in a right versus left anterior oblique (RAO/LAO) fluoroscopic view with no parallax in the delivery system. The impact of these different implantation views on the spatial relationship between THV and native aortic annulus and the risk of conduction disturbances and PPMI after TAVR was studied.

Results

A total of 366 matched TAVR patients were studied: 183 in the RAO group and 183 in the LAO group. The degree of aortic annulus plane tilt was significantly smaller in the RAO versus LAO group (median: 0° vs. 23°, p < 0.001), with no plane tilt in 105 out of 183 cases (57.3%) in the RAO group. At 30 days after TAVR, the overall PPMI and guideline-directed PPMI rates were 12.6% versus 18.0% (p = 0.15) and 8.2% versus 15.3% (p = 0.04) in the RAO versus LAO group, respectively.

Conclusions

Use of a R−L cusp overlap (RAO-caudal) view for implantation of the Portico/Navitor^TM valve results in less tilt of the native aortic annulus plane and a clear trend toward a lower 30-day PPMI rate as compared to TAVR using the conventional LAO implantation view.     

Tortuosity of coronary arteries in chronic pressure and volume overload

The role of coronary tortuosity in the pathophysiology of chronic pressure and volume overload is still unclear. A new method for measuring coronary tortuosity in patients with chronic pressure and volume overload was evaluated in 62 patients. Sixteen controls, 14 patients with arterial hypertension, and 32 patients with aortic regurgitation were included in the present analysis. The left anterior descending (LAD) and circumflex (LCX) coronary arteries were traced, and tortuosity was determined in the 30° right (RAO) and 60° left (LAO) anterior oblique projection. Tortuosity index (TI, %) was defined as the percent ratio of calculated shortest distance divided by total length of the coronary artery. TI was 104.1 ± 3.2% at end-diastole in controls, 105.7 ± 3.8% in hypertensives (P < 0.05 vs. controls), and 102.9 ± 2.5% in patients with aortic regurgitation (P < 0.05 vs. controls, P < 0.001 vs. hypertensives). Respective values at end-systole were 107.8 ± 4.7% in controls, 109.8 ± 7.1% in hypertensives (ns vs. controls), and 104.3 ± 3.3% in patients with aortic regurgitation (P < 0.001 vs. controls and vs. hypertensives). No differences were found in tortuosity between RAO and LAO projection or between LAD and LCX artery. There was a significant correlation between TI and left ventricular (LV) muscle mass, LV volume, and age. Females tended to have more tortuous vessels than males. Coronary tortuosity is more pronounced in patients with chronic pressure than with volume overload. Determinants of coronary tortuosity are gender, age, LV volume, and muscle mass. Thus, coronary tortuosity seems to play an important role as a physiologic determinant for the flow and the mechanics of the vessel wall. © 1996 Wiley-Liss, Inc.     

Optimal Fluoroscopic Projections of Coronary Ostia and Bifurcations Defined by Computed Tomographic Coronary Angiography

ObjectivesThe aim of this study was to define the optimal fluoroscopic viewing angles of both coronary ostia and important coronary bifurcations by using 3-dimensional multislice computed tomographic data.BackgroundOptimal fluoroscopic projections are crucial for coronary imaging and interventions. Historically, coronary fluoroscopic viewing angles were derived empirically from experienced operators.MethodsIn this analysis, 100 consecutive patients who underwent computed tomographic coronary angiography (CTCA) for suspected coronary artery disease were studied. A CTCA-based method is described to define optimal viewing angles of both coronary ostia and important coronary bifurcations to guide percutaneous coronary interventions.ResultsThe average optimal viewing angle for ostial left main stenting was left anterior oblique (LAO) 37°, cranial (CRA) 22° (95% confidence interval [CI]: LAO 33° to 40°, CRA 19° to 25°) and for ostial right coronary stenting was LAO 79°, CRA 41° (95% CI: LAO 74° to 84°, CRA 37° to 45°). Estimated mean optimal viewing angles for bifurcation stenting were as follows: left main: LAO 0°, caudal (CAU) 49° (95% CI: right anterior oblique [RAO] 8° to LAO 8°, CAU 43° to 54°); left anterior descending with first diagonal branch: LAO 11°, CRA 71° (95% CI: RAO 6° to LAO 27°, CRA 66° to 77°); left circumflex bifurcation with first marginal branch: LAO 24°, CAU 33° (95% CI: LAO 15° to 33°, CAU 25° to 41°); and posterior descending artery and posterolateral branch: LAO 44°, CRA 34° (95% CI: LAO 35° to 52°, CRA 27° to 41°).ConclusionsCTCA can suggest optimal fluoroscopic viewing angles of coronary artery ostia and bifurcations. As the frequency of use of diagnostic CTCA increases in the future, it has the potential to provide additional information for planning and guiding percutaneous coronary intervention procedures.     

“Device landing zone” calcification,assessed by MSCT,as a predictive factor for pacemaker implantation after TAVI

Background : After trans‐catheter aortic valve implantation (TAVI), the need for postinterventional pacemaker (PM) implantation can occur in as many as 10–50% of cases, but it is not yet clear, how this need can be predicted. The aim of this study was to assess the possible predictive factors of post TAVI PM implantation based on Computed Tomography (CT) measured aortic valve calcification and its distribution. Methods : We prospectively analyzed 81 consecutive symptomatic patients with severe AS scheduled for TAVI using the CoreValve prosthesis (Medtronic, Minneapolis, USA). In all patients, a native and contrast‐enhanced multislice cardiac CT was performed preinterventionally, estimating calcification load of the native valve cusps and of the adjacent outflow tract (so called “device landing zone”, DLZ) by the Agatston Score (AgS). Objective, computer‐evaluated, preprocedural ECG‐analysis was performed with regards to pre‐existing conduction abnormalities. Transthoracic echocardiography was performed pre and post TAVI. Results : TAVI was successful in all cases. PM implantation was deemed necessary in altogether 32 patients, out of 67 without a PM pre‐TAVI (32/67, 47%). Various parameters were tested as predictors of post TAVI PM in a multivariate logistic regression analysis model. Female sex (P = 0,005) and depressed EF (P = 0,023) showed a significant correlation. PM implantation correlated also to the DLZ calcification, as assessed by CT (P = 0,004). This model leads to an AUC (area under the ROC—receiver operator characteristics—curve) of 0.83. Conclusion : Calcium amount in the CoreValve DLZ in combination with clinical data could predict the need for post TAVI PM implantation. © 2010 Wiley‐Liss, Inc.     

Three-dimensional reconstruction of the coronary sinus with rotational angiography.

BACKGROUND: High-speed rotational coronary venous (CV) angiography (RCVA) permits dynamic, multi-angle visualization of the CV anatomy. METHODS AND RESULTS: RCVA uses a rapid isocentric rotation over a 108 degrees arc, right anterior oblique (RAO) 54 degrees to left anterior oblique (LAO) 54 degrees, in 4 s. Three-dimensional models of the venous tree were reconstructed, and the rotational images were analyzed using a full range of gantry angles, providing the operator with considerably more information about the CV anatomy than standard coronary sinus angiography images (SCVA). CONCLUSIONS: The SCVA view, which optimally displayed the appropriate coronary sinus branch for left ventricular lead implantation, was often different from the conventional RAO and LAO views.     

Renal artery angiography: "the right ipsilateral oblique" myth.

BACKGROUND: Finding the optimal image intensifier angle of obliquity during renal intervention is important for accurate stent placement but can require multiple catheter rotations and test injections of contrast. OBJECTIVE: Explore the usefulness of axial magnetic resonance angiography (MRA) as a roadmap for predicting image intensifier position during subsequent renal intervention. METHODS: MRA images were reviewed in 137 consecutive patients (255 renal arteries) undergoing workup for renal artery stenosis. The axial angle of renal artery incidence perpendicular to the spine was estimated by two operators and results averaged. RESULTS: The average angle of incidence for the renal artery ostia was +21.24 degrees +/-2.31 degrees for the right and +8.81 degrees +/-2.0 degrees for the left (P < .0001). The positive numbers correlate with left anterior oblique (LAO) and negative right anterior oblique (RAO). CONCLUSIONS: MRA can be used to define the origin of the renal artery and is most likely to predict an LAO image window for subsequent angiography of the left and right renal arteries displacing the "ipsilateral oblique" axiom. In patients without baseline MRA the 10 to 20 degree LAO "empiric" position will allow coaxial imaging of both renal ostia in 75% of cases. However, there can be extreme variation in the renal origin (53 degrees RAO to 85 degrees LAO) and we advocate using the simple technique reported herein to define the renal origin in patients with pre-procedure MRA.     

Prognostic benefit of transcatheter aortic valve implantation compared with medical therapy in patients with inoperable aortic stenosis

Objectives : To compare survival in patients with inoperable aortic stenosis who undergo transcatheter aortic valve implantation against those managed medically. Background : Without surgical correction, survival of patients with severe symptomatic aortic stenosis is poor. It is unknown whether patients undergoing transcatheter aortic valve implantation (TAVI) have a better prognosis than similar patients who are treated with medical management. Methods : Survival rates were compared in consecutive patients with severe symptomatic aortic stenosis who either underwent TAVI or continued on medical management following multidisciplinary team assessment. All patients had been turned down, or considered at unacceptably high risk, for conventional aortic valve surgery. Patients were reviewed in clinic or by telephone six monthly. Mortality data was obtained from the United Kingdom Office of National Statistics. Results : The study group included 85 patients aged 81 ± 7 years (range 62–94), of whom 48 were male. Thirty eight patients underwent TAVI while 47 patients were deemed unsuitable based on echocardiographic, angiographic, or clinical criteria and remained on medical therapy. The calculated EuroSCORE for the TAVI group was 11 ± 2 and for the medical group 9 ± 2 (P < 0.001). TAVI‐related procedural mortality was 2.6%, and 30‐day mortality was 5.2%. Among the medically‐treated patients, 14 (30%) underwent palliative balloon aortic valvuloplasty, with a trend toward improved survival (P = 0.06). During overall follow‐up of 215 ± 115 days there were a total of 18 deaths; TAVI N = 5 (13%); Medical N = 13 (28%) (P = 0.04). Conclusions : Patients with severe aortic valve disease who are not suitable for surgical aortic valve replacement have an improved prognosis if treated with transcatheter aortic valve implantation rather than continuing on medical management alone. © 2010 Wiley‐Liss, Inc.     

Outcomes of patients with low‐pressure aortic gradient undergoing transcatheter aortic valve implantation

Background: The risk/benefit balance of transcatheter aortic valve implantation (TAVI) in patients with low‐gradient aortic stenosis (LGAS) remains to be well defined. Aim of the study was to investigate the impact of LGAS in patients undergoing TAVI. Methods: Medline, Cochrane Library, and Scopus were searched for articles reporting outcome of patients with LGAS undergoing TAVI. The primary endpoint was 12‐months all‐cause mortality and the secondary endpoint was 30‐day all‐cause mortality. Using event‐rates as dependent variable, a meta‐regression was performed to test for interaction between baseline clinical features (age, gender, diabetes mellitus, coronary artery disease, left ventricular ejection fraction (LVEF) and type of implanted valve) and transaortic gradient for the primary endpoint. Results: Eight studies with a total of 12,589 patients were included. Almost one‐third of the patients presented with LGAS (27.3%: 24.4–29.2). Median LVEF was 48% in patients with LGAS and 56% in patients with high‐gradient AS. Patients with LGAS were more likely to have diabetes mellitus, previous coronary artery disease, higher mean Logistic EuroSCORE, and lower EF. At 12 (12–16.6) months, low transaortic gradient emerged as independently associated with all‐cause death, both if evaluated as a dichotomous and continuous value (respectively OR 1.17; 1.11–1.23 and OR 1.02; 1–1.04, all CI 95%). Clinical variables, including EF did not affect this result. Conclusions: In a population of TAVI patients, LGAS appears to be independently related to dismal prognosis. © 2016 Wiley Periodicals, Inc.     

根据冠状窦电极走行个体化选择房间隔穿刺时右前斜位透视角度的应用体会

目的总结在行房间隔穿刺时根据冠状窦电极走行特征个体化选择右前斜位透视角度的实际应用体会。方法选择50例因接受房颤导管消融手术而需行房间隔穿刺的患者为研究对象。每例均先经左侧或右侧锁骨下静脉放置冠状窦电极,在后前位透视下,将房间隔穿刺针及长鞘管从上腔静脉回撤至冠状窦口上方1．0～1．5个椎体高度,然后在右前斜位透视下完成穿刺。右前斜位透视角度根据冠状窦电极走行特征选择。记录每例穿刺时的透视角度。结果50例均顺利完成房间隔穿刺,无并发症发生。穿刺时右前斜位透视角度为（35．5±87．21）°,其中多数病例（33例,66％）透视角度为25°～35°。透视角度与左房内径呈弱负相关（P=-0．055,r=-0．27）。结论根据冠状窦电极走行选择房间隔穿刺时的右前斜位透视角度,可以更好地展示房间隔平面,有利于穿刺点准确定位,提高穿刺的成功率及安全性。     

Use of Fluoroscopic Views for Detecting Marshall's Vein in Patients with Cardiac Arrhythmias

Introduction: Recently, several studies showed that focal atrial fibrillation (AF) can be initiated by ectopic beats from the vein of Marshall (VOM). However, the incidence and best fluoroscopic views of VOM have never been reported. Methods and Results: 106 patients (Non-AF = 52, AF = 54) underwent balloon-occluded coronary sinus angiography using seven fluoroscopic views (PA, Lateral, RAO 30°, RA 30° + Caudal 20°, LAO 30°, LAO 60°, LAO 60° + Cranial 20°). The total incidence of VOM was 74.5% (79/106), without significant difference in age (81.1 vs. 71.0%, >65 vs. 65 yrs, p = 0.257) and sex (male vs. female = 72.7 vs. 77.5%, p = 0.585). Furthermore, similar incidence of VOM was noted in patients with Non-AF (71.2%) and AF group (77.8%, p = 0.434). The RAO 30° fluoroscopic view can demonstrate all the left atrial veins and VOM. However, only the LAO 30° fluoroscopic view could confirm VOM and differentiate it from left atrial veins (after vs. before junction of coronary sinus and great cardiac vein, respectively). Conclusion: VOM was equally distributed in patients with different arrhythmias, and the appropriate fluoroscopic view was important for the differential diagnosis of VOM and left atrial veins.     

Transfemorally or transapically deployed Sapien Edwards bioprosthesis is always deformed

Objective: To study the impact of femoral compared to apical access on the Sapien‐Edwards (SE) prosthesis deployment and geometry in patients treated with transcatheter aortic valve implantation (TAVI) for aortic stenosis. Background: SE prosthesis deformation exists after its deployment through transfemoral (TF ‐ TAVI) approach. However, no study comparing the deformation between TF ‐ TAVI and transapical (TA ‐ TAVI) approaches has yet been published. Methods: Forty consecutive patients received TAVI with the SE prosthesis (TF ‐ TAVI n = 25; TA ‐ TAVI n = 15). A fluoroscopic analysis of the prosthesis was then performed. The stent frame geometry was assessed during deployment in the profile view, and after implantation in the profile and frontal views. Results: Expansion kinetics revealed a triphasic stent deployment with both approaches; the aortic extremity being the first to open. After implantation, on the profile view, the stent shape was never rectangular (therefore never cylindrical) in both groups. It had a biconic shape in most of the patients (76% vs. 93.3% for TF ‐ TAVI and TA ‐ TAVI patients, respectively, P = 0.224) with a wider aortic extremity relative to the ventricular one. The frontal view analysis showed that circular deployment of the stent was never achieved. A greater leaflet to stent mismatch was noted in TA ‐ TAVI patients, however, the difference was not statistically significant (12% vs. 33.3%, P = 0.126). Conclusion: Fluoroscopically assessed, the geometry of SE prosthesis was never cylindrical after deployment, whatever the access for implantation was. Longitudinal deformation was greater after TF ‐ TAVI whereas leaflet to stent mismatch tended to be more pronounced after TA ‐ TAVI. (J Interven Cardiol 2012;25:53–61)     

Transcatheter aortic valve implantation for treatment of patients with degenerated aortic bioprostheses—valve‐in‐valve technique

Background: The management of patients with degeneration of surgical bioprosthetic valve replacement remains a challenge because of the higher risk of re‐do aortic valve replacement. We present a case series of five patients with degenerated aortic bioprostheses treated with transfemoral transcatheter aortic valve implantation (TAVI). Methods: From December 2009 to May 2010, five patients with degenerated aortic valve bioprostheses (aortic valve area < 1 cm² or severe aortic regurgitation), an excessive operative risk (EuroSCORE ≥ 30%), symptoms of heart failure (NYHA ≥ III) and an internal diameter of bioprosthetic aortic valve 20.5 ± 0.5 mm were included. Procedures were performed without hemodynamic support using femoral arteries. Balloon valvuloplasty with a 20‐mm balloon under rapid pacing was carried out before valve implantation. The 26‐mm CoreValve prosthesis, 18‐F‐generation (Medtronic, Minneapolis, Minnesota) was inserted retrograde under fluoroscopic guidance. Invasive and echocardiographic measurements were done immediately before and after TAVI. Clinical followup and echocardiography were performed after procedure (mean followup 72 days ± 60, range: 176–30 days). Results: In all patients TAVI was successful with immediate decrease of transaortic peak‐to‐peak pressure (P = 0.002). Mild aortic regurgitation occurred in two patients and one patient received a new permanent pacemaker. Major adverse cardiac and cerebrovascular events did not arise. NYHA functional class improved in all patients and left ventricular ejection fraction increased (P = 0.019). Conclusion: Our experiences with the valve‐in‐valve technique using the CoreValve prosthesis suggest that transfemoral TAVI is feasible in high risk patients with degenerated aortic bioprostheses. © 2010 Wiley‐Liss, Inc.     

Standard contraction curves of the left ventricle for the objective quantification of segmental kinetics

Two left ventricle angiographically-standard contraction curves are proposed: one for the 30-degree right anterior oblique (RAO) projection, and the other for the 60-degree left anterior oblique (LAO) projection. These curves are obtained by a calculation which uses the end-diastolic and end-systolic silhouettes along with the longitudinal axes. The best calculation method, which is different in the two projections, has been identified by computer testing of a number of hypothesis over a "normal" population of 18 pairs of RAO and 7 pairs of LAO silhouettes. The working hypothesis was selected by minimizing the standard deviation. In both projections the percent reduction of 20 areas is performed. The 20 RAO areas are defined by 10 equidistant orthogonal coordinates which intersect the longitudinal axis; moreover, the longitudinal axis "angiographic shortening", becomes divided into "cavity real shortening" and "apical parietal effacement'. The 20 LAO areas are defined by radial axes spaced by 15 degree intervals. The proposed standard curves show a low standard deviation of the calculated points: mean 7.8% +/- 3.68 (SD) for the RAO curve, and mean 9.8% +/- 3.68 for the LAO curve. These curves achieve the goal of a standard reference for the objective evaluation of the left ventricle segmentary contraction analysis.     

超声心动图在主动脉瓣狭窄经导管主动脉瓣植入术中的应用价值

目的探讨超声心动图在主动脉瓣狭窄患者经导管主动脉瓣植入术中的作用。方法3例重度主动脉瓣瓣膜狭窄患者接受经导管主动脉瓣人工瓣膜植入术。使用PhilipS iE33型彩色多普勒超声诊断仪,配备经胸探头S5—1和经食道探头S7—2,X7—2t。超声观察内容包括明确主动脉瓣膜病变范围和程度,测量主动脉瓣环前后径,人工瓣膜植入术后瓣膜功能等。结果3例患者经导管主动脉瓣植入术均取得了成功,人工瓣膜位置稳定,常规超声心动图3例患者术前经胸超声心动图与术中经食管超声心动图诊断相符,跨瓣压差较术前明显下降,主动脉瓣瓣上流速明显下降,瓣周漏瞬时反流量平均约1．2mL。结论经导管主动脉瓣人工瓣膜植入术在治疗严重主动脉瓣瓣膜狭窄中方法可行,效果良好;超声心动图在这项工作中具有重要的辅助作用。     

Effect of transcatheter aortic valve implantation on QT dispersion in patients with aortic stenosis

Background QT dispersion （QTd） is a predictor of ventricular arrhythmia. Ventricular arrhythmia is an important factor influencing morbidity and mortality in patients with aortic stenosis. Surgical aortic valve replacement reduced the QTd in this patients group. However, the effect of transcatheter aortic valve implantation （TAVI） on QTd in patients with aortic stenosis is unknown. The aim of this study was to investigate the effect of TAVI on QTd in patients with aortic stenosis. Methods Patients with severe aortic stenosis, who were not candi-dates for surgical aortic valve replacement due to contraindications or high surgical risk, were included in the study. All patients underwent electrocardiographic and echocardiographic evaluation before, and at the 6th month after TAVI, computed QTd and left ventricular mass index （LVMI）. Results A total 30 patients were admitted to the study （mean age 83.2 ± 1.0 years, female 21 and male 9, mean valve area 0.7 ± 3 mm2）. Edwards SAPIEN heart valves, 23 mm （21 patients） and 26 mm （9 patients）, by the transfemoral approach were used in the TAVI procedures. All TAVI procedures were successful. Both QTd and LVMI at the 6th month after TAVI were significantly reduced com-pared with baseline values of QTd and LVMI before TAVI （73.8 ± 4 ms vs. 68 ± 2 ms, P=0.001 and 198 ± 51 g/m2 vs. 184 ± 40 g/m2, P=0.04, respectively）. There was a significant correlation between QTd and LVMI （r=0.646, P〈0.001）. Conclusions QTd, which malign ventricular arrhythmia marker, and LVMI were significantly reduced after TAVI procedure. TAVI may decrease the possibility of ventricu-lar arrhythmia in patients with aortic stenosis.     

Atrioventricular Conduction After Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement

AV Conduction After TAVI and SAVR . Introduction: Atrioventricular conduction abnormalities (AVCA) may complicate transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). The aim of this study was to prospectively evaluate AVCA after TAVI and SAVR. Methods and Results: Among 50 patients undergoing TAVI and 25 patients undergoing SAVR a continuous 7‐day Holter electrocardiogram (ECG) was recorded after the procedure. ECGs during TAVI and 12‐lead ECGs before and 1 and 7 days after TAVI and SAVR were analyzed. At baseline, TAVI patients were older (mean 82.1 vs 75.4, P < 0.001), had a longer PR interval (median 200 milliseconds vs 175 milliseconds, P = 0.004) and broader QRS width (median 100 milliseconds vs 80 milliseconds, P = 0.007) than SAVR patients. New AVCA were observed among 29 TAVI patients (58%), mostly new left bundle branch block (76%). Predilatation induced new AVCA in 14 TAVI patients (28%). New AVCA resolved within 24 hours in 15 TAVI patients (30%), and persisted in 14 TAVI (28%) and 3 SAVR patients (12%, P = 0.12). Among patients with persistent QRS width <120 milliseconds during the first 24 hours after TAVI, QRS width remained stable during the remainder of the observation period. During Holter monitoring complete AV block was observed in 4 TAVI patients (8%) and 3 SAVR patients (12%; P = 0.68). Conclusions: Almost half of AVCA during TAVI are induced by predilatation, but half of them resolve within 24 hours. Persistent AVCA are more frequently observed after TAVI than SAVR. If QRS width is below 120 milliseconds the first day after TAVI, the risk of late AVCA seems low. (J Cardiovasc Electrophysiol, Vol. 23 pp. 1115‐1122, October 2012)     

Difficulties with horizontal aortic root in transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) emerged to be a viable treatment option for failing bioprosthesis in the aortic position. Transfemoral approach is the most common access route for TAVI and associated with most favorable clinical outcome. However, in the presence of unfavorable aortic root anatomy, TAVI via transfemoral approach provides inadequate support for device manipulation during valve positioning, particularly performed for the indication of severe aortic regurgitation. We report our experience on TAVI utilizing CoreValve for a patient with regurgitant failing bioprosthesis with horizontal aortic root where we encountered difficulties during implantation and retrieval of valve delivery system. © 2012 Wiley Periodicals, Inc.